hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Monroe Surgical Hospital LLC,2024-07-01,2.0.0,Monroe Surgical Hospital LLC,"2408 Broadmoor Blvd Monroe, LA 71201",721479756,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA|MEDICARE ADVANTAGE|negotiated_dollar,standard_charge|AETNA|MEDICARE ADVANTAGE|negotiated_percentage,standard_charge|AETNA|MEDICARE ADVANTAGE|negotiated_algorithm,estimated_amount|AETNA|MEDICARE ADVANTAGE,standard_charge|AETNA|MEDICARE ADVANTAGE|methodology,additional_payer_notes|AETNA|MEDICARE ADVANTAGE,standard_charge|AETNA|WORK COMP|negotiated_dollar,standard_charge|AETNA|WORK COMP|negotiated_percentage,standard_charge|AETNA|WORK COMP|negotiated_algorithm,estimated_amount|AETNA|WORK COMP,standard_charge|AETNA|WORK COMP|methodology,additional_payer_notes|AETNA|WORK COMP,standard_charge|BEECH ST|COMMERCIAL|negotiated_dollar,standard_charge|BEECH ST|COMMERCIAL|negotiated_percentage,standard_charge|BEECH ST|COMMERCIAL|negotiated_algorithm,estimated_amount|BEECH ST|COMMERCIAL,standard_charge|BEECH ST|COMMERCIAL|methodology,additional_payer_notes|BEECH ST|COMMERCIAL,standard_charge|BLUE CROSS BLUE SHIELD|COMMERCIAL|negotiated_dollar,standard_charge|BLUE CROSS BLUE SHIELD|COMMERCIAL|negotiated_percentage,standard_charge|BLUE CROSS BLUE SHIELD|COMMERCIAL|negotiated_algorithm,estimated_amount|BLUE CROSS BLUE SHIELD|COMMERCIAL,standard_charge|BLUE CROSS BLUE SHIELD|COMMERCIAL|methodology,additional_payer_notes|BLUE CROSS BLUE SHIELD|COMMERCIAL,standard_charge|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE|negotiated_dollar,standard_charge|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE|negotiated_percentage,standard_charge|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE|negotiated_algorithm,estimated_amount|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE,standard_charge|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE|methodology,additional_payer_notes|BLUE CROSS BLUE SHIELD|MEDICARE ADVANTAGE,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|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|FORD BACON AND DAVIS|MEDICARE|negotiated_dollar,standard_charge|FORD BACON AND DAVIS|MEDICARE|negotiated_percentage,standard_charge|FORD BACON AND DAVIS|MEDICARE|negotiated_algorithm,estimated_amount|FORD BACON AND DAVIS|MEDICARE,standard_charge|FORD BACON AND DAVIS|MEDICARE|methodology,additional_payer_notes|FORD BACON AND DAVIS|MEDICARE,standard_charge|GILSBAR|MEDICARE|negotiated_dollar,standard_charge|GILSBAR|MEDICARE|negotiated_percentage,standard_charge|GILSBAR|MEDICARE|negotiated_algorithm,estimated_amount|GILSBAR|MEDICARE,standard_charge|GILSBAR|MEDICARE|methodology,additional_payer_notes|GILSBAR|MEDICARE,standard_charge|HEALTHY BLUE|MEDICAID|negotiated_dollar,standard_charge|HEALTHY BLUE|MEDICAID|negotiated_percentage,standard_charge|HEALTHY BLUE|MEDICAID|negotiated_algorithm,estimated_amount|HEALTHY BLUE|MEDICAID,standard_charge|HEALTHY BLUE|MEDICAID|methodology,additional_payer_notes|HEALTHY BLUE|MEDICAID,standard_charge|HUMANA|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA|COMMERCIAL,standard_charge|HUMANA|COMMERCIAL|methodology,additional_payer_notes|HUMANA|COMMERCIAL,standard_charge|HUMANA|MEDICARE ADVANTAGE|negotiated_dollar,standard_charge|HUMANA|MEDICARE ADVANTAGE|negotiated_percentage,standard_charge|HUMANA|MEDICARE ADVANTAGE|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE ADVANTAGE,standard_charge|HUMANA|MEDICARE ADVANTAGE|methodology,additional_payer_notes|HUMANA|MEDICARE ADVANTAGE,standard_charge|IMA|COMMERCIAL|negotiated_dollar,standard_charge|IMA|COMMERCIAL|negotiated_percentage,standard_charge|IMA|COMMERCIAL|negotiated_algorithm,estimated_amount|IMA|COMMERCIAL,standard_charge|IMA|COMMERCIAL|methodology,additional_payer_notes|IMA|COMMERCIAL,standard_charge|INSURANCE SYSTEMS|MEDICARE|negotiated_dollar,standard_charge|INSURANCE SYSTEMS|MEDICARE|negotiated_percentage,standard_charge|INSURANCE SYSTEMS|MEDICARE|negotiated_algorithm,estimated_amount|INSURANCE SYSTEMS|MEDICARE,standard_charge|INSURANCE SYSTEMS|MEDICARE|methodology,additional_payer_notes|INSURANCE SYSTEMS|MEDICARE,standard_charge|INSURANCE SYSTEMS|SMSO EMPLOYEE|negotiated_dollar,standard_charge|INSURANCE SYSTEMS|SMSO EMPLOYEE|negotiated_percentage,standard_charge|INSURANCE SYSTEMS|SMSO EMPLOYEE|negotiated_algorithm,estimated_amount|INSURANCE SYSTEMS|SMSO EMPLOYEE,standard_charge|INSURANCE SYSTEMS|SMSO EMPLOYEE|methodology,additional_payer_notes|INSURANCE SYSTEMS|SMSO EMPLOYEE,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|AMERIHEALTH|MEDICAID|negotiated_dollar,standard_charge|AMERIHEALTH|MEDICAID|negotiated_percentage,standard_charge|AMERIHEALTH|MEDICAID|negotiated_algorithm,estimated_amount|AMERIHEALTH|MEDICAID,standard_charge|AMERIHEALTH|MEDICAID|methodology,additional_payer_notes|AMERIHEALTH|MEDICAID,standard_charge|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|MEDICARE ADVANTAGE|negotiated_dollar,standard_charge|UHC|MEDICARE ADVANTAGE|negotiated_percentage,standard_charge|UHC|MEDICARE ADVANTAGE|negotiated_algorithm,estimated_amount|UHC|MEDICARE ADVANTAGE,standard_charge|UHC|MEDICARE ADVANTAGE|methodology,additional_payer_notes|UHC|MEDICARE ADVANTAGE,standard_charge|VACCN OPTUM|MEDICARE|negotiated_dollar,standard_charge|VACCN OPTUM|MEDICARE|negotiated_percentage,standard_charge|VACCN OPTUM|MEDICARE|negotiated_algorithm,estimated_amount|VACCN OPTUM|MEDICARE,standard_charge|VACCN OPTUM|MEDICARE|methodology,additional_payer_notes|VACCN OPTUM|MEDICARE,standard_charge|VANTAGE|MEDICARE|negotiated_dollar,standard_charge|VANTAGE|MEDICARE|negotiated_percentage,standard_charge|VANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|VANTAGE|MEDICARE,standard_charge|VANTAGE|MEDICARE|methodology,additional_payer_notes|VANTAGE|MEDICARE,standard_charge|VANTAGE|MEDICARE ADVANTAGE|negotiated_dollar,standard_charge|VANTAGE|MEDICARE ADVANTAGE|negotiated_percentage,standard_charge|VANTAGE|MEDICARE ADVANTAGE|negotiated_algorithm,estimated_amount|VANTAGE|MEDICARE ADVANTAGE,standard_charge|VANTAGE|MEDICARE ADVANTAGE|methodology,additional_payer_notes|VANTAGE|MEDICARE ADVANTAGE,standard_charge|VERITY|COMMERCIAL|negotiated_dollar,standard_charge|VERITY|COMMERCIAL|negotiated_percentage,standard_charge|VERITY|COMMERCIAL|negotiated_algorithm,estimated_amount|VERITY|COMMERCIAL,standard_charge|VERITY|COMMERCIAL|methodology,additional_payer_notes|VERITY|COMMERCIAL,standard_charge|WORKERS COMP|COMMERCIAL|negotiated_dollar,standard_charge|WORKERS COMP|COMMERCIAL|negotiated_percentage,standard_charge|WORKERS COMP|COMMERCIAL|negotiated_algorithm,estimated_amount|WORKERS COMP|COMMERCIAL,standard_charge|WORKERS COMP|COMMERCIAL|methodology,additional_payer_notes|WORKERS COMP|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
AFB CULTURE SMEAR,220586,CDM,300,RC,87206,HCPCS,Outpatient,,,24.26,21.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.59,84.88,,16.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.2,75,,14.56,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,80,,15.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.2,100,,,Fee Schedule,100% of Custom Fee Schedule,21.83,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,21.83,
AEROBIC/FACULTATIVELY ANAEROBIC SUSCEPT,201357,CDM,300,RC,87076,HCPCS,Outpatient,,,36.36,32.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.45,70,,20.36,percent of total billed charges,70% of total billed charges for outpatient setting,30.86,84.88,,24.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.27,75,,21.82,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,70,,20.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.09,80,,23.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.33,100,,,Fee Schedule,100% of Custom Fee Schedule,32.72,90,,26.18,percent of total billed charges,90% of total billed charges for outpatient setting,8.08,32.72,
"ALBUMIN, SERUM",202371,CDM,310,RC,82040,HCPCS,Outpatient,,,22.28,20.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,84.88,,15.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.71,75,,13.37,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,80,,14.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,100,,,Fee Schedule,100% of Custom Fee Schedule,20.05,90,,16.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,20.05,
ANA REFLEX PANEL,200804,CDM,302,RC,86039,HCPCS,Outpatient,,,50.22,45.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.15,70,,28.12,percent of total billed charges,70% of total billed charges for outpatient setting,42.63,84.88,,34.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.67,75,,30.14,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,70,,28.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,80,,32.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,100,,,Fee Schedule,100% of Custom Fee Schedule,45.2,90,,36.16,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,45.2,
ASCA ANTIBODIES,201082,CDM,302,RC,86671,HCPCS,Outpatient,,,55.13,49.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.59,70,,30.87,percent of total billed charges,70% of total billed charges for outpatient setting,46.79,84.88,,37.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.35,75,,33.08,percent of total billed charges,75% of total billed charges for outpatient setting,38.59,70,,30.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,80,,35.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.24,100,,,Fee Schedule,100% of Custom Fee Schedule,49.62,90,,39.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,49.62,
C REACTIVE PROTEIN,201735,CDM,300,RC,86140,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
CARBAMEZEPINE,200820,CDM,300,RC,80156,HCPCS,Outpatient,,,65.57,59.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,55.66,84.88,,44.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.18,75,,39.34,percent of total billed charges,75% of total billed charges for outpatient setting,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.46,80,,41.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,59.01,90,,47.21,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,59.01,
CBC PLATELET AUTO 5 DIFF,200270,CDM,305,RC,85025,HCPCS,Outpatient,,,34.97,31.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,29.68,84.88,,23.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.23,75,,20.98,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.98,80,,22.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,100,,,Fee Schedule,100% of Custom Fee Schedule,31.47,90,,25.18,percent of total billed charges,90% of total billed charges for outpatient setting,7.77,31.47,
CBC/PLTS,201190,CDM,300,RC,85027,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,26.21,
CLOSTRIDIUM DIFFICILE TOXIN A,200710,CDM,300,RC,87324,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
CULTURE AEROBIC BACTERIA,201111,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE AEROBIC BACTERIA,201112,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE WOUND (ORDER AERO/ANA CULTURE),201355,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
DEAMIDATED GLIADIN PEPTIDE AB IGA,201556,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
DEAMIDATED GLIADIN PEPTIDE AB IGG,201558,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
DRUG SCREEN 10 DRUG PANEL SERUM,220807,CDM,300,RC,80307,HCPCS,Outpatient,,,279.63,251.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,237.35,84.88,,189.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.72,75,,167.78,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.7,80,,178.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,79.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of Custom Fee Schedule,251.67,90,,201.34,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,251.67,
DRUG SCREEN 7 DRUG PANEL,220346,CDM,300,RC,80307,HCPCS,Outpatient,,,279.63,251.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,237.35,84.88,,189.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.72,75,,167.78,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.7,80,,178.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,79.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of Custom Fee Schedule,251.67,90,,201.34,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,251.67,
GLUCOSE 6 PHOSPHATE DEHYDROGENASE,200128,CDM,301,RC,82955,HCPCS,Outpatient,,,43.65,39.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,70,,24.45,percent of total billed charges,70% of total billed charges for outpatient setting,37.05,84.88,,29.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.74,75,,26.19,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,70,,24.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,80,,27.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.16,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,100,,,Fee Schedule,100% of Custom Fee Schedule,39.29,90,,31.43,percent of total billed charges,90% of total billed charges for outpatient setting,9.7,39.29,
H PYLORI BREATH TEST UREASE NONRADIOACT,200885,CDM,300,RC,83013,HCPCS,Outpatient,,,303.12,272.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.18,70,,169.74,percent of total billed charges,70% of total billed charges for outpatient setting,257.29,84.88,,205.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,227.34,75,,181.87,percent of total billed charges,75% of total billed charges for outpatient setting,212.18,70,,169.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.5,80,,194,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,98.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.88,100,,,Fee Schedule,100% of Custom Fee Schedule,272.81,90,,218.25,percent of total billed charges,90% of total billed charges for outpatient setting,40.27,272.81,
HEMOGLOBIN ELECTROPHORESIS,200923,CDM,300,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
HERPES SIMPLEX VIRUS 1&2 IGM,220483,CDM,302,RC,86694,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,58.28,
HERPES SIMPLEX VIRUS 2 IGG,201091,CDM,302,RC,86696,HCPCS,Outpatient,,,87.08,78.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,73.91,84.88,,59.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.31,75,,52.25,percent of total billed charges,75% of total billed charges for outpatient setting,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.66,80,,55.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.7,100,,,Fee Schedule,100% of Custom Fee Schedule,78.37,90,,62.7,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,78.37,
HGB ELECTROPHORESIS,200808,CDM,300,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
LAMOTRIGINE,220027,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
"LEGIONELLA AB TYPES 1-6, IGM",201439,CDM,300,RC,86713,HCPCS,Outpatient,,,68.85,61.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,58.44,84.88,,46.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.64,75,,41.31,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.08,80,,44.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.02,100,,,Fee Schedule,100% of Custom Fee Schedule,61.97,90,,49.58,percent of total billed charges,90% of total billed charges for outpatient setting,15.3,61.97,
M-BASIC METABOLIC PANEL W/CALCIUM TOTAL,221001,CDM,300,RC,80048,HCPCS,Outpatient,,,38.07,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,32.31,84.88,,25.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.55,75,,22.84,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,80,,24.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,100,,,Fee Schedule,100% of Custom Fee Schedule,34.26,90,,27.41,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,34.26,
M-COMP METABOLIC PANEL,221000,CDM,301,RC,80053,HCPCS,Outpatient,,,47.52,42.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,40.33,84.88,,32.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.64,75,,28.51,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,80,,30.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of Custom Fee Schedule,42.77,90,,34.22,percent of total billed charges,90% of total billed charges for outpatient setting,10.56,42.77,
MSH-TIBC,201732,CDM,300,RC,83550,HCPCS,Outpatient,,,39.33,35.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,84.88,,26.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.5,75,,23.6,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,80,,25.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.58,100,,,Fee Schedule,100% of Custom Fee Schedule,35.4,90,,28.32,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,35.4,
"PROTEIN ELECTRO FRACT AND QUANT,SERUM",200766,CDM,300,RC,84165,HCPCS,Outpatient,,,48.33,43.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,41.02,84.88,,32.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.25,75,,29,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,80,,30.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,100,,,Fee Schedule,100% of Custom Fee Schedule,43.5,90,,34.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,43.5,
RAST MICRO SCREEN,201073,CDM,302,RC,86005,HCPCS,Outpatient,,,35.87,32.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.11,70,,20.09,percent of total billed charges,70% of total billed charges for outpatient setting,30.45,84.88,,24.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.9,75,,21.52,percent of total billed charges,75% of total billed charges for outpatient setting,25.11,70,,20.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.7,80,,22.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.64,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,100,,,Fee Schedule,100% of Custom Fee Schedule,32.28,90,,25.82,percent of total billed charges,90% of total billed charges for outpatient setting,7.97,32.28,
RAST PANEL ZONE 7,200269,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
RAST PROFILE MINI RAST,201072,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
"RAST, PEDIATRIC ALLERGEN, 0-3YRS",202258,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
RUBELLA,201700,CDM,302,RC,86762,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,58.28,
"RUBEOLA / MEASLES TITER, IGG",201701,CDM,302,RC,86765,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
TRIGLYCERIDES,201426,CDM,301,RC,84478,HCPCS,Outpatient,,,25.83,23.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of Custom Fee Schedule,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,23.25,
TRIGLYCERIDES,201459,CDM,301,RC,84478,HCPCS,Outpatient,,,25.83,23.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of Custom Fee Schedule,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,23.25,
VASOPRESSIN ANTIDIURETIC HORMONE  ADH,200311,CDM,301,RC,84588,HCPCS,Outpatient,,,152.73,137.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.91,70,,85.53,percent of total billed charges,70% of total billed charges for outpatient setting,129.64,84.88,,103.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,114.55,75,,91.64,percent of total billed charges,75% of total billed charges for outpatient setting,106.91,70,,85.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.18,80,,97.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,49.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of Custom Fee Schedule,137.46,90,,109.97,percent of total billed charges,90% of total billed charges for outpatient setting,27.3,137.46,
VITAMIN D,201504,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
..TESTING CULTURE ENVIRONMENTAL,929192,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
..TESTING ONLY BMP,919191,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
..TESTING ONLY CBC,919192,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
..TESTING ONLY COV2,929191,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
..TESTING ONLY PTT,919193,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
..TESTING ONLY RENAL PANEL,919194,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
0 CHROMIC CT-1 / 812H,6150174,CDM,272,RC,,,Outpatient,,,20.25,20.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,70,,11.34,percent of total billed charges,70% of total billed charges for outpatient setting,17.19,84.88,,13.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.13,50,,8.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.19,75,,12.15,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,70,,11.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.2,80,,12.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.16,65,,10.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,35,,5.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.23,90,,14.58,percent of total billed charges,90% of total billed charges for outpatient setting,2.6,18.23,
0 ETHIBOND CT-1 CR8 / CX21D,6152088,CDM,272,RC,,,Outpatient,,,73.66,73.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.56,70,,41.25,percent of total billed charges,70% of total billed charges for outpatient setting,62.52,84.88,,50.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.83,50,,29.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.25,75,,44.2,percent of total billed charges,75% of total billed charges for outpatient setting,51.56,70,,41.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,12.84,,7.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,80,,47.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,12.84,,7.57,percent of total billed charges,12.84% of total billed charges,9.46,12.84,,7.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.88,65,,38.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,35,,20.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.29,90,,53.03,percent of total billed charges,90% of total billed charges for outpatient setting,9.46,66.29,
0 ETHIBOND EN-3    EC11,69161373,CDM,272,RC,,,Outpatient,,,166.76,166.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.73,70,,93.38,percent of total billed charges,70% of total billed charges for outpatient setting,141.55,84.88,,113.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,83.38,50,,66.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.07,75,,100.06,percent of total billed charges,75% of total billed charges for outpatient setting,116.73,70,,93.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,12.84,,17.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.41,80,,106.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,12.84,,17.13,percent of total billed charges,12.84% of total billed charges,21.41,12.84,,17.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,108.39,65,,86.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.37,35,,46.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.08,90,,120.06,percent of total billed charges,90% of total billed charges for outpatient setting,21.41,150.08,
0 ETHIBOND SH 30IN / X834H,6153003,CDM,272,RC,,,Outpatient,,,14.13,14.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,11.99,84.88,,9.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.07,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.6,75,,8.48,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,80,,9.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.18,65,,7.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,35,,3.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.72,90,,10.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.72,
0 MONOCRYL MO-4 CR8 / 701D,69169152,CDM,272,RC,,,Outpatient,,,90.58,90.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.41,70,,50.73,percent of total billed charges,70% of total billed charges for outpatient setting,76.88,84.88,,61.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.29,50,,36.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.94,75,,54.35,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,70,,50.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.63,12.84,,9.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.46,80,,57.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.63,12.84,,9.3,percent of total billed charges,12.84% of total billed charges,11.63,12.84,,9.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.88,65,,47.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,35,,25.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.52,90,,65.22,percent of total billed charges,90% of total billed charges for outpatient setting,11.63,81.52,
0 NUROLON CT-1 CR8 / C521D,69160188,CDM,272,RC,,,Outpatient,,,74.64,74.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,70,,41.8,percent of total billed charges,70% of total billed charges for outpatient setting,63.35,84.88,,50.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.32,50,,29.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.98,75,,44.78,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,70,,41.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,12.84,,7.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.71,80,,47.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,9.58,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.52,65,,38.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.12,35,,20.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.18,90,,53.74,percent of total billed charges,90% of total billed charges for outpatient setting,9.58,67.18,
0 PDS CT-2 / Z334H,69160631,CDM,272,RC,,,Outpatient,,,22.44,22.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.71,70,,12.57,percent of total billed charges,70% of total billed charges for outpatient setting,19.05,84.88,,15.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.22,50,,8.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.83,75,,13.46,percent of total billed charges,75% of total billed charges for outpatient setting,15.71,70,,12.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,80,,14.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.59,65,,11.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,35,,6.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.2,90,,16.16,percent of total billed charges,90% of total billed charges for outpatient setting,2.88,20.2,
0 SILK SH / K834H,6150457,CDM,272,RC,,,Outpatient,,,8.38,8.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.87,70,,4.7,percent of total billed charges,70% of total billed charges for outpatient setting,7.11,84.88,,5.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.19,50,,3.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.29,75,,5.03,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,70,,4.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,12.84,,0.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,80,,5.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,1.08,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.45,65,,4.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,35,,2.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.54,90,,6.03,percent of total billed charges,90% of total billed charges for outpatient setting,1.08,7.54,
0 SILK TIES 18IN / A186H,6150223,CDM,272,RC,,,Outpatient,,,5.04,5.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,84.88,,3.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.52,50,,2.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.78,75,,3.02,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,80,,3.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.28,65,,2.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,35,,1.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.54,90,,3.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.65,4.54,
0 SILK TIES 30IN // A306H,6150227,CDM,272,RC,,,Outpatient,,,11.62,11.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,9.86,84.88,,7.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.81,50,,4.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.72,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,80,,7.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.55,65,,6.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.46,90,,8.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.46,
0 STRATAFIX CT-1  6 IN PDS  / SXPP1B406,69169475,CDM,272,RC,,,Outpatient,,,163.33,163.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.33,70,,91.46,percent of total billed charges,70% of total billed charges for outpatient setting,138.63,84.88,,110.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.67,50,,65.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.5,75,,98,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,70,,91.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,12.84,,16.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.66,80,,104.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,12.84,,16.78,percent of total billed charges,12.84% of total billed charges,20.97,12.84,,16.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.16,65,,84.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.17,35,,45.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,147,90,,117.6,percent of total billed charges,90% of total billed charges for outpatient setting,20.97,147,
0 TICRON  V-20       3015-61,69160132,CDM,272,RC,,,Outpatient,,,74.31,74.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.02,70,,41.62,percent of total billed charges,70% of total billed charges for outpatient setting,63.07,84.88,,50.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.16,50,,29.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.73,75,,44.58,percent of total billed charges,75% of total billed charges for outpatient setting,52.02,70,,41.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,12.84,,7.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.45,80,,47.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,12.84,,7.63,percent of total billed charges,12.84% of total billed charges,9.54,12.84,,7.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.3,65,,38.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,35,,20.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.88,90,,53.5,percent of total billed charges,90% of total billed charges for outpatient setting,9.54,66.88,
0 VICRYL CT-1 27IN DYED CR8 / JJ31G,6153104,CDM,278,RC,,,Outpatient,,,60.48,60.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,60,,29.03,percent of total billed charges,60% of total Billed charges for outpatient setting,51.34,84.88,,41.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.24,50,,24.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.36,75,,36.29,percent of total billed charges,75% of total billed charges for outpatient setting,30.24,50,,24.19,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,12.84,,6.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.38,80,,38.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,7.77,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.48,65,,48.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,35,,16.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.29,60,,29.03,percent of total billed charges,60% of total billed charges for outpatient setting,7.77,60.48,
0 VICRYL CT-1 36 / VCP946H,6150303,CDM,272,RC,,,Outpatient,,,12.6,12.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.69,84.88,,8.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,50,,5.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.45,75,,7.56,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,80,,8.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.19,65,,6.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.34,90,,9.07,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.34,
0 VICRYL CT-1 CR8 18IN / VCP740D,6150299,CDM,272,RC,,,Outpatient,,,66.22,66.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.35,70,,37.08,percent of total billed charges,70% of total billed charges for outpatient setting,56.21,84.88,,44.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.11,50,,26.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.67,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,70,,37.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,12.84,,6.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.98,80,,42.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,12.84,,6.8,percent of total billed charges,12.84% of total billed charges,8.5,12.84,,6.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.04,65,,34.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,35,,18.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.6,90,,47.68,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,59.6,
0 VICRYL CT-1 UND 27IN / J260H,6150358,CDM,272,RC,,,Outpatient,,,11.62,11.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,9.86,84.88,,7.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.81,50,,4.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.72,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,80,,7.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.55,65,,6.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.46,90,,8.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.46,
0 VICRYL CT-2 UND / J270H,6150359,CDM,272,RC,,,Outpatient,,,11.52,11.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,9.78,84.88,,7.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.76,50,,4.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.64,75,,6.91,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,80,,7.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.49,65,,5.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,35,,3.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.37,90,,8.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.48,10.37,
0 VICRYL MO-4 CR8 / VCP701D,6150296,CDM,272,RC,,,Outpatient,,,86.87,86.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.81,70,,48.65,percent of total billed charges,70% of total billed charges for outpatient setting,73.74,84.88,,58.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.44,50,,34.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.15,75,,52.12,percent of total billed charges,75% of total billed charges for outpatient setting,60.81,70,,48.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,80,,55.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.47,65,,45.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.4,35,,24.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.18,90,,62.54,percent of total billed charges,90% of total billed charges for outpatient setting,11.15,78.18,
0 VICRYL SH UND 27IN / J418H,69162908,CDM,272,RC,,,Outpatient,,,11.49,11.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.04,70,,6.43,percent of total billed charges,70% of total billed charges for outpatient setting,9.75,84.88,,7.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.75,50,,4.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.62,75,,6.9,percent of total billed charges,75% of total billed charges for outpatient setting,8.04,70,,6.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,80,,7.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.47,65,,5.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.02,35,,3.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.34,90,,8.27,percent of total billed charges,90% of total billed charges for outpatient setting,1.48,10.34,
0 VICRYL UR-5 / J376H,6152698,CDM,272,RC,,,Outpatient,,,25.29,25.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,70,,14.16,percent of total billed charges,70% of total billed charges for outpatient setting,21.47,84.88,,17.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.65,50,,10.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.97,75,,15.18,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,70,,14.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.23,80,,16.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.44,65,,13.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,35,,7.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.76,90,,18.21,percent of total billed charges,90% of total billed charges for outpatient setting,3.25,22.76,
0 VICRYL UR-6 / VCP603H,6150294,CDM,272,RC,,,Outpatient,,,15.5,15.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,70,,8.68,percent of total billed charges,70% of total billed charges for outpatient setting,13.16,84.88,,10.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.75,50,,6.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.63,75,,9.3,percent of total billed charges,75% of total billed charges for outpatient setting,10.85,70,,8.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.4,80,,9.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.08,65,,8.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,35,,4.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.99,13.95,
1 CHROMIC CT-1 // 813H,6150175,CDM,272,RC,,,Outpatient,,,26.02,26.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,22.09,84.88,,17.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.01,50,,10.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.52,75,,15.62,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,12.84,,2.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.82,80,,16.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,12.84,,2.67,percent of total billed charges,12.84% of total billed charges,3.34,12.84,,2.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.91,65,,13.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,35,,7.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.42,90,,18.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.34,23.42,
1 ETHIBOND CT-1  / X425H,69162010,CDM,272,RC,,,Outpatient,,,15.48,15.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,70,,8.67,percent of total billed charges,70% of total billed charges for outpatient setting,13.14,84.88,,10.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.74,50,,6.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.61,75,,9.29,percent of total billed charges,75% of total billed charges for outpatient setting,10.84,70,,8.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,80,,9.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.06,65,,8.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.42,35,,4.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.93,90,,11.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.99,13.93,
1 ETHIBOND CTX CR8/CX30D,6152031,CDM,272,RC,,,Outpatient,,,93.47,93.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.43,70,,52.34,percent of total billed charges,70% of total billed charges for outpatient setting,79.34,84.88,,63.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.74,50,,37.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.1,75,,56.08,percent of total billed charges,75% of total billed charges for outpatient setting,65.43,70,,52.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.78,80,,59.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.76,65,,48.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.71,35,,26.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.12,90,,67.3,percent of total billed charges,90% of total billed charges for outpatient setting,12,84.12,
1 PDS CT-1 / Z341H,6152616,CDM,272,RC,,,Outpatient,,,21.7,21.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,70,,12.15,percent of total billed charges,70% of total billed charges for outpatient setting,18.42,84.88,,14.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.85,50,,8.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.28,75,,13.02,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,70,,12.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.79,12.84,,2.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,80,,13.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.79,12.84,,2.23,percent of total billed charges,12.84% of total billed charges,2.79,12.84,,2.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.11,65,,11.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,35,,6.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.53,90,,15.62,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,19.53,
1 PDS TP-1 / Z880G,69161566,CDM,272,RC,,,Outpatient,,,37.04,37.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.93,70,,20.74,percent of total billed charges,70% of total billed charges for outpatient setting,31.44,84.88,,25.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.52,50,,14.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.78,75,,22.22,percent of total billed charges,75% of total billed charges for outpatient setting,25.93,70,,20.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,12.84,,3.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,80,,23.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,12.84,,3.81,percent of total billed charges,12.84% of total billed charges,4.76,12.84,,3.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.08,65,,19.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.96,35,,10.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.34,90,,26.67,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,33.34,
1 PDS XLH       Z881G,6152134,CDM,272,RC,,,Outpatient,,,41.7,41.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.19,70,,23.35,percent of total billed charges,70% of total billed charges for outpatient setting,35.39,84.88,,28.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.85,50,,16.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.28,75,,25.02,percent of total billed charges,75% of total billed charges for outpatient setting,29.19,70,,23.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,80,,26.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.11,65,,21.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,35,,11.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.53,90,,30.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.35,37.53,
1 PROLENE CT-1 / 8425H,6150180,CDM,272,RC,,,Outpatient,,,17.91,17.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,15.2,84.88,,12.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,50,,7.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.43,75,,10.74,percent of total billed charges,75% of total billed charges for outpatient setting,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.33,80,,11.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.64,65,,9.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,35,,5.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.12,90,,12.9,percent of total billed charges,90% of total billed charges for outpatient setting,2.3,16.12,
1 SILK TIES 30IN / A307H,6152262,CDM,272,RC,,,Outpatient,,,8.61,8.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.31,84.88,,5.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.31,50,,3.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,75,,5.17,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,80,,5.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.6,65,,4.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,35,,2.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.75,90,,6.2,percent of total billed charges,90% of total billed charges for outpatient setting,1.11,7.75,
1 STRATAFIX CT-1 12 IN / SXPP1A435,69169366,CDM,272,RC,,,Outpatient,,,154.05,154.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.84,70,,86.27,percent of total billed charges,70% of total billed charges for outpatient setting,130.76,84.88,,104.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.03,50,,61.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.54,75,,92.43,percent of total billed charges,75% of total billed charges for outpatient setting,107.84,70,,86.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.78,12.84,,15.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.24,80,,98.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.78,12.84,,15.82,percent of total billed charges,12.84% of total billed charges,19.78,12.84,,15.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.13,65,,80.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,35,,43.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.65,90,,110.92,percent of total billed charges,90% of total billed charges for outpatient setting,19.78,138.65,
1 STRATAFIX CT-1 18 IN PDS / SXPP1A404,69162779,CDM,272,RC,,,Outpatient,,,139.18,139.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,70,,77.94,percent of total billed charges,70% of total billed charges for outpatient setting,118.14,84.88,,94.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.59,50,,55.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.39,75,,83.51,percent of total billed charges,75% of total billed charges for outpatient setting,97.43,70,,77.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.87,12.84,,14.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.34,80,,89.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.87,12.84,,14.3,percent of total billed charges,12.84% of total billed charges,17.87,12.84,,14.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.47,65,,72.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.71,35,,38.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.26,90,,100.21,percent of total billed charges,90% of total billed charges for outpatient setting,17.87,125.26,
1 STRATAFIX CTX PDS / SXPP1B402,69169229,CDM,272,RC,,,Outpatient,,,143,143,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.1,70,,80.08,percent of total billed charges,70% of total billed charges for outpatient setting,121.38,84.88,,97.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.5,50,,57.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.25,75,,85.8,percent of total billed charges,75% of total billed charges for outpatient setting,100.1,70,,80.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,12.84,,14.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.4,80,,91.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,12.84,,14.69,percent of total billed charges,12.84% of total billed charges,18.36,12.84,,14.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.95,65,,74.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.05,35,,40.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.7,90,,102.96,percent of total billed charges,90% of total billed charges for outpatient setting,18.36,128.7,
1 STRATAFIX KNTLS VIOL / SXPP2B402,71000990,CDM,272,RC,,,Outpatient,,,245.15,245.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.61,70,,137.29,percent of total billed charges,70% of total billed charges for outpatient setting,208.08,84.88,,166.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,122.58,50,,98.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.86,75,,147.09,percent of total billed charges,75% of total billed charges for outpatient setting,171.61,70,,137.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.48,12.84,,25.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.12,80,,156.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.48,12.84,,25.18,percent of total billed charges,12.84% of total billed charges,31.48,12.84,,25.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,159.35,65,,127.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.8,35,,68.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,220.64,90,,176.51,percent of total billed charges,90% of total billed charges for outpatient setting,31.48,220.64,
1 STRATAFIX SYMM CTX / SXPP1A445,2529120,CDM,272,RC,,,Outpatient,,,169.45,169.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.62,70,,94.9,percent of total billed charges,70% of total billed charges for outpatient setting,143.83,84.88,,115.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.73,50,,67.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.09,75,,101.67,percent of total billed charges,75% of total billed charges for outpatient setting,118.62,70,,94.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,12.84,,17.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.56,80,,108.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,12.84,,17.41,percent of total billed charges,12.84% of total billed charges,21.76,12.84,,17.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.14,65,,88.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.31,35,,47.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.51,90,,122.01,percent of total billed charges,90% of total billed charges for outpatient setting,21.76,152.51,
1 VICRYL CT-1 / J341H,6150284,CDM,272,RC,,,Outpatient,,,12.1,12.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,70,,6.78,percent of total billed charges,70% of total billed charges for outpatient setting,10.27,84.88,,8.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.05,50,,4.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.08,75,,7.26,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,70,,6.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.68,80,,7.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.87,65,,6.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,35,,3.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.89,90,,8.71,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,10.89,
1 VICRYL CTX 27IN / J365H,69169897,CDM,272,RC,,,Outpatient,,,11.34,11.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,70,,6.35,percent of total billed charges,70% of total billed charges for outpatient setting,9.63,84.88,,7.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.67,50,,4.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.51,75,,6.81,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,70,,6.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,80,,7.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.37,65,,5.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,35,,3.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.21,90,,8.17,percent of total billed charges,90% of total billed charges for outpatient setting,1.46,10.21,
1 VICRYL MO-4 CR-8 / VCP702D,6150297,CDM,272,RC,,,Outpatient,,,87.43,87.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,70,,48.96,percent of total billed charges,70% of total billed charges for outpatient setting,74.21,84.88,,59.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.72,50,,34.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.57,75,,52.46,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,70,,48.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.94,80,,55.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.83,65,,45.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.6,35,,24.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.69,90,,62.95,percent of total billed charges,90% of total billed charges for outpatient setting,11.23,78.69,
1 VICRYL OS-6 UND / VCP535H,6150291,CDM,272,RC,,,Outpatient,,,19.08,19.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.36,70,,10.69,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,84.88,,12.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.54,50,,7.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.31,75,,11.45,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,70,,10.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.26,80,,12.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.4,65,,9.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,35,,5.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.17,90,,13.74,percent of total billed charges,90% of total billed charges for outpatient setting,2.45,17.17,
1.4MM DRILL BIT JUGGERKNOT SHRT 912071,69161977,CDM,272,RC,,,Outpatient,,,540.75,540.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,70,,302.82,percent of total billed charges,70% of total billed charges for outpatient setting,458.99,84.88,,367.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,270.38,50,,216.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.56,75,,324.45,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,70,,302.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.43,12.84,,55.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.6,80,,346.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.43,12.84,,55.54,percent of total billed charges,12.84% of total billed charges,69.43,12.84,,55.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.49,65,,281.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.26,35,,151.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,486.68,90,,389.34,percent of total billed charges,90% of total billed charges for outpatient setting,69.43,486.68,
1.6 K WIRE / 829016006,69161867,CDM,278,RC,,,Outpatient,,,156.82,156.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.09,60,,75.27,percent of total billed charges,60% of total Billed charges for outpatient setting,133.11,84.88,,106.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.41,50,,62.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.62,75,,94.1,percent of total billed charges,75% of total billed charges for outpatient setting,78.41,50,,62.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.14,12.84,,16.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.46,80,,100.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.14,12.84,,16.11,percent of total billed charges,12.84% of total billed charges,20.14,12.84,,16.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156.82,65,,125.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.89,35,,43.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.09,60,,75.27,percent of total billed charges,60% of total billed charges for outpatient setting,20.14,156.82,
1-0 STRATAFIX CP-2 PDS / SXPP1B403,1914379,CDM,272,RC,,,Outpatient,,,143,143,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.1,70,,80.08,percent of total billed charges,70% of total billed charges for outpatient setting,121.38,84.88,,97.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.5,50,,57.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.25,75,,85.8,percent of total billed charges,75% of total billed charges for outpatient setting,100.1,70,,80.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,12.84,,14.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.4,80,,91.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,12.84,,14.69,percent of total billed charges,12.84% of total billed charges,18.36,12.84,,14.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.95,65,,74.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.05,35,,40.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.7,90,,102.96,percent of total billed charges,90% of total billed charges for outpatient setting,18.36,128.7,
10-0 NYLON CS1160-6 / 9000G,6152180,CDM,272,RC,,,Outpatient,,,89.04,89.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,70,,49.86,percent of total billed charges,70% of total billed charges for outpatient setting,75.58,84.88,,60.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.52,50,,35.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.78,75,,53.42,percent of total billed charges,75% of total billed charges for outpatient setting,62.33,70,,49.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,12.84,,9.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.23,80,,56.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,12.84,,9.14,percent of total billed charges,12.84% of total billed charges,11.43,12.84,,9.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.88,65,,46.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.16,35,,24.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.14,90,,64.11,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,80.14,
10-0 PROLENE CS160-6   7761,6152877,CDM,272,RC,,,Outpatient,,,120.09,120.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.06,70,,67.25,percent of total billed charges,70% of total billed charges for outpatient setting,101.93,84.88,,81.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.05,50,,48.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.07,75,,72.06,percent of total billed charges,75% of total billed charges for outpatient setting,84.06,70,,67.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,12.84,,12.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.07,80,,76.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,12.84,,12.34,percent of total billed charges,12.84% of total billed charges,15.42,12.84,,12.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78.06,65,,62.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.03,35,,33.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108.08,90,,86.46,percent of total billed charges,90% of total billed charges for outpatient setting,15.42,108.08,
10-0 PROLENE STC-6    1713G,6150030,CDM,272,RC,,,Outpatient,,,99.24,99.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.47,70,,55.58,percent of total billed charges,70% of total billed charges for outpatient setting,84.23,84.88,,67.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.62,50,,39.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.43,75,,59.54,percent of total billed charges,75% of total billed charges for outpatient setting,69.47,70,,55.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,12.84,,10.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.39,80,,63.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,12.84,,10.19,percent of total billed charges,12.84% of total billed charges,12.74,12.84,,10.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.51,65,,51.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.73,35,,27.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.32,90,,71.46,percent of total billed charges,90% of total billed charges for outpatient setting,12.74,89.32,
"11-DEOXYCORTISOL QUANTITATIVE, SERUM",200702,CDM,301,RC,82634,HCPCS,Outpatient,,,131.76,118.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.23,70,,73.78,percent of total billed charges,70% of total billed charges for outpatient setting,111.84,84.88,,89.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,98.82,75,,79.06,percent of total billed charges,75% of total billed charges for outpatient setting,92.23,70,,73.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.41,80,,84.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,42.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.52,100,,,Fee Schedule,100% of Custom Fee Schedule,118.58,90,,94.86,percent of total billed charges,90% of total billed charges for outpatient setting,29.28,118.58,
1-2 NERVE CONDUCTION STUDIES,6000602,CDM,740,RC,95907,HCPCS,Outpatient,,,98.03,98.03,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,83.21,84.88,,66.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.52,75,,58.82,percent of total billed charges,75% of total billed charges for outpatient setting,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.42,80,,62.74,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,88.23,90,,70.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,323,
13.5 TAPER POST   8135-0032,69161536,CDM,278,RC,,,Outpatient,,,3095.65,3095.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1857.39,60,,1485.91,percent of total billed charges,60% of total Billed charges for outpatient setting,2627.59,84.88,,2102.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,1547.83,50,,1238.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2321.74,75,,1857.39,percent of total billed charges,75% of total billed charges for outpatient setting,1547.83,50,,1238.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.48,12.84,,317.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2476.52,80,,1981.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.48,12.84,,317.98,percent of total billed charges,12.84% of total billed charges,397.48,12.84,,317.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3250.43,105,,2600.34,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1083.48,35,,866.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1857.39,60,,1485.91,percent of total billed charges,60% of total billed charges for outpatient setting,397.48,3250.43,
17 HYDROXYPROGESTERONE,220880,CDM,301,RC,83498,HCPCS,Outpatient,,,122.27,110.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.59,70,,68.47,percent of total billed charges,70% of total billed charges for outpatient setting,103.78,84.88,,83.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,91.7,75,,73.36,percent of total billed charges,75% of total billed charges for outpatient setting,85.59,70,,68.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.82,80,,78.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,39.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.53,100,,,Fee Schedule,100% of Custom Fee Schedule,110.04,90,,88.03,percent of total billed charges,90% of total billed charges for outpatient setting,27.17,110.04,
17 KETOSTEROIDS,202522,CDM,301,RC,83586,HCPCS,Outpatient,,,57.6,51.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,70,,32.26,percent of total billed charges,70% of total billed charges for outpatient setting,48.89,84.88,,39.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.2,75,,34.56,percent of total billed charges,75% of total billed charges for outpatient setting,40.32,70,,32.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.08,80,,36.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.28,100,,,Fee Schedule,100% of Custom Fee Schedule,51.84,90,,41.47,percent of total billed charges,90% of total billed charges for outpatient setting,12.8,51.84,
2 ETHIBOND V-37 GREEN / MX69G,69162907,CDM,272,RC,,,Outpatient,,,86.44,86.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.51,70,,48.41,percent of total billed charges,70% of total billed charges for outpatient setting,73.37,84.88,,58.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.22,50,,34.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.83,75,,51.86,percent of total billed charges,75% of total billed charges for outpatient setting,60.51,70,,48.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.1,12.84,,8.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.15,80,,55.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.1,12.84,,8.88,percent of total billed charges,12.84% of total billed charges,11.1,12.84,,8.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.19,65,,44.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,35,,24.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,77.8,90,,62.24,percent of total billed charges,90% of total billed charges for outpatient setting,11.1,77.8,
2 ETHILON   LR   460T,69160823,CDM,272,RC,,,Outpatient,,,20.88,20.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,70,,11.7,percent of total billed charges,70% of total billed charges for outpatient setting,17.72,84.88,,14.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.44,50,,8.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.66,75,,12.53,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,70,,11.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,12.84,,2.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,80,,13.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,2.68,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.57,65,,10.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,35,,5.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.79,90,,15.03,percent of total billed charges,90% of total billed charges for outpatient setting,2.68,18.79,
2 PDO QUILL DBL ARM / RX-1062Q,69169218,CDM,272,RC,,,Outpatient,,,99.42,99.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.59,70,,55.67,percent of total billed charges,70% of total billed charges for outpatient setting,84.39,84.88,,67.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.71,50,,39.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.57,75,,59.66,percent of total billed charges,75% of total billed charges for outpatient setting,69.59,70,,55.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,12.84,,10.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,80,,63.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,12.84,,10.22,percent of total billed charges,12.84% of total billed charges,12.77,12.84,,10.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.62,65,,51.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.8,35,,27.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.48,90,,71.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.77,89.48,
2 TICRON  HGS-21 / 88863113-81,6150325,CDM,272,RC,,,Outpatient,,,74.41,74.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.09,70,,41.67,percent of total billed charges,70% of total billed charges for outpatient setting,63.16,84.88,,50.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.21,50,,29.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.81,75,,44.65,percent of total billed charges,75% of total billed charges for outpatient setting,52.09,70,,41.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.55,12.84,,7.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.53,80,,47.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.55,12.84,,7.64,percent of total billed charges,12.84% of total billed charges,9.55,12.84,,7.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.37,65,,38.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,35,,20.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.97,90,,53.58,percent of total billed charges,90% of total billed charges for outpatient setting,9.55,66.97,
2 VICRYL TP-1 / J649G,69161547,CDM,272,RC,,,Outpatient,,,81.69,81.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.18,70,,45.74,percent of total billed charges,70% of total billed charges for outpatient setting,69.34,84.88,,55.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.85,50,,32.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.27,75,,49.02,percent of total billed charges,75% of total billed charges for outpatient setting,57.18,70,,45.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.49,12.84,,8.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.35,80,,52.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.49,12.84,,8.39,percent of total billed charges,12.84% of total billed charges,10.49,12.84,,8.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.1,65,,42.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.59,35,,22.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.52,90,,58.82,percent of total billed charges,90% of total billed charges for outpatient setting,10.49,73.52,
2.0MM ABRASION BURR / 275-641-000,6150566,CDM,270,RC,,,Outpatient,,,224.95,224.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.47,70,,125.98,percent of total billed charges,70% of total billed charges for outpatient setting,190.94,84.88,,152.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.48,50,,89.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.71,75,,134.97,percent of total billed charges,75% of total billed charges for outpatient setting,157.47,70,,125.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.88,12.84,,23.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.96,80,,143.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.88,12.84,,23.1,percent of total billed charges,12.84% of total billed charges,28.88,12.84,,23.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.22,65,,116.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.73,35,,62.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.46,90,,161.97,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,202.46,
2.0MM INFERIOR TURBINATE BLD / 1882040HR,69161596,CDM,272,RC,,,Outpatient,,,953.72,953.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.6,70,,534.08,percent of total billed charges,70% of total billed charges for outpatient setting,809.52,84.88,,647.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,476.86,50,,381.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.29,75,,572.23,percent of total billed charges,75% of total billed charges for outpatient setting,667.6,70,,534.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.46,12.84,,97.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.98,80,,610.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.46,12.84,,97.97,percent of total billed charges,12.84% of total billed charges,122.46,12.84,,97.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,619.92,65,,495.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.8,35,,267.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,858.35,90,,686.68,percent of total billed charges,90% of total billed charges for outpatient setting,122.46,858.35,
20 CC SYRINGE ONLY LUER LOCK,760320,CDM,270,RC,,,Outpatient,,,12.69,12.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,10.77,84.88,,8.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.35,50,,5.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.52,75,,7.62,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.15,80,,8.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.25,65,,6.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,35,,3.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.42,90,,9.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.63,11.42,
2-0 CHROMIC CT-1 / 811H,6150173,CDM,272,RC,,,Outpatient,,,26.47,26.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.53,70,,14.82,percent of total billed charges,70% of total billed charges for outpatient setting,22.47,84.88,,17.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.24,50,,10.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.85,75,,15.88,percent of total billed charges,75% of total billed charges for outpatient setting,18.53,70,,14.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,80,,16.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.21,65,,13.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.26,35,,7.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.82,90,,19.06,percent of total billed charges,90% of total billed charges for outpatient setting,3.4,23.82,
2-0 CHROMIC SH / G123H,6150351,CDM,272,RC,,,Outpatient,,,20.98,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.69,70,,11.75,percent of total billed charges,70% of total billed charges for outpatient setting,17.81,84.88,,14.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.49,50,,8.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.74,75,,12.59,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,70,,11.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,12.84,,2.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.78,80,,13.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,12.84,,2.15,percent of total billed charges,12.84% of total billed charges,2.69,12.84,,2.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.64,65,,10.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.34,35,,5.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.88,90,,15.1,percent of total billed charges,90% of total billed charges for outpatient setting,2.69,18.88,
2-0 ETHIBOND SH 30IN / MX833,69162235,CDM,272,RC,,,Outpatient,,,42.91,42.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,36.42,84.88,,29.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.46,50,,17.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.18,75,,25.74,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,80,,27.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.89,65,,22.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.02,35,,12.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.62,90,,30.9,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,38.62,
2-0 ETHILON FS / 664G,69160949,CDM,272,RC,,,Outpatient,,,10.8,10.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,9.17,84.88,,7.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.4,50,,4.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.1,75,,6.48,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,80,,6.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.02,65,,5.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,35,,3.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.72,90,,7.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.39,9.72,
2-0 ETHILON PSLX / 1697H,6150029,CDM,272,RC,,,Outpatient,,,22.59,22.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.3,50,,9.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.68,65,,11.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,35,,6.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,20.33,
2-0 GS-22 9IN 180 VLOC /VLOCL2145,69162233,CDM,272,RC,,,Outpatient,,,140.85,140.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.6,70,,78.88,percent of total billed charges,70% of total billed charges for outpatient setting,119.55,84.88,,95.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.43,50,,56.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.64,75,,84.51,percent of total billed charges,75% of total billed charges for outpatient setting,98.6,70,,78.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,12.84,,14.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.68,80,,90.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,12.84,,14.47,percent of total billed charges,12.84% of total billed charges,18.09,12.84,,14.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.55,65,,73.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.3,35,,39.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.77,90,,101.42,percent of total billed charges,90% of total billed charges for outpatient setting,18.09,126.77,
2-0 MONOCRYL CT-1 / Y945H,69161021,CDM,272,RC,,,Outpatient,,,14.46,14.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,12.27,84.88,,9.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.23,50,,5.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.85,75,,8.68,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,80,,9.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.4,65,,7.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,35,,4.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.01,90,,10.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.86,13.01,
2-0 MONOCRYL SH / Y417H,6152261,CDM,272,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
2-0 PDS CT-1 / Z259,69162743,CDM,272,RC,,,Outpatient,,,22.39,22.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,70,,12.54,percent of total billed charges,70% of total billed charges for outpatient setting,19,84.88,,15.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.2,50,,8.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.79,75,,13.43,percent of total billed charges,75% of total billed charges for outpatient setting,15.67,70,,12.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.87,12.84,,2.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.91,80,,14.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.87,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,2.87,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.55,65,,11.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,35,,6.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.15,90,,16.12,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,20.15,
2-0 PDS CT-2 / Z333H,69162614,CDM,272,RC,,,Outpatient,,,17.55,17.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,84.88,,11.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.78,50,,7.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.16,75,,10.53,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,80,,11.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.41,65,,9.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,35,,4.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.8,90,,12.64,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,15.8,
2-0 PLAIN CT-1 / 843H,6150182,CDM,272,RC,,,Outpatient,,,19.71,19.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,50,,7.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.81,65,,10.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,35,,5.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,2.53,17.74,
2-0 PLAIN FN2   N863H,6152564,CDM,272,RC,,,Outpatient,,,25.83,25.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,50,,10.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.79,65,,13.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,35,,7.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,3.32,23.25,
2-0 PROLENE CT-1 / 8423H,6150179,CDM,272,RC,,,Outpatient,,,17.91,17.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,15.2,84.88,,12.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,50,,7.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.43,75,,10.74,percent of total billed charges,75% of total billed charges for outpatient setting,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.33,80,,11.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.64,65,,9.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,35,,5.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.12,90,,12.9,percent of total billed charges,90% of total billed charges for outpatient setting,2.3,16.12,
2-0 PROLENE CT-2 / 8411H,6150178,CDM,272,RC,,,Outpatient,,,17.73,17.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,70,,9.93,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,84.88,,12.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.87,50,,7.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,75,,10.64,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,70,,9.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,80,,11.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.52,65,,9.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,35,,4.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.96,90,,12.77,percent of total billed charges,90% of total billed charges for outpatient setting,2.28,15.96,
2-0 PROLENE SH  DBL ARM / 8523H,6152047,CDM,272,RC,,,Outpatient,,,32.96,32.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,70,,18.46,percent of total billed charges,70% of total billed charges for outpatient setting,27.98,84.88,,22.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.48,50,,13.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.72,75,,19.78,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,70,,18.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,80,,21.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.42,65,,17.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.54,35,,9.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.66,90,,23.73,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,29.66,
2-0 SILK KS / 623H,69162137,CDM,272,RC,,,Outpatient,,,9.63,9.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,70,,5.39,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,84.88,,6.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.82,50,,3.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,75,,5.78,percent of total billed charges,75% of total billed charges for outpatient setting,6.74,70,,5.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,80,,6.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.26,65,,5.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,35,,2.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.67,90,,6.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,8.67,
2-0 SILK PSL / 486H,6150148,CDM,272,RC,,,Outpatient,,,24.48,24.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,20.78,84.88,,16.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.24,50,,9.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,75,,14.69,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,80,,15.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.91,65,,12.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,35,,6.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.03,90,,17.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.14,22.03,
2-0 SILK SH 30IN / K833H,6152335,CDM,272,RC,,,Outpatient,,,8.19,8.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,70,,4.58,percent of total billed charges,70% of total billed charges for outpatient setting,6.95,84.88,,5.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.1,50,,3.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.14,75,,4.91,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,70,,4.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.55,80,,5.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.32,65,,4.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.87,35,,2.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.37,90,,5.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.05,7.37,
2-0 SILK SH CR8 / C012D,6152587,CDM,272,RC,,,Outpatient,,,43.81,43.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,37.19,84.88,,29.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.91,50,,17.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.86,75,,26.29,percent of total billed charges,75% of total billed charges for outpatient setting,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.05,80,,28.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.48,65,,22.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.33,35,,12.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.43,90,,31.54,percent of total billed charges,90% of total billed charges for outpatient setting,5.63,39.43,
2-0 SILK SH CR8 30IN / C016D,6152250,CDM,272,RC,,,Outpatient,,,46.83,46.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.78,70,,26.22,percent of total billed charges,70% of total billed charges for outpatient setting,39.75,84.88,,31.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.42,50,,18.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.12,75,,28.1,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,70,,26.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.46,80,,29.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.44,65,,24.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.39,35,,13.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.15,90,,33.72,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,42.15,
2-0 SILK TIES 18IN / A185H,6150221,CDM,272,RC,,,Outpatient,,,10.3,10.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,70,,5.77,percent of total billed charges,70% of total billed charges for outpatient setting,8.74,84.88,,6.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.15,50,,4.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.73,75,,6.18,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,70,,5.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,80,,6.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.7,65,,5.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,35,,2.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.27,90,,7.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.32,9.27,
2-0 SILK TIES 30IN / A305H,6150226,CDM,272,RC,,,Outpatient,,,22.29,22.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,18.92,84.88,,15.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.15,50,,8.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.72,75,,13.38,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,12.84,,2.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,80,,14.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,12.84,,2.29,percent of total billed charges,12.84% of total billed charges,2.86,12.84,,2.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.49,65,,11.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,35,,6.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.06,90,,16.05,percent of total billed charges,90% of total billed charges for outpatient setting,2.86,20.06,
2-0 STRATAFIX CT-1 MONOCRYL / SXMP1B414,69169271,CDM,272,RC,,,Outpatient,,,139.8,139.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.86,70,,78.29,percent of total billed charges,70% of total billed charges for outpatient setting,118.66,84.88,,94.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.9,50,,55.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.85,75,,83.88,percent of total billed charges,75% of total billed charges for outpatient setting,97.86,70,,78.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,12.84,,14.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.84,80,,89.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,12.84,,14.36,percent of total billed charges,12.84% of total billed charges,17.95,12.84,,14.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.87,65,,72.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.93,35,,39.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.82,90,,100.66,percent of total billed charges,90% of total billed charges for outpatient setting,17.95,125.82,
2-0 STRATAFIX CT-2 MONO / SXMP1B417,69169867,CDM,272,RC,,,Outpatient,,,138.5,138.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.95,70,,77.56,percent of total billed charges,70% of total billed charges for outpatient setting,117.56,84.88,,94.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.25,50,,55.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.88,75,,83.1,percent of total billed charges,75% of total billed charges for outpatient setting,96.95,70,,77.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.78,12.84,,14.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.8,80,,88.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.78,12.84,,14.22,percent of total billed charges,12.84% of total billed charges,17.78,12.84,,14.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.03,65,,72.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,35,,38.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.65,90,,99.72,percent of total billed charges,90% of total billed charges for outpatient setting,17.78,124.65,
2-0 STRATAFIX FS DBL / SXPD2B419,69161539,CDM,272,RC,,,Outpatient,,,129.45,129.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.62,70,,72.5,percent of total billed charges,70% of total billed charges for outpatient setting,109.88,84.88,,87.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.73,50,,51.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.09,75,,77.67,percent of total billed charges,75% of total billed charges for outpatient setting,90.62,70,,72.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.62,12.84,,13.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.56,80,,82.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.62,12.84,,13.3,percent of total billed charges,12.84% of total billed charges,16.62,12.84,,13.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.14,65,,67.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.31,35,,36.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.51,90,,93.21,percent of total billed charges,90% of total billed charges for outpatient setting,16.62,116.51,
2-0 SURGILON V-20 / 888619510-51,69162668,CDM,272,RC,,,Outpatient,,,8.27,8.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,70,,4.63,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,84.88,,5.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.14,50,,3.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.2,75,,4.96,percent of total billed charges,75% of total billed charges for outpatient setting,5.79,70,,4.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,80,,5.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,65,,4.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.89,35,,2.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.44,90,,5.95,percent of total billed charges,90% of total billed charges for outpatient setting,1.06,7.44,
2-0 VICRYL CP-2 CR8 UNDYED / VCP762D,69161699,CDM,272,RC,,,Outpatient,,,88.35,88.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,70,,49.48,percent of total billed charges,70% of total billed charges for outpatient setting,74.99,84.88,,59.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.18,50,,35.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.26,75,,53.01,percent of total billed charges,75% of total billed charges for outpatient setting,61.85,70,,49.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,12.84,,9.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.68,80,,56.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,12.84,,9.07,percent of total billed charges,12.84% of total billed charges,11.34,12.84,,9.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.43,65,,45.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.92,35,,24.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.52,90,,63.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.34,79.52,
2-0 VICRYL CT-1 / VCP345H,6150285,CDM,272,RC,,,Outpatient,,,14.46,14.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,12.27,84.88,,9.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.23,50,,5.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.85,75,,8.68,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,80,,9.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.4,65,,7.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,35,,4.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.01,90,,10.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.86,13.01,
2-0 VICRYL CT-1 CR-8 / J739D,6150971,CDM,272,RC,,,Outpatient,,,61.11,61.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.78,70,,34.22,percent of total billed charges,70% of total billed charges for outpatient setting,51.87,84.88,,41.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.56,50,,24.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.83,75,,36.66,percent of total billed charges,75% of total billed charges for outpatient setting,42.78,70,,34.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.89,80,,39.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.72,65,,31.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,35,,17.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55,90,,44,percent of total billed charges,90% of total billed charges for outpatient setting,7.85,55,
2-0 VICRYL CT-1 CR8 UNDYED / VCP839D,6152754,CDM,272,RC,,,Outpatient,,,64.61,64.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.23,70,,36.18,percent of total billed charges,70% of total billed charges for outpatient setting,54.84,84.88,,43.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.31,50,,25.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.46,75,,38.77,percent of total billed charges,75% of total billed charges for outpatient setting,45.23,70,,36.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.69,80,,41.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42,65,,33.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.61,35,,18.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.15,90,,46.52,percent of total billed charges,90% of total billed charges for outpatient setting,8.3,58.15,
2-0 VICRYL CT-1 UNDYED / VCP259H,6152756,CDM,272,RC,,,Outpatient,,,12.47,12.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,10.58,84.88,,8.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.35,75,,7.48,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,35,,3.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.22,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.22,
2-0 VICRYL CT-2 / VCP333H,6150282,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
2-0 VICRYL CT-2 CR8 / VCP726D,69160858,CDM,272,RC,,,Outpatient,,,67.47,67.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.23,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.27,84.88,,45.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.74,50,,26.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.23,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,12.84,,6.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.98,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,12.84,,6.93,percent of total billed charges,12.84% of total billed charges,8.66,12.84,,6.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.86,65,,35.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,35,,18.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.72,90,,48.58,percent of total billed charges,90% of total billed charges for outpatient setting,8.66,60.72,
2-0 VICRYL CT-2 UNDYED / J269H,69169840,CDM,272,RC,,,Outpatient,,,11.79,11.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.25,70,,6.6,percent of total billed charges,70% of total billed charges for outpatient setting,10.01,84.88,,8.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.9,50,,4.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.84,75,,7.07,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,70,,6.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.43,80,,7.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.66,65,,6.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,35,,3.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.61,90,,8.49,percent of total billed charges,90% of total billed charges for outpatient setting,1.51,10.61,
2-0 VICRYL CT-3 / J328H,70000189,CDM,272,RC,,,Outpatient,,,14.21,14.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,84.88,,9.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.11,50,,5.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.66,75,,8.53,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,80,,9.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.24,65,,7.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,35,,3.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.79,90,,10.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.79,
2-0 VICRYL OS-6 UNDYED / VCP533H,6152561,CDM,272,RC,,,Outpatient,,,24.43,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,70,,13.68,percent of total billed charges,70% of total billed charges for outpatient setting,20.74,84.88,,16.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.22,50,,9.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,75,,14.66,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,70,,13.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.54,80,,15.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.88,65,,12.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,35,,6.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.99,90,,17.59,percent of total billed charges,90% of total billed charges for outpatient setting,3.14,21.99,
2-0 VICRYL SH / J317H,6150281,CDM,272,RC,,,Outpatient,,,11.62,11.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,9.86,84.88,,7.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.81,50,,4.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.72,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,80,,7.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.55,65,,6.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.46,90,,8.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.46,
2-0 VICRYL SH CR8 / J775D,6150301,CDM,272,RC,,,Outpatient,,,58.94,58.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.26,70,,33.01,percent of total billed charges,70% of total billed charges for outpatient setting,50.03,84.88,,40.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.47,50,,23.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.21,75,,35.37,percent of total billed charges,75% of total billed charges for outpatient setting,41.26,70,,33.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.57,12.84,,6.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.15,80,,37.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.57,12.84,,6.06,percent of total billed charges,12.84% of total billed charges,7.57,12.84,,6.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.31,65,,30.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.63,35,,16.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.05,90,,42.44,percent of total billed charges,90% of total billed charges for outpatient setting,7.57,53.05,
2-0 VICRYL SH UND 27IN / J417H,761070,CDM,272,RC,,,Outpatient,,,11.62,11.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,9.86,84.88,,7.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.81,50,,4.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.72,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,70,,6.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,80,,7.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.55,65,,6.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.46,90,,8.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.46,
2-0 VICRYL TIE(REEL) J286G,6152135,CDM,272,RC,,,Outpatient,,,21.91,21.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,70,,12.27,percent of total billed charges,70% of total billed charges for outpatient setting,18.6,84.88,,14.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.96,50,,8.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.43,75,,13.14,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,70,,12.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,12.84,,2.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.53,80,,14.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,12.84,,2.25,percent of total billed charges,12.84% of total billed charges,2.81,12.84,,2.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.24,65,,11.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.67,35,,6.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.72,90,,15.78,percent of total billed charges,90% of total billed charges for outpatient setting,2.81,19.72,
2-0 VICRYL UR-6 / J602H,6150293,CDM,272,RC,,,Outpatient,,,13.86,13.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,70,,7.76,percent of total billed charges,70% of total billed charges for outpatient setting,11.76,84.88,,9.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.93,50,,5.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.4,75,,8.32,percent of total billed charges,75% of total billed charges for outpatient setting,9.7,70,,7.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.09,80,,8.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.01,65,,7.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,35,,3.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.47,90,,9.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.78,12.47,
2-0 VICRYL X-1 UNDYED / J459H,6150286,CDM,272,RC,,,Outpatient,,,19.18,19.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,70,,10.74,percent of total billed charges,70% of total billed charges for outpatient setting,16.28,84.88,,13.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.59,50,,7.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.39,75,,11.51,percent of total billed charges,75% of total billed charges for outpatient setting,13.43,70,,10.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,12.84,,1.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,80,,12.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,12.84,,1.97,percent of total billed charges,12.84% of total billed charges,2.46,12.84,,1.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.47,65,,9.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.71,35,,5.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.26,90,,13.81,percent of total billed charges,90% of total billed charges for outpatient setting,2.46,17.26,
3-0 CHROMIC FS-2 / 636H,760875,CDM,272,RC,,,Outpatient,,,56.18,56.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,70,,31.46,percent of total billed charges,70% of total billed charges for outpatient setting,47.69,84.88,,38.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.09,50,,22.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.14,75,,33.71,percent of total billed charges,75% of total billed charges for outpatient setting,39.33,70,,31.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,80,,35.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.52,65,,29.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.66,35,,15.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.56,90,,40.45,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,50.56,
3-0 CHROMIC RB-1  U204H,6150272,CDM,272,RC,,,Outpatient,,,26.03,26.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,70,,14.58,percent of total billed charges,70% of total billed charges for outpatient setting,22.09,84.88,,17.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.02,50,,10.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.52,75,,15.62,percent of total billed charges,75% of total billed charges for outpatient setting,18.22,70,,14.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,12.84,,2.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.82,80,,16.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,12.84,,2.67,percent of total billed charges,12.84% of total billed charges,3.34,12.84,,2.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.92,65,,13.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,35,,7.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.43,90,,18.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.34,23.43,
3-0 CHROMIC SH / G122H,6150990,CDM,272,RC,,,Outpatient,,,20.25,20.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,70,,11.34,percent of total billed charges,70% of total billed charges for outpatient setting,17.19,84.88,,13.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.13,50,,8.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.19,75,,12.15,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,70,,11.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.2,80,,12.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,2.6,12.84,,2.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.16,65,,10.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,35,,5.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.23,90,,14.58,percent of total billed charges,90% of total billed charges for outpatient setting,2.6,18.23,
3-0 ETHIBOND SH / X832H,69169678,CDM,272,RC,,,Outpatient,,,14.84,14.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.39,70,,8.31,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,84.88,,10.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.42,50,,5.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.13,75,,8.9,percent of total billed charges,75% of total billed charges for outpatient setting,10.39,70,,8.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,80,,9.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.65,65,,7.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,35,,4.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.36,90,,10.69,percent of total billed charges,90% of total billed charges for outpatient setting,1.91,13.36,
3-0 ETHILON PS-1 / 1663H,6150021,CDM,272,RC,,,Outpatient,,,24.75,24.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,70,,13.86,percent of total billed charges,70% of total billed charges for outpatient setting,21.01,84.88,,16.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.38,50,,9.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.56,75,,14.85,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,70,,13.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,80,,15.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.09,65,,12.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,35,,6.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.28,90,,17.82,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,22.28,
3-0 ETHILON PS-2 / 1669H,6150025,CDM,272,RC,,,Outpatient,,,23.63,23.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.54,70,,13.23,percent of total billed charges,70% of total billed charges for outpatient setting,20.06,84.88,,16.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.82,50,,9.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.72,75,,14.18,percent of total billed charges,75% of total billed charges for outpatient setting,16.54,70,,13.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,80,,15.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.36,65,,12.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.27,35,,6.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.27,90,,17.02,percent of total billed charges,90% of total billed charges for outpatient setting,3.03,21.27,
3-0 ETHILON PSL / 1691H,6150028,CDM,272,RC,,,Outpatient,,,22.86,22.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16,70,,12.8,percent of total billed charges,70% of total billed charges for outpatient setting,19.4,84.88,,15.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.43,50,,9.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.15,75,,13.72,percent of total billed charges,75% of total billed charges for outpatient setting,16,70,,12.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.29,80,,14.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.86,65,,11.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,35,,6.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.57,90,,16.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.94,20.57,
3-0 ETHILON PSLX / 1683H,69169768,CDM,272,RC,,,Outpatient,,,22.41,22.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.69,70,,12.55,percent of total billed charges,70% of total billed charges for outpatient setting,19.02,84.88,,15.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.21,50,,8.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.81,75,,13.45,percent of total billed charges,75% of total billed charges for outpatient setting,15.69,70,,12.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.93,80,,14.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.57,65,,11.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,35,,6.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.17,90,,16.14,percent of total billed charges,90% of total billed charges for outpatient setting,2.88,20.17,
3-0 MONOCRYL CT-1 / Y944H,69162634,CDM,272,RC,,,Outpatient,,,19.17,19.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,70,,10.74,percent of total billed charges,70% of total billed charges for outpatient setting,16.27,84.88,,13.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.59,50,,7.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.38,75,,11.5,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,70,,10.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,12.84,,1.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,80,,12.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,12.84,,1.97,percent of total billed charges,12.84% of total billed charges,2.46,12.84,,1.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.46,65,,9.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.71,35,,5.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.25,90,,13.8,percent of total billed charges,90% of total billed charges for outpatient setting,2.46,17.25,
3-0 MONOCRYL PS-1 / Y936H,69162269,CDM,272,RC,,,Outpatient,,,33.04,33.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.13,70,,18.5,percent of total billed charges,70% of total billed charges for outpatient setting,28.04,84.88,,22.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.52,50,,13.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.78,75,,19.82,percent of total billed charges,75% of total billed charges for outpatient setting,23.13,70,,18.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.43,80,,21.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.48,65,,17.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,35,,9.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.74,90,,23.79,percent of total billed charges,90% of total billed charges for outpatient setting,4.24,29.74,
3-0 MONOCRYL PS-2 / MCP497GA,6150490,CDM,272,RC,,,Outpatient,,,34.78,34.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.35,70,,19.48,percent of total billed charges,70% of total billed charges for outpatient setting,29.52,84.88,,23.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.39,50,,13.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.09,75,,20.87,percent of total billed charges,75% of total billed charges for outpatient setting,24.35,70,,19.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,12.84,,3.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,80,,22.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,12.84,,3.58,percent of total billed charges,12.84% of total billed charges,4.47,12.84,,3.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.61,65,,18.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.17,35,,9.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.3,90,,25.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.47,31.3,
3-0 MONOCRYL SH / Y416H,761220,CDM,272,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
3-0 PDS SH / Z316H,69161394,CDM,272,RC,,,Outpatient,,,16.83,16.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.78,70,,9.42,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,84.88,,11.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.42,50,,6.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.62,75,,10.1,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,70,,9.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,12.84,,1.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,80,,10.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,12.84,,1.73,percent of total billed charges,12.84% of total billed charges,2.16,12.84,,1.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.94,65,,8.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.89,35,,4.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.15,90,,12.12,percent of total billed charges,90% of total billed charges for outpatient setting,2.16,15.15,
3-0 PLAIN CT-1 / 842H,6150181,CDM,272,RC,,,Outpatient,,,24.49,24.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,20.79,84.88,,16.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.25,50,,9.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.37,75,,14.7,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,80,,15.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.92,65,,12.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,35,,6.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.04,90,,17.63,percent of total billed charges,90% of total billed charges for outpatient setting,3.14,22.04,
3-0 PLAIN PS-2 / 1630H,6150018,CDM,272,RC,,,Outpatient,,,44.11,44.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.88,70,,24.7,percent of total billed charges,70% of total billed charges for outpatient setting,37.44,84.88,,29.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.06,50,,17.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.08,75,,26.46,percent of total billed charges,75% of total billed charges for outpatient setting,30.88,70,,24.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,12.84,,4.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.29,80,,28.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,12.84,,4.53,percent of total billed charges,12.84% of total billed charges,5.66,12.84,,4.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.67,65,,22.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.44,35,,12.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.7,90,,31.76,percent of total billed charges,90% of total billed charges for outpatient setting,5.66,39.7,
3-0 PLAIN SH / G322H,6150352,CDM,272,RC,,,Outpatient,,,21.26,21.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,84.88,,14.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.63,50,,8.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.95,75,,12.76,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,12.84,,2.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.01,80,,13.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.73,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.82,65,,11.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,35,,5.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.13,90,,15.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.73,19.13,
3-0 PLAIN TIES 54IN / L102G,6150477,CDM,272,RC,,,Outpatient,,,26.65,26.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.66,70,,14.93,percent of total billed charges,70% of total billed charges for outpatient setting,22.62,84.88,,18.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.33,50,,10.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.99,75,,15.99,percent of total billed charges,75% of total billed charges for outpatient setting,18.66,70,,14.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.42,12.84,,2.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.32,80,,17.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.42,12.84,,2.74,percent of total billed charges,12.84% of total billed charges,3.42,12.84,,2.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.32,65,,13.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.33,35,,7.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.99,90,,19.19,percent of total billed charges,90% of total billed charges for outpatient setting,3.42,23.99,
3-0 PROLENE BB DBL / 8862H,69162163,CDM,272,RC,,,Outpatient,,,39.84,39.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,70,,22.31,percent of total billed charges,70% of total billed charges for outpatient setting,33.82,84.88,,27.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.92,50,,15.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.88,75,,23.9,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,70,,22.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,80,,25.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.9,65,,20.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,35,,11.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.86,90,,28.69,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,35.86,
3-0 PROLENE FSL / 8675H,760975,CDM,272,RC,,,Outpatient,,,21.8,21.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.26,70,,12.21,percent of total billed charges,70% of total billed charges for outpatient setting,18.5,84.88,,14.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.9,50,,8.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.35,75,,13.08,percent of total billed charges,75% of total billed charges for outpatient setting,15.26,70,,12.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.8,12.84,,2.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,80,,13.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.8,12.84,,2.24,percent of total billed charges,12.84% of total billed charges,2.8,12.84,,2.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.17,65,,11.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,35,,6.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.62,90,,15.7,percent of total billed charges,90% of total billed charges for outpatient setting,2.8,19.62,
3-0 PROLENE PS-2 / 8687H,6150192,CDM,272,RC,,,Outpatient,,,28.72,28.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,70,,16.08,percent of total billed charges,70% of total billed charges for outpatient setting,24.38,84.88,,19.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.36,50,,11.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.54,75,,17.23,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,70,,16.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.69,12.84,,2.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.98,80,,18.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.69,12.84,,2.95,percent of total billed charges,12.84% of total billed charges,3.69,12.84,,2.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.67,65,,14.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.05,35,,8.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.85,90,,20.68,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,25.85,
3-0 PROLENE SH / 8832H,6152565,CDM,272,RC,,,Outpatient,,,19.8,19.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,16.81,84.88,,13.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.9,50,,7.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,75,,11.88,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,80,,12.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.87,65,,10.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.93,35,,5.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.82,90,,14.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,17.82,
3-0 PROLENE SH DBL ARM / 8522H,69169839,CDM,272,RC,,,Outpatient,,,33.12,33.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,70,,18.54,percent of total billed charges,70% of total billed charges for outpatient setting,28.11,84.88,,22.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.56,50,,13.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.84,75,,19.87,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,70,,18.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,12.84,,3.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,80,,21.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,12.84,,3.4,percent of total billed charges,12.84% of total billed charges,4.25,12.84,,3.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.53,65,,17.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,35,,9.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.81,90,,23.85,percent of total billed charges,90% of total billed charges for outpatient setting,4.25,29.81,
3-0 SILK PS-1 / 1684G,6152086,CDM,272,RC,,,Outpatient,,,23.81,23.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,84.88,,16.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.91,50,,9.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.86,75,,14.29,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.05,80,,15.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.48,65,,12.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,35,,6.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.43,90,,17.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.06,21.43,
3-0 SILK RB-1 / C053D,6150361,CDM,272,RC,,,Outpatient,,,73.58,73.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.51,70,,41.21,percent of total billed charges,70% of total billed charges for outpatient setting,62.45,84.88,,49.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.79,50,,29.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.19,75,,44.15,percent of total billed charges,75% of total billed charges for outpatient setting,51.51,70,,41.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,12.84,,7.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.86,80,,47.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,12.84,,7.56,percent of total billed charges,12.84% of total billed charges,9.45,12.84,,7.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.83,65,,38.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.75,35,,20.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.22,90,,52.98,percent of total billed charges,90% of total billed charges for outpatient setting,9.45,66.22,
3-0 SILK SH 30IN / K832H,69160149,CDM,272,RC,,,Outpatient,,,8.6,8.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,84.88,,5.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.3,50,,3.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.45,75,,5.16,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,80,,5.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.59,65,,4.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,35,,2.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.74,90,,6.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.74,
3-0 SILK SH CR8 / C013D,6152125,CDM,272,RC,,,Outpatient,,,43.51,43.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,70,,24.37,percent of total billed charges,70% of total billed charges for outpatient setting,36.93,84.88,,29.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.76,50,,17.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.63,75,,26.1,percent of total billed charges,75% of total billed charges for outpatient setting,30.46,70,,24.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.81,80,,27.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.28,65,,22.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,35,,12.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.16,90,,31.33,percent of total billed charges,90% of total billed charges for outpatient setting,5.59,39.16,
3-0 SILK SH CR8 30IN / C017D,6152251,CDM,272,RC,,,Outpatient,,,64.2,64.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,70,,35.95,percent of total billed charges,70% of total billed charges for outpatient setting,54.49,84.88,,43.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.1,50,,25.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,75,,38.52,percent of total billed charges,75% of total billed charges for outpatient setting,44.94,70,,35.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,12.84,,6.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,80,,41.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,12.84,,6.59,percent of total billed charges,12.84% of total billed charges,8.24,12.84,,6.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.73,65,,33.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,35,,17.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.78,90,,46.22,percent of total billed charges,90% of total billed charges for outpatient setting,8.24,57.78,
3-0 SILK SH-1 / M3T,70000296,CDM,272,RC,,,Outpatient,,,52.85,52.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,44.86,84.88,,35.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.43,50,,21.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,75,,31.71,percent of total billed charges,75% of total billed charges for outpatient setting,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.28,80,,33.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.35,65,,27.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,35,,14.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.57,90,,38.06,percent of total billed charges,90% of total billed charges for outpatient setting,6.79,47.57,
3-0 SILK TIES 18IN / A184H,6150219,CDM,272,RC,,,Outpatient,,,10.8,10.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,9.17,84.88,,7.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.4,50,,4.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.1,75,,6.48,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,80,,6.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.02,65,,5.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,35,,3.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.72,90,,7.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.39,9.72,
3-0 SILK TIES 30IN / A304H,6150225,CDM,272,RC,,,Outpatient,,,23.27,23.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.29,70,,13.03,percent of total billed charges,70% of total billed charges for outpatient setting,19.75,84.88,,15.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.64,50,,9.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.45,75,,13.96,percent of total billed charges,75% of total billed charges for outpatient setting,16.29,70,,13.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,80,,14.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.13,65,,12.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.14,35,,6.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.94,90,,16.75,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,20.94,
3-0 STRATAFIX PS-2 MONOCRYL / SXMP1B107,747650,CDM,272,RC,,,Outpatient,,,165.95,165.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.17,70,,92.94,percent of total billed charges,70% of total billed charges for outpatient setting,140.86,84.88,,112.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.98,50,,66.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.46,75,,99.57,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,70,,92.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,12.84,,17.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.76,80,,106.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,12.84,,17.05,percent of total billed charges,12.84% of total billed charges,21.31,12.84,,17.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,107.87,65,,86.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.08,35,,46.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,149.36,90,,119.49,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,149.36,
3-0 SUPRAMID EXTRA II / HEA-30-20,69169644,CDM,272,RC,,,Outpatient,,,132.24,132.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.57,70,,74.06,percent of total billed charges,70% of total billed charges for outpatient setting,112.25,84.88,,89.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.12,50,,52.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.18,75,,79.34,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,70,,74.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,12.84,,13.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.79,80,,84.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,12.84,,13.58,percent of total billed charges,12.84% of total billed charges,16.98,12.84,,13.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.96,65,,68.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.28,35,,37.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,119.02,90,,95.22,percent of total billed charges,90% of total billed charges for outpatient setting,16.98,119.02,
3-0 VICRYL  SH-1  CR 8  / J772D,69160530,CDM,272,RC,,,Outpatient,,,71.93,71.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.35,70,,40.28,percent of total billed charges,70% of total billed charges for outpatient setting,61.05,84.88,,48.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.97,50,,28.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.95,75,,43.16,percent of total billed charges,75% of total billed charges for outpatient setting,50.35,70,,40.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.24,12.84,,7.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.54,80,,46.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.24,12.84,,7.39,percent of total billed charges,12.84% of total billed charges,9.24,12.84,,7.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.75,65,,37.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.18,35,,20.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.74,90,,51.79,percent of total billed charges,90% of total billed charges for outpatient setting,9.24,64.74,
3-0 VICRYL CP-2 CR8 UNDYED / VCP761D,69161698,CDM,272,RC,,,Outpatient,,,85.05,85.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.54,70,,47.63,percent of total billed charges,70% of total billed charges for outpatient setting,72.19,84.88,,57.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.53,50,,34.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.79,75,,51.03,percent of total billed charges,75% of total billed charges for outpatient setting,59.54,70,,47.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.92,12.84,,8.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.04,80,,54.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.92,12.84,,8.74,percent of total billed charges,12.84% of total billed charges,10.92,12.84,,8.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.28,65,,44.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,35,,23.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.55,90,,61.24,percent of total billed charges,90% of total billed charges for outpatient setting,10.92,76.55,
3-0 VICRYL KS  DYED/ J523H,69162584,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
3-0 VICRYL KS UNDYED / J663H,69169868,CDM,272,RC,,,Outpatient,,,14.31,14.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,70,,8.02,percent of total billed charges,70% of total billed charges for outpatient setting,12.15,84.88,,9.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.16,50,,5.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.73,75,,8.58,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,70,,8.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.84,12.84,,1.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,80,,9.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.84,12.84,,1.47,percent of total billed charges,12.84% of total billed charges,1.84,12.84,,1.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.3,65,,7.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.01,35,,4.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.88,90,,10.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.84,12.88,
3-0 VICRYL PS-1 UND J936H,6150302,CDM,272,RC,,,Outpatient,,,38.12,38.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.68,70,,21.34,percent of total billed charges,70% of total billed charges for outpatient setting,32.36,84.88,,25.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.06,50,,15.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.59,75,,22.87,percent of total billed charges,75% of total billed charges for outpatient setting,26.68,70,,21.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.89,12.84,,3.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.5,80,,24.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.89,12.84,,3.91,percent of total billed charges,12.84% of total billed charges,4.89,12.84,,3.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.78,65,,19.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,35,,10.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.31,90,,27.45,percent of total billed charges,90% of total billed charges for outpatient setting,4.89,34.31,
3-0 VICRYL PS-2 UND / VCP497H,761090,CDM,272,RC,,,Outpatient,,,31.58,31.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.11,70,,17.69,percent of total billed charges,70% of total billed charges for outpatient setting,26.81,84.88,,21.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.79,50,,12.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.69,75,,18.95,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,70,,17.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.26,80,,20.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.53,65,,16.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.05,35,,8.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.42,90,,22.74,percent of total billed charges,90% of total billed charges for outpatient setting,4.05,28.42,
3-0 VICRYL RB-1 UNDYED / J215H,69162669,CDM,272,RC,,,Outpatient,,,12.42,12.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,70,,6.95,percent of total billed charges,70% of total billed charges for outpatient setting,10.54,84.88,,8.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.21,50,,4.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.32,75,,7.46,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,70,,6.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,80,,7.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.07,65,,6.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,35,,3.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.18,90,,8.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,11.18,
3-0 VICRYL SH CR8 / VCP774D,6152241,CDM,272,RC,,,Outpatient,,,65.1,65.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.57,70,,36.46,percent of total billed charges,70% of total billed charges for outpatient setting,55.26,84.88,,44.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.55,50,,26.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.83,75,,39.06,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,70,,36.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,12.84,,6.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,80,,41.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,12.84,,6.69,percent of total billed charges,12.84% of total billed charges,8.36,12.84,,6.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.32,65,,33.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.79,35,,18.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.59,90,,46.87,percent of total billed charges,90% of total billed charges for outpatient setting,8.36,58.59,
3-0 VICRYL SH CR8 UNDYED / VCP864D,69160298,CDM,272,RC,,,Outpatient,,,69.83,69.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.88,70,,39.1,percent of total billed charges,70% of total billed charges for outpatient setting,59.27,84.88,,47.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.92,50,,27.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.37,75,,41.9,percent of total billed charges,75% of total billed charges for outpatient setting,48.88,70,,39.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,12.84,,7.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.86,80,,44.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,12.84,,7.18,percent of total billed charges,12.84% of total billed charges,8.97,12.84,,7.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.39,65,,36.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,35,,19.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.85,90,,50.28,percent of total billed charges,90% of total billed charges for outpatient setting,8.97,62.85,
3-0 VICRYL SH DYED / VCP316H,6150280,CDM,272,RC,,,Outpatient,,,11.97,11.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,10.16,84.88,,8.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.99,50,,4.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.98,75,,7.18,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,80,,7.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.78,65,,6.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.19,35,,3.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.77,90,,8.62,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.77,
3-0 VICRYL SH UND / VCP416H,761065,CDM,272,RC,,,Outpatient,,,12.57,12.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,70,,7.04,percent of total billed charges,70% of total billed charges for outpatient setting,10.67,84.88,,8.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.29,50,,5.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.43,75,,7.54,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,70,,7.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.06,80,,8.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.17,65,,6.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,35,,3.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.31,90,,9.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.61,11.31,
3-0 VICRYL TIES 18  J110T,6150357,CDM,272,RC,,,Outpatient,,,66.24,66.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,56.22,84.88,,44.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.12,50,,26.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.68,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,80,,42.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.06,65,,34.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,35,,18.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.62,90,,47.7,percent of total billed charges,90% of total billed charges for outpatient setting,8.51,59.62,
3-4 NERVE CONDUCTION STUDIES,6000654,CDM,920,RC,95908,HCPCS,Outpatient,,,98.03,98.03,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,83.21,84.88,,66.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.52,75,,58.82,percent of total billed charges,75% of total billed charges for outpatient setting,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.42,80,,62.74,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,88.23,90,,70.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,509.88,
3D  MAMMO NEEDLE LOCALIZATION,2710065,CDM,320,RC,19281,HCPCS,Outpatient,,,917.7,688.28,,892.21,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,642.39,70,,513.91,percent of total billed charges,70% of total billed charges for outpatient setting,778.94,84.88,,623.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,796.72,50,,637.38,percent of total billed charges,50% of total Billed charges for outpatient setting,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,688.28,75,,550.62,percent of total billed charges,75% of total billed charges for outpatient setting,642.39,70,,513.91,percent of total billed charges,70% of total billed charges for outpatient setting,947.98,170,,,Fee Schedule,170% of Medicare OPPS rate,1198.91,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,117.83,12.84,,94.264,percent of total billed charges,12.84% of total billed charges,975.86,175,,,Fee Schedule,175% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,734.16,80,,587.33,percent of total billed charges,80% of total billed charges for outpatient setting,780.68,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,697.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,117.83,12.84,,94.26,percent of total billed charges,12.84% of total billed charges,117.83,12.84,,94.26,percent of total billed charges,12.84% of total billed charges,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,825.93,90,,660.74,percent of total billed charges,90% of total billed charges for outpatient setting,116.88,1198.91,
3D MAMMO DIAGNOSTIC BIL W/CAD PP,2710052,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
3D MAMMO DIAGNOSTIC BILATERAL,2710056,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
3D MAMMO DIAGNOSTIC w/ CAD BIL,2710050,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
3D MAMMO DIAGNOSTIC w/ CAD BIL,2710055,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
3D MAMMO SCREENING BIL IMPLANTS CAD,2710054,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
3D MAMMO SCREENING UNI W/ CAD,2710061,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
3D MAMMO SCREENING w/ CAD BIL,2710051,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
3D MAMMO SCREENING w/ CAD BIL PP,2710053,CDM,403,RC,77067,HCPCS,Outpatient,,,309.75,309.75,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,216.83,70,,173.46,percent of total billed charges,70% of total billed charges for outpatient setting,262.92,84.88,,210.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,232.31,75,,185.85,percent of total billed charges,75% of total billed charges for outpatient setting,216.83,70,,173.46,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,39.77,12.84,,31.816,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,247.8,80,,198.24,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,39.77,12.84,,31.82,percent of total billed charges,12.84% of total billed charges,39.77,12.84,,31.82,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,278.78,90,,223.02,percent of total billed charges,90% of total billed charges for outpatient setting,39.77,281.76,
3D MAMMO SPOT COMPRESSION,2710057,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
3D MAMMOGRAPHY AXILLARY,2710058,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
3D MAMMOGRAPHY DIAG UNI,2710060,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
3D MAMMOGRAPHY DIAG UNI w CAD,2710059,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
3D MAMMOGRAPHY IMPLANTS,2710062,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
3D MAMMOGRAPHY UNILATERAL DIAG,2710063,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
3D MAMMOGRAPHY UNILATERAL DX - LTD,2710064,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
4.0 WASHER 14461I,69161866,CDM,278,RC,,,Outpatient,,,227.24,227.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.34,60,,109.07,percent of total billed charges,60% of total Billed charges for outpatient setting,192.88,84.88,,154.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.62,50,,90.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,75,,136.34,percent of total billed charges,75% of total billed charges for outpatient setting,113.62,50,,90.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,12.84,,23.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.79,80,,145.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,227.24,65,,181.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.53,35,,63.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.34,60,,109.07,percent of total billed charges,60% of total billed charges for outpatient setting,29.18,227.24,
4-0 CHROMIC P-3 / 1654G,6150020,CDM,272,RC,,,Outpatient,,,37.55,37.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,70,,21.03,percent of total billed charges,70% of total billed charges for outpatient setting,31.87,84.88,,25.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.78,50,,15.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.16,75,,22.53,percent of total billed charges,75% of total billed charges for outpatient setting,26.29,70,,21.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,80,,24.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.41,65,,19.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.14,35,,10.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.8,90,,27.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.82,33.8,
4-0 CHROMIC RB-1 / U203H,6152659,CDM,272,RC,,,Outpatient,,,21.24,21.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.87,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,18.03,84.88,,14.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.62,50,,8.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.93,75,,12.74,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,12.84,,2.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.99,80,,13.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.73,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.81,65,,11.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,35,,5.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.12,90,,15.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.73,19.12,
4-0 CHROMIC SH / G121H,6150349,CDM,272,RC,,,Outpatient,,,20.97,20.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.68,70,,11.74,percent of total billed charges,70% of total billed charges for outpatient setting,17.8,84.88,,14.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.49,50,,8.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.73,75,,12.58,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,70,,11.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,12.84,,2.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.78,80,,13.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,12.84,,2.15,percent of total billed charges,12.84% of total billed charges,2.69,12.84,,2.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.63,65,,10.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.34,35,,5.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.87,90,,15.1,percent of total billed charges,90% of total billed charges for outpatient setting,2.69,18.87,
4-0 ETHILON  PC-5 1894G,6150038,CDM,272,RC,,,Outpatient,,,41.25,41.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.88,70,,23.1,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,84.88,,28.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.63,50,,16.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.94,75,,24.75,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,70,,23.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,12.84,,4.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,80,,26.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,12.84,,4.24,percent of total billed charges,12.84% of total billed charges,5.3,12.84,,4.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.81,65,,21.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.44,35,,11.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.13,90,,29.7,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,37.13,
4-0 ETHILON PS-2 / 1667H,6150024,CDM,272,RC,,,Outpatient,,,23.81,23.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,84.88,,16.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.91,50,,9.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.86,75,,14.29,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.05,80,,15.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.48,65,,12.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,35,,6.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.43,90,,17.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.06,21.43,
4-0 MERSILENE S-2 / 1779G,69169848,CDM,272,RC,,,Outpatient,,,26.16,26.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,84.88,,17.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.08,50,,10.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.62,75,,15.7,percent of total billed charges,75% of total billed charges for outpatient setting,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,80,,16.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17,65,,13.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.16,35,,7.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.54,90,,18.83,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,23.54,
4-0 MONOCRYL P-3 / MCP494G,6150279,CDM,272,RC,,,Outpatient,,,35.68,35.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,70,,19.98,percent of total billed charges,70% of total billed charges for outpatient setting,30.29,84.88,,24.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.84,50,,14.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.76,75,,21.41,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,70,,19.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.54,80,,22.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.19,65,,18.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.49,35,,9.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.11,90,,25.69,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,32.11,
4-0 MONOCRYL PS-2 / MCP426H,6150489,CDM,272,RC,,,Outpatient,,,35.7,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,84.88,,24.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.85,50,,14.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,75,,21.42,percent of total billed charges,75% of total billed charges for outpatient setting,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,80,,22.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.21,65,,18.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,35,,10,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.13,90,,25.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,32.13,
4-0 MONOCRYL RB-1 / Y214H,69169464,CDM,272,RC,,,Outpatient,,,13.41,13.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,70,,7.51,percent of total billed charges,70% of total billed charges for outpatient setting,11.38,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.71,50,,5.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.06,75,,8.05,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,70,,7.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,80,,8.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.72,65,,6.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.07,90,,9.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.07,
4-0 NURLON TF  CR8 / C584D,69161700,CDM,272,RC,,,Outpatient,,,81.92,81.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.34,70,,45.87,percent of total billed charges,70% of total billed charges for outpatient setting,69.53,84.88,,55.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.96,50,,32.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.44,75,,49.15,percent of total billed charges,75% of total billed charges for outpatient setting,57.34,70,,45.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,12.84,,8.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,80,,52.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,12.84,,8.42,percent of total billed charges,12.84% of total billed charges,10.52,12.84,,8.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.25,65,,42.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.67,35,,22.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.73,90,,58.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.52,73.73,
4-0 NUROLON FS  CR8 / C570D,69161723,CDM,272,RC,,,Outpatient,,,92.97,92.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.08,70,,52.06,percent of total billed charges,70% of total billed charges for outpatient setting,78.91,84.88,,63.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.49,50,,37.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.73,75,,55.78,percent of total billed charges,75% of total billed charges for outpatient setting,65.08,70,,52.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.38,80,,59.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.43,65,,48.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.54,35,,26.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.67,90,,66.94,percent of total billed charges,90% of total billed charges for outpatient setting,11.94,83.67,
4-0 PLAIN PS-2 / 1627H,6150017,CDM,272,RC,,,Outpatient,,,43.23,43.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.26,70,,24.21,percent of total billed charges,70% of total billed charges for outpatient setting,36.69,84.88,,29.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.62,50,,17.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.42,75,,25.94,percent of total billed charges,75% of total billed charges for outpatient setting,30.26,70,,24.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.58,80,,27.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.1,65,,22.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.13,35,,12.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.91,90,,31.13,percent of total billed charges,90% of total billed charges for outpatient setting,5.55,38.91,
4-0 PLAIN SC-1 / 1824H,6150036,CDM,272,RC,,,Outpatient,,,20.7,20.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,17.57,84.88,,14.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.35,50,,8.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,75,,12.42,percent of total billed charges,75% of total billed charges for outpatient setting,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,12.84,,2.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.56,80,,13.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,12.84,,2.13,percent of total billed charges,12.84% of total billed charges,2.66,12.84,,2.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.46,65,,10.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,35,,5.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.63,90,,14.9,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,18.63,
4-0 PROLENE BB 36 IN DBL / 8581H,69161735,CDM,272,RC,,,Outpatient,,,38.48,38.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,70,,21.55,percent of total billed charges,70% of total billed charges for outpatient setting,32.66,84.88,,26.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.24,50,,15.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.86,75,,23.09,percent of total billed charges,75% of total billed charges for outpatient setting,26.94,70,,21.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.78,80,,24.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.01,65,,20.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.47,35,,10.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.63,90,,27.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.63,
4-0 PROLENE PS-2 / 8682H,6150190,CDM,272,RC,,,Outpatient,,,30.47,30.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.33,70,,17.06,percent of total billed charges,70% of total billed charges for outpatient setting,25.86,84.88,,20.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.24,50,,12.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.85,75,,18.28,percent of total billed charges,75% of total billed charges for outpatient setting,21.33,70,,17.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.38,80,,19.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.81,65,,15.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,35,,8.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.42,90,,21.94,percent of total billed charges,90% of total billed charges for outpatient setting,3.91,27.42,
4-0 SILK TIES 18IN / A183H,6150218,CDM,272,RC,,,Outpatient,,,17.15,17.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.01,70,,9.61,percent of total billed charges,70% of total billed charges for outpatient setting,14.56,84.88,,11.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.58,50,,6.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.86,75,,10.29,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,70,,9.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.72,80,,10.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.15,65,,8.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,35,,4.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.44,90,,12.35,percent of total billed charges,90% of total billed charges for outpatient setting,2.2,15.44,
4-0 VICRYL FS-2 UND 27 J422H,69160962,CDM,272,RC,,,Outpatient,,,21.95,21.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,18.63,84.88,,14.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.98,50,,8.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.46,75,,13.17,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,12.84,,2.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.56,80,,14.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,2.82,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.27,65,,11.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,35,,6.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.76,90,,15.81,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,19.76,
4-0 VICRYL KS  (undyed)  J662H,69160923,CDM,272,RC,,,Outpatient,,,22.61,22.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,70,,12.66,percent of total billed charges,70% of total billed charges for outpatient setting,19.19,84.88,,15.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.31,50,,9.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.96,75,,13.57,percent of total billed charges,75% of total billed charges for outpatient setting,15.83,70,,12.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,80,,14.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.7,65,,11.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,35,,6.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.35,90,,16.28,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,20.35,
4-0 VICRYL P-3 UND / VCP494G,6150289,CDM,272,RC,,,Outpatient,,,29.12,29.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.56,50,,11.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.74,12.84,,2.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.74,12.84,,2.99,percent of total billed charges,12.84% of total billed charges,3.74,12.84,,2.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.93,65,,15.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,35,,8.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,3.74,26.21,
4-0 VICRYL PS-2 18IN RAPIDES / VR496,69169857,CDM,272,RC,,,Outpatient,,,12.54,12.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,70,,7.02,percent of total billed charges,70% of total billed charges for outpatient setting,10.64,84.88,,8.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.27,50,,5.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.41,75,,7.53,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,70,,7.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,80,,8.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.15,65,,6.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,35,,3.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.29,90,,9.03,percent of total billed charges,90% of total billed charges for outpatient setting,1.61,11.29,
4-0 VICRYL PS-2 UND 27IN / VCP426H,6150290,CDM,272,RC,,,Outpatient,,,56.25,56.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,70,,31.5,percent of total billed charges,70% of total billed charges for outpatient setting,47.75,84.88,,38.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.13,50,,22.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.19,75,,33.75,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,70,,31.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,12.84,,5.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,80,,36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,7.22,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.56,65,,29.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,35,,15.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.63,90,,40.5,percent of total billed charges,90% of total billed charges for outpatient setting,7.22,50.63,
4-0 VICRYL RB-1 / J214H,6152742,CDM,272,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,70,,6.72,percent of total billed charges,70% of total billed charges for outpatient setting,10.19,84.88,,8.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,6,50,,4.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,75,,7.2,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,70,,6.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,80,,7.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.8,65,,6.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,35,,3.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.8,90,,8.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.8,
4-0 VICRYL SH CR8 / J773D,6150300,CDM,272,RC,,,Outpatient,,,103.69,103.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.58,70,,58.06,percent of total billed charges,70% of total billed charges for outpatient setting,88.01,84.88,,70.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.85,50,,41.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.77,75,,62.22,percent of total billed charges,75% of total billed charges for outpatient setting,72.58,70,,58.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,12.84,,10.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.95,80,,66.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,12.84,,10.65,percent of total billed charges,12.84% of total billed charges,13.31,12.84,,10.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.4,65,,53.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,35,,29.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.32,90,,74.66,percent of total billed charges,90% of total billed charges for outpatient setting,13.31,93.32,
4-0 VICRYL SH UND / J415H,6152124,CDM,272,RC,,,Outpatient,,,11.34,11.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,70,,6.35,percent of total billed charges,70% of total billed charges for outpatient setting,9.63,84.88,,7.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.67,50,,4.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.51,75,,6.81,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,70,,6.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,80,,7.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.37,65,,5.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,35,,3.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.21,90,,8.17,percent of total billed charges,90% of total billed charges for outpatient setting,1.46,10.21,
4FR FILLIFORM STRAIGHT 12.5    021904,69161791,CDM,272,RC,,,Outpatient,,,203.74,203.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.62,70,,114.1,percent of total billed charges,70% of total billed charges for outpatient setting,172.93,84.88,,138.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.87,50,,81.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.81,75,,122.25,percent of total billed charges,75% of total billed charges for outpatient setting,142.62,70,,114.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,12.84,,20.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.99,80,,130.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,12.84,,20.93,percent of total billed charges,12.84% of total billed charges,26.16,12.84,,20.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.43,65,,105.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.31,35,,57.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,183.37,90,,146.7,percent of total billed charges,90% of total billed charges for outpatient setting,26.16,183.37,
4MM TRICUT  BLADE / 1884004,6152973,CDM,272,RC,,,Outpatient,,,769.72,769.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.8,70,,431.04,percent of total billed charges,70% of total billed charges for outpatient setting,653.34,84.88,,522.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,384.86,50,,307.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,577.29,75,,461.83,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,70,,431.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.83,12.84,,79.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.78,80,,492.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.83,12.84,,79.06,percent of total billed charges,12.84% of total billed charges,98.83,12.84,,79.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500.32,65,,400.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.4,35,,215.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,692.75,90,,554.2,percent of total billed charges,90% of total billed charges for outpatient setting,98.83,692.75,
5 PRIME NUCLEOTIDASE,201574,CDM,301,RC,83915,HCPCS,Outpatient,,,50.18,45.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.13,70,,28.1,percent of total billed charges,70% of total billed charges for outpatient setting,42.59,84.88,,34.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.64,75,,30.11,percent of total billed charges,75% of total billed charges for outpatient setting,35.13,70,,28.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,80,,32.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.14,100,,,Fee Schedule,100% of Custom Fee Schedule,45.16,90,,36.13,percent of total billed charges,90% of total billed charges for outpatient setting,11.15,45.16,
5 TICRON HGS-21 / 63111-79,69169873,CDM,272,RC,,,Outpatient,,,34.32,34.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.02,70,,19.22,percent of total billed charges,70% of total billed charges for outpatient setting,29.13,84.88,,23.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.16,50,,13.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.74,75,,20.59,percent of total billed charges,75% of total billed charges for outpatient setting,24.02,70,,19.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.46,80,,21.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.31,65,,17.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.01,35,,9.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.89,90,,24.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.41,30.89,
5 TICRON HOS-14 / 3027-79,6150113,CDM,272,RC,,,Outpatient,,,98.49,98.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,83.6,84.88,,66.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.25,50,,39.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.87,75,,59.1,percent of total billed charges,75% of total billed charges for outpatient setting,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.79,80,,63.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.02,65,,51.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,35,,27.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.64,90,,70.91,percent of total billed charges,90% of total billed charges for outpatient setting,12.65,88.64,
5-0 CHROMIC P-3  687G,6150163,CDM,272,RC,,,Outpatient,,,44.14,44.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.9,70,,24.72,percent of total billed charges,70% of total billed charges for outpatient setting,37.47,84.88,,29.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.07,50,,17.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.11,75,,26.49,percent of total billed charges,75% of total billed charges for outpatient setting,30.9,70,,24.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.31,80,,28.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.69,65,,22.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,35,,12.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.73,90,,31.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,39.73,
5-0 ETHILON PC-1 / 1855G,69169837,CDM,272,RC,,,Outpatient,,,33.59,33.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,70,,18.81,percent of total billed charges,70% of total billed charges for outpatient setting,28.51,84.88,,22.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.8,50,,13.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.19,75,,20.15,percent of total billed charges,75% of total billed charges for outpatient setting,23.51,70,,18.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.87,80,,21.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.83,65,,17.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,35,,9.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.23,90,,24.18,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,30.23,
5-0 ETHILON PC-3 / 1865G,6150037,CDM,272,RC,,,Outpatient,,,33.59,33.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,70,,18.81,percent of total billed charges,70% of total billed charges for outpatient setting,28.51,84.88,,22.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.8,50,,13.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.19,75,,20.15,percent of total billed charges,75% of total billed charges for outpatient setting,23.51,70,,18.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.87,80,,21.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.83,65,,17.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,35,,9.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.23,90,,24.18,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,30.23,
5-0 ETHILON PS-2 / 1666H,6150023,CDM,272,RC,,,Outpatient,,,29.63,29.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.74,70,,16.59,percent of total billed charges,70% of total billed charges for outpatient setting,25.15,84.88,,20.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.82,50,,11.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.22,75,,17.78,percent of total billed charges,75% of total billed charges for outpatient setting,20.74,70,,16.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,80,,18.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.26,65,,15.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,35,,8.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.67,90,,21.34,percent of total billed charges,90% of total billed charges for outpatient setting,3.8,26.67,
5-0 ETHILON R-5  8065215501,6150528,CDM,272,RC,,,Outpatient,,,132.94,132.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.06,70,,74.45,percent of total billed charges,70% of total billed charges for outpatient setting,112.84,84.88,,90.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.47,50,,53.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.71,75,,79.77,percent of total billed charges,75% of total billed charges for outpatient setting,93.06,70,,74.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,12.84,,13.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.35,80,,85.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,12.84,,13.66,percent of total billed charges,12.84% of total billed charges,17.07,12.84,,13.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.41,65,,69.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.53,35,,37.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,119.65,90,,95.72,percent of total billed charges,90% of total billed charges for outpatient setting,17.07,119.65,
5-0 MONOCRYL P-3 / Y493G,6150278,CDM,272,RC,,,Outpatient,,,33.04,33.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.13,70,,18.5,percent of total billed charges,70% of total billed charges for outpatient setting,28.04,84.88,,22.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.52,50,,13.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.78,75,,19.82,percent of total billed charges,75% of total billed charges for outpatient setting,23.13,70,,18.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.43,80,,21.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.48,65,,17.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,35,,9.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.74,90,,23.79,percent of total billed charges,90% of total billed charges for outpatient setting,4.24,29.74,
5-0 MONOCRYL PS-2 / MCP495G,69160366,CDM,272,RC,,,Outpatient,,,40.58,40.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,34.44,84.88,,27.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.29,50,,16.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.44,75,,24.35,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,12.84,,4.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.46,80,,25.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,12.84,,4.17,percent of total billed charges,12.84% of total billed charges,5.21,12.84,,4.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.38,65,,21.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.2,35,,11.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.52,90,,29.22,percent of total billed charges,90% of total billed charges for outpatient setting,5.21,36.52,
5-0 PLAIN P-3 / 686G,69161530,CDM,272,RC,,,Outpatient,,,44.26,44.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,70,,24.78,percent of total billed charges,70% of total billed charges for outpatient setting,37.57,84.88,,30.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.13,50,,17.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.2,75,,26.56,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,70,,24.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.41,80,,28.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.77,65,,23.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.49,35,,12.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,39.83,
5-0 PLAIN PC-1 / 1915G,69161348,CDM,272,RC,,,Outpatient,,,39.6,39.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.72,70,,22.18,percent of total billed charges,70% of total billed charges for outpatient setting,33.61,84.88,,26.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,50,,15.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,75,,23.76,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,70,,22.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.08,12.84,,4.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,80,,25.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.08,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,5.08,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.74,65,,20.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.86,35,,11.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.64,90,,28.51,percent of total billed charges,90% of total billed charges for outpatient setting,5.08,35.64,
5-0 PROLENE BB 36IN DBL / 8580H,69160235,CDM,272,RC,,,Outpatient,,,38.4,38.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,70,,21.5,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,84.88,,26.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.2,50,,15.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.8,75,,23.04,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,70,,21.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.93,12.84,,3.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,80,,24.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.93,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,4.93,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.96,65,,19.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,35,,10.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.56,90,,27.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.93,34.56,
5-0 PROLENE P-3 / 8698G,6150193,CDM,272,RC,,,Outpatient,,,30.48,30.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.34,70,,17.07,percent of total billed charges,70% of total billed charges for outpatient setting,25.87,84.88,,20.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.24,50,,12.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.86,75,,18.29,percent of total billed charges,75% of total billed charges for outpatient setting,21.34,70,,17.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.38,80,,19.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.81,65,,15.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.67,35,,8.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.43,90,,21.94,percent of total billed charges,90% of total billed charges for outpatient setting,3.91,27.43,
5-0 PROLENE PS-2 / 8686G,6150191,CDM,272,RC,,,Outpatient,,,28.32,28.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,24.04,84.88,,19.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.16,50,,11.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.24,75,,16.99,percent of total billed charges,75% of total billed charges for outpatient setting,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.66,80,,18.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.41,65,,14.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,35,,7.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.49,90,,20.39,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,25.49,
5-0 SILK P-3  / 640G,69169680,CDM,272,RC,,,Outpatient,,,24.48,24.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,20.78,84.88,,16.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.24,50,,9.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,75,,14.69,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,70,,13.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,80,,15.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.91,65,,12.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,35,,6.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.03,90,,17.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.14,22.03,
5-0 VICRYL P-3 dyed  J463G,69160925,CDM,272,RC,,,Outpatient,,,38.14,38.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.7,70,,21.36,percent of total billed charges,70% of total billed charges for outpatient setting,32.37,84.88,,25.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.07,50,,15.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.61,75,,22.89,percent of total billed charges,75% of total billed charges for outpatient setting,26.7,70,,21.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.51,80,,24.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.79,65,,19.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.35,35,,10.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.33,90,,27.46,percent of total billed charges,90% of total billed charges for outpatient setting,4.9,34.33,
5-0 VICRYL P-3 UNDYED / VCP493G,6150288,CDM,272,RC,S0630,HCPCS,Outpatient,,,29.36,29.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,70,,16.44,percent of total billed charges,70% of total billed charges for outpatient setting,24.92,84.88,,19.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.68,50,,11.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.02,75,,17.62,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,70,,16.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,12.84,,3.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.49,80,,18.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,3.77,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.08,65,,15.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,35,,8.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.42,90,,21.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.77,26.42,
5FR FILLIFORM SPIRAL 18    022005,69160304,CDM,272,RC,,,Outpatient,,,261.06,261.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.74,70,,146.19,percent of total billed charges,70% of total billed charges for outpatient setting,221.59,84.88,,177.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.53,50,,104.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.8,75,,156.64,percent of total billed charges,75% of total billed charges for outpatient setting,182.74,70,,146.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.52,12.84,,26.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.85,80,,167.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.52,12.84,,26.82,percent of total billed charges,12.84% of total billed charges,33.52,12.84,,26.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,169.69,65,,135.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.37,35,,73.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,234.95,90,,187.96,percent of total billed charges,90% of total billed charges for outpatient setting,33.52,234.95,
5FR FILLIFORM SPIRAL TIP,6152118,CDM,270,RC,,,Outpatient,,,203.74,203.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.62,70,,114.1,percent of total billed charges,70% of total billed charges for outpatient setting,172.93,84.88,,138.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.87,50,,81.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.81,75,,122.25,percent of total billed charges,75% of total billed charges for outpatient setting,142.62,70,,114.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,12.84,,20.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.99,80,,130.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,12.84,,20.93,percent of total billed charges,12.84% of total billed charges,26.16,12.84,,20.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.43,65,,105.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.31,35,,57.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,183.37,90,,146.7,percent of total billed charges,90% of total billed charges for outpatient setting,26.16,183.37,
"5-HIAA, PLASMA",221895,CDM,301,RC,83497,HCPCS,Outpatient,,,58.05,52.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,49.27,84.88,,39.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.54,75,,34.83,percent of total billed charges,75% of total billed charges for outpatient setting,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,80,,37.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.83,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,100,,,Fee Schedule,100% of Custom Fee Schedule,52.25,90,,41.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,52.25,
"5-HIAA, URINE 24 HR",220112,CDM,301,RC,83497,HCPCS,Outpatient,,,58.05,52.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,49.27,84.88,,39.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.54,75,,34.83,percent of total billed charges,75% of total billed charges for outpatient setting,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,80,,37.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.83,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,100,,,Fee Schedule,100% of Custom Fee Schedule,52.25,90,,41.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,52.25,
"5mm CAUTERY, MONOPOLAR 428052",69161358,CDM,272,RC,,,Outpatient,,,590.84,590.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.59,70,,330.87,percent of total billed charges,70% of total billed charges for outpatient setting,501.5,84.88,,401.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,295.42,50,,236.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.13,75,,354.5,percent of total billed charges,75% of total billed charges for outpatient setting,413.59,70,,330.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.86,12.84,,60.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.67,80,,378.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.86,12.84,,60.69,percent of total billed charges,12.84% of total billed charges,75.86,12.84,,60.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,384.05,65,,307.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.79,35,,165.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,531.76,90,,425.41,percent of total billed charges,90% of total billed charges for outpatient setting,75.86,531.76,
5MM ENDO PUSHER / 28-0801,6150482,CDM,272,RC,,,Outpatient,,,58.52,58.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.96,70,,32.77,percent of total billed charges,70% of total billed charges for outpatient setting,49.67,84.88,,39.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.26,50,,23.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,75,,35.11,percent of total billed charges,75% of total billed charges for outpatient setting,40.96,70,,32.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.51,12.84,,6.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.82,80,,37.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.51,12.84,,6.01,percent of total billed charges,12.84% of total billed charges,7.51,12.84,,6.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.04,65,,30.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.48,35,,16.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.67,90,,42.14,percent of total billed charges,90% of total billed charges for outpatient setting,7.51,52.67,
6-0 ETHILON P-3 / 1698G,6152127,CDM,272,RC,,,Outpatient,,,29.7,29.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,70,,16.63,percent of total billed charges,70% of total billed charges for outpatient setting,25.21,84.88,,20.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.85,50,,11.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.28,75,,17.82,percent of total billed charges,75% of total billed charges for outpatient setting,20.79,70,,16.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,80,,19.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.31,65,,15.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.4,35,,8.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.73,90,,21.38,percent of total billed charges,90% of total billed charges for outpatient setting,3.81,26.73,
6-0 PROLENE BV-1 DBL ARM / 8709H,69161975,CDM,272,RC,,,Outpatient,,,67.2,67.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,70,,37.63,percent of total billed charges,70% of total billed charges for outpatient setting,57.04,84.88,,45.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.6,50,,26.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,75,,40.32,percent of total billed charges,75% of total billed charges for outpatient setting,47.04,70,,37.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,12.84,,6.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.76,80,,43.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,8.63,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.68,65,,34.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,35,,18.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.48,90,,48.38,percent of total billed charges,90% of total billed charges for outpatient setting,8.63,60.48,
6-0 PROLENE P-3 / 8695G,6152645,CDM,272,RC,,,Outpatient,,,37.74,37.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.42,70,,21.14,percent of total billed charges,70% of total billed charges for outpatient setting,32.03,84.88,,25.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.87,50,,15.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.31,75,,22.65,percent of total billed charges,75% of total billed charges for outpatient setting,26.42,70,,21.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.19,80,,24.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.53,65,,19.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.21,35,,10.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.97,90,,27.18,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,33.97,
6-0 VICRYL P-3 UNDYED / J492G,69160936,CDM,272,RC,,,Outpatient,,,28.81,28.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,84.88,,19.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.41,50,,11.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.61,75,,17.29,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.05,80,,18.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.73,65,,14.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,35,,8.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.93,90,,20.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.93,
6-0 VICRYL S-14 / J590G,6152185,CDM,272,RC,,,Outpatient,,,81.33,81.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.93,70,,45.54,percent of total billed charges,70% of total billed charges for outpatient setting,69.03,84.88,,55.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.67,50,,32.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,75,,48.8,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,70,,45.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,12.84,,8.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,80,,52.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,12.84,,8.35,percent of total billed charges,12.84% of total billed charges,10.44,12.84,,8.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.86,65,,42.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.47,35,,22.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.2,90,,58.56,percent of total billed charges,90% of total billed charges for outpatient setting,10.44,73.2,
6-0 VICRYL TG100-8 / J544G,69169327,CDM,272,RC,,,Outpatient,,,81.44,81.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.01,70,,45.61,percent of total billed charges,70% of total billed charges for outpatient setting,69.13,84.88,,55.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.72,50,,32.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.08,75,,48.86,percent of total billed charges,75% of total billed charges for outpatient setting,57.01,70,,45.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.46,12.84,,8.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.15,80,,52.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.46,12.84,,8.37,percent of total billed charges,12.84% of total billed charges,10.46,12.84,,8.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.94,65,,42.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.5,35,,22.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.3,90,,58.64,percent of total billed charges,90% of total billed charges for outpatient setting,10.46,73.3,
68KD AB,220871,CDM,301,RC,84181,HCPCS,Outpatient,,,76.64,68.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,65.05,84.88,,52.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.48,75,,45.98,percent of total billed charges,75% of total billed charges for outpatient setting,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.31,80,,49.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.87,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,100% of Custom Fee Schedule,68.98,90,,55.18,percent of total billed charges,90% of total billed charges for outpatient setting,9.84,68.98,
6FR FILLIFORM SPIRAL 18    022006,69160305,CDM,272,RC,,,Outpatient,,,230.82,230.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.57,70,,129.26,percent of total billed charges,70% of total billed charges for outpatient setting,195.92,84.88,,156.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.41,50,,92.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.12,75,,138.5,percent of total billed charges,75% of total billed charges for outpatient setting,161.57,70,,129.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.64,12.84,,23.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.66,80,,147.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.64,12.84,,23.71,percent of total billed charges,12.84% of total billed charges,29.64,12.84,,23.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.03,65,,120.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,35,,64.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.74,90,,166.19,percent of total billed charges,90% of total billed charges for outpatient setting,29.64,207.74,
6FR FILLIFORM STRAIGHT 18    021806,69160306,CDM,272,RC,,,Outpatient,,,233.89,233.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.72,70,,130.98,percent of total billed charges,70% of total billed charges for outpatient setting,198.53,84.88,,158.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.95,50,,93.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.42,75,,140.34,percent of total billed charges,75% of total billed charges for outpatient setting,163.72,70,,130.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.03,12.84,,24.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,80,,149.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.03,12.84,,24.02,percent of total billed charges,12.84% of total billed charges,30.03,12.84,,24.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.03,65,,121.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.86,35,,65.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.5,90,,168.4,percent of total billed charges,90% of total billed charges for outpatient setting,30.03,210.5,
7-0 PROLENE P-1 / 8696G,6151013,CDM,272,RC,,,Outpatient,,,11.97,11.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,10.16,84.88,,8.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.99,50,,4.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.98,75,,7.18,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,80,,7.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.78,65,,6.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.19,35,,3.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.77,90,,8.62,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.77,
7-0 SILK TG140-8    7733G,6150531,CDM,272,RC,,,Outpatient,,,84.06,84.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,71.35,84.88,,57.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.03,50,,33.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.05,75,,50.44,percent of total billed charges,75% of total billed charges for outpatient setting,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,12.84,,8.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.25,80,,53.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,12.84,,8.63,percent of total billed charges,12.84% of total billed charges,10.79,12.84,,8.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.64,65,,43.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,35,,23.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.65,90,,60.52,percent of total billed charges,90% of total billed charges for outpatient setting,10.79,75.65,
7-0 VICRYL  TG140-8 J546G,6150292,CDM,272,RC,,,Outpatient,,,102.26,102.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.58,70,,57.26,percent of total billed charges,70% of total billed charges for outpatient setting,86.8,84.88,,69.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.13,50,,40.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.7,75,,61.36,percent of total billed charges,75% of total billed charges for outpatient setting,71.58,70,,57.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.13,12.84,,10.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.81,80,,65.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.13,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,13.13,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.47,65,,53.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.79,35,,28.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.03,90,,73.62,percent of total billed charges,90% of total billed charges for outpatient setting,13.13,92.03,
8-0 VICRYL TG140-8 / J548G,69169272,CDM,272,RC,,,Outpatient,,,77.49,77.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,70,,43.39,percent of total billed charges,70% of total billed charges for outpatient setting,65.77,84.88,,52.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.75,50,,31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.12,75,,46.5,percent of total billed charges,75% of total billed charges for outpatient setting,54.24,70,,43.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,12.84,,7.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.99,80,,49.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,12.84,,7.96,percent of total billed charges,12.84% of total billed charges,9.95,12.84,,7.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.37,65,,40.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,35,,21.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.74,90,,55.79,percent of total billed charges,90% of total billed charges for outpatient setting,9.95,69.74,
9-0 ETHILON TG140-8 / 7717G,69169326,CDM,272,RC,,,Outpatient,,,58.73,58.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,49.85,84.88,,39.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.37,50,,23.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.05,75,,35.24,percent of total billed charges,75% of total billed charges for outpatient setting,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.54,12.84,,6.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,80,,37.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.54,12.84,,6.03,percent of total billed charges,12.84% of total billed charges,7.54,12.84,,6.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.17,65,,30.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.56,35,,16.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.86,90,,42.29,percent of total billed charges,90% of total billed charges for outpatient setting,7.54,52.86,
9-0 ETHILON VAS100-4   2890G,6152878,CDM,272,RC,,,Outpatient,,,132.93,132.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.05,70,,74.44,percent of total billed charges,70% of total billed charges for outpatient setting,112.83,84.88,,90.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.47,50,,53.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.7,75,,79.76,percent of total billed charges,75% of total billed charges for outpatient setting,93.05,70,,74.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,12.84,,13.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.34,80,,85.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,12.84,,13.66,percent of total billed charges,12.84% of total billed charges,17.07,12.84,,13.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,65,,69.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.53,35,,37.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,119.64,90,,95.71,percent of total billed charges,90% of total billed charges for outpatient setting,17.07,119.64,
9-0 VICRYL BV100-3    V402G,761180,CDM,272,RC,,,Outpatient,,,116.34,116.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.44,70,,65.15,percent of total billed charges,70% of total billed charges for outpatient setting,98.75,84.88,,79,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.17,50,,46.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.26,75,,69.81,percent of total billed charges,75% of total billed charges for outpatient setting,81.44,70,,65.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.94,12.84,,11.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.07,80,,74.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.94,12.84,,11.95,percent of total billed charges,12.84% of total billed charges,14.94,12.84,,11.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.62,65,,60.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.72,35,,32.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.71,90,,83.77,percent of total billed charges,90% of total billed charges for outpatient setting,14.94,104.71,
ABD 1 VIEW,2400561,CDM,320,RC,74018,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.67,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,26.67,240.13,
ABD 2 VIEWS,2400571,CDM,320,RC,74019,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.54,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,32.54,295.41,
ABD 3 OR MORE VIEWS,2400572,CDM,320,RC,74021,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.16,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,38.16,295.41,
ABD ACUTE W/CHEST,2400575,CDM,320,RC,74022,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
ABD BINDER 12IN 30-45 / 13651056,61590155,CDM,270,RC,L0625,HCPCS,Outpatient,,,52.99,52.99,,94.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,44.98,84.88,,35.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.5,50,,21.2,percent of total billed charges,50% of total Billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,39.74,75,,31.79,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,100.5,170,,,Fee Schedule,170% of Medicare OPPS rate,127.11,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,103.46,175,,,Fee Schedule,175% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.39,80,,33.91,percent of total billed charges,80% of total billed charges for outpatient setting,82.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,73.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,34.44,65,,27.55,percent of total billed charges,65% of total billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.84,100,,,Fee Schedule,100% of Custom Fee Schedule,47.69,90,,38.15,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,127.11,
ABD BINDER 12IN 46-62 / 13652067,61590156,CDM,274,RC,L0625,HCPCS,Outpatient,,,52.99,52.99,,94.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,44.98,84.88,,35.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.5,50,,21.2,percent of total billed charges,50% of total Billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,39.74,75,,31.79,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,50,,21.2,percent of total billed charges,50% of total billed charges for Outpatient setting,100.5,170,,,Fee Schedule,170% of Medicare OPPS rate,127.11,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,103.46,175,,,Fee Schedule,175% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.39,80,,33.91,percent of total billed charges,80% of total billed charges for outpatient setting,82.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,73.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.99,65,,42.39,percent of total billed charges,65% of total billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.84,100,,,Fee Schedule,100% of Custom Fee Schedule,47.69,90,,38.15,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,127.11,
ABD BINDER 12IN 62-74 / 79-89220,69161418,CDM,274,RC,L0625,HCPCS,Outpatient,,,55.02,55.02,,94.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.51,70,,30.81,percent of total billed charges,70% of total billed charges for outpatient setting,46.7,84.88,,37.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.51,50,,22.01,percent of total billed charges,50% of total Billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,41.27,75,,33.02,percent of total billed charges,75% of total billed charges for outpatient setting,27.51,50,,22.01,percent of total billed charges,50% of total billed charges for Outpatient setting,100.5,170,,,Fee Schedule,170% of Medicare OPPS rate,127.11,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,7.06,12.84,,5.648,percent of total billed charges,12.84% of total billed charges,103.46,175,,,Fee Schedule,175% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.02,80,,35.22,percent of total billed charges,80% of total billed charges for outpatient setting,82.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,73.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.02,65,,44.02,percent of total billed charges,65% of total billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.84,100,,,Fee Schedule,100% of Custom Fee Schedule,49.52,90,,39.62,percent of total billed charges,90% of total billed charges for outpatient setting,7.06,127.11,
ABD BINDER 9IN 30-45 / 13991000,6152680,CDM,274,RC,L0625,HCPCS,Outpatient,,,90.63,90.63,,94.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.44,70,,50.75,percent of total billed charges,70% of total billed charges for outpatient setting,76.93,84.88,,61.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.32,50,,36.26,percent of total billed charges,50% of total Billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,67.97,75,,54.38,percent of total billed charges,75% of total billed charges for outpatient setting,45.32,50,,36.26,percent of total billed charges,50% of total billed charges for Outpatient setting,100.5,170,,,Fee Schedule,170% of Medicare OPPS rate,127.11,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.64,12.84,,9.312,percent of total billed charges,12.84% of total billed charges,103.46,175,,,Fee Schedule,175% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.5,80,,58,percent of total billed charges,80% of total billed charges for outpatient setting,82.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,73.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,90.63,65,,72.5,percent of total billed charges,65% of total billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.84,100,,,Fee Schedule,100% of Custom Fee Schedule,81.57,90,,65.26,percent of total billed charges,90% of total billed charges for outpatient setting,11.64,127.11,
ABD BINDER 9IN 46-62 / 79-89071,6152681,CDM,274,RC,L0625,HCPCS,Outpatient,,,38.32,38.32,,94.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.82,70,,21.46,percent of total billed charges,70% of total billed charges for outpatient setting,32.53,84.88,,26.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.16,50,,15.33,percent of total billed charges,50% of total Billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.74,75,,22.99,percent of total billed charges,75% of total billed charges for outpatient setting,19.16,50,,15.33,percent of total billed charges,50% of total billed charges for Outpatient setting,100.5,170,,,Fee Schedule,170% of Medicare OPPS rate,127.11,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,4.92,12.84,,3.936,percent of total billed charges,12.84% of total billed charges,103.46,175,,,Fee Schedule,175% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.66,80,,24.53,percent of total billed charges,80% of total billed charges for outpatient setting,82.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,73.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,4.92,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,4.92,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.32,65,,30.66,percent of total billed charges,65% of total billed charges for outpatient setting,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.84,100,,,Fee Schedule,100% of Custom Fee Schedule,34.49,90,,27.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,127.11,
ABG,1300035,CDM,301,RC,82803,HCPCS,Outpatient,,,117.32,105.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.12,70,,65.7,percent of total billed charges,70% of total billed charges for outpatient setting,99.58,84.88,,79.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,87.99,75,,70.39,percent of total billed charges,75% of total billed charges for outpatient setting,82.12,70,,65.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.86,80,,75.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,105.59,90,,84.47,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,105.59,
ABORTED PROCEDURE,6100030,CDM,360,RC,,,Outpatient,,,2092.59,2092.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.81,70,,1171.85,percent of total billed charges,70% of total billed charges for outpatient setting,1776.19,84.88,,1420.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,1046.3,50,,837.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1569.44,75,,1255.55,percent of total billed charges,75% of total billed charges for outpatient setting,1464.81,70,,1171.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.69,12.84,,214.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1674.07,80,,1339.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.69,12.84,,214.95,percent of total billed charges,12.84% of total billed charges,268.69,12.84,,214.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.41,35,,585.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1883.33,90,,1506.66,percent of total billed charges,90% of total billed charges for outpatient setting,268.69,1883.33,
ABREVA (DOCOSANOL)10% CRM 2 GM,3303250,CDM,259,RC,,,Outpatient,,,56.83,56.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.78,70,,31.82,percent of total billed charges,70% of total billed charges for outpatient setting,48.24,84.88,,38.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.42,50,,22.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.62,75,,34.1,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,70,,31.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.46,80,,36.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.94,65,,29.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.89,35,,15.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.15,90,,40.92,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,51.15,
AC JNTS BILAT W/OR W/O WTS.,2400495,CDM,320,RC,73050,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ACCESS PORT 12X100MM BLADELESS / iAS12-1,69162122,CDM,272,RC,,,Outpatient,,,367.24,367.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.07,70,,205.66,percent of total billed charges,70% of total billed charges for outpatient setting,311.71,84.88,,249.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,183.62,50,,146.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.43,75,,220.34,percent of total billed charges,75% of total billed charges for outpatient setting,257.07,70,,205.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.15,12.84,,37.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.79,80,,235.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.15,12.84,,37.72,percent of total billed charges,12.84% of total billed charges,47.15,12.84,,37.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,238.71,65,,190.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.53,35,,102.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,330.52,90,,264.42,percent of total billed charges,90% of total billed charges for outpatient setting,47.15,330.52,
ACCESS PORT 12X120MM / iAS12-120LP,69169521,CDM,272,RC,,,Outpatient,,,367.71,367.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.4,70,,205.92,percent of total billed charges,70% of total billed charges for outpatient setting,312.11,84.88,,249.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,183.86,50,,147.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.78,75,,220.62,percent of total billed charges,75% of total billed charges for outpatient setting,257.4,70,,205.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.17,80,,235.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,239.01,65,,191.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,35,,102.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,330.94,90,,264.75,percent of total billed charges,90% of total billed charges for outpatient setting,47.21,330.94,
ACCESS PORT 8X100MM / iAS8-100LP,69162120,CDM,272,RC,,,Outpatient,,,318.49,318.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.94,70,,178.35,percent of total billed charges,70% of total billed charges for outpatient setting,270.33,84.88,,216.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.25,50,,127.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.87,75,,191.1,percent of total billed charges,75% of total billed charges for outpatient setting,222.94,70,,178.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.89,12.84,,32.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.79,80,,203.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.89,12.84,,32.71,percent of total billed charges,12.84% of total billed charges,40.89,12.84,,32.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,207.02,65,,165.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.47,35,,89.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.64,90,,229.31,percent of total billed charges,90% of total billed charges for outpatient setting,40.89,286.64,
ACCESS PORT 8X120MM / iAS8-120LP,69162121,CDM,272,RC,,,Outpatient,,,321.97,321.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.38,70,,180.3,percent of total billed charges,70% of total billed charges for outpatient setting,273.29,84.88,,218.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.99,50,,128.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.48,75,,193.18,percent of total billed charges,75% of total billed charges for outpatient setting,225.38,70,,180.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.34,12.84,,33.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.58,80,,206.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.34,12.84,,33.07,percent of total billed charges,12.84% of total billed charges,41.34,12.84,,33.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.28,65,,167.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.69,35,,90.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.77,90,,231.82,percent of total billed charges,90% of total billed charges for outpatient setting,41.34,289.77,
ACCLARENT AERA W/VENT CAP / EU061655,69169506,CDM,272,RC,,,Outpatient,,,4020,4020,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2814,70,,2251.2,percent of total billed charges,70% of total billed charges for outpatient setting,3412.18,84.88,,2729.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2010,50,,1608,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3015,75,,2412,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.17,12.84,,412.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3216,80,,2572.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.17,12.84,,412.94,percent of total billed charges,12.84% of total billed charges,516.17,12.84,,412.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2613,65,,2090.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1407,35,,1125.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3618,90,,2894.4,percent of total billed charges,90% of total billed charges for outpatient setting,516.17,3618,
ACE 2IN VELCRO STRL / DYNJ05152LF,7650495,CDM,270,RC,A6449,HCPCS,Outpatient,,,5.94,5.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,70,,3.33,percent of total billed charges,70% of total billed charges for outpatient setting,5.04,84.88,,4.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,75,,3.57,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,70,,3.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,80,,3.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.86,65,,3.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,90,,4.28,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.35,
ACE 3IN VELCOR / DYNJ05153LF,6153032,CDM,270,RC,A6449,HCPCS,Outpatient,,,6.55,6.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,70,,3.67,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,84.88,,4.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,75,,3.93,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,70,,3.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,80,,4.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.26,65,,3.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.9,90,,4.72,percent of total billed charges,90% of total billed charges for outpatient setting,0.84,5.9,
ACE 4IN VELCRO / DYNJ05154LF,7650505,CDM,270,RC,A6449,HCPCS,Outpatient,,,7.11,7.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,70,,3.98,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,84.88,,4.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,75,,4.26,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,70,,3.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,80,,4.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.62,65,,3.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,90,,5.12,percent of total billed charges,90% of total billed charges for outpatient setting,0.91,6.4,
ACE 6IN VELCRO / DYNJ05156LF,7650510,CDM,270,RC,A6450,HCPCS,Outpatient,,,4.59,4.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,70,,2.57,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,84.88,,3.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,75,,2.75,percent of total billed charges,75% of total billed charges for outpatient setting,3.21,70,,2.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.59,12.84,,0.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,80,,2.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.59,12.84,,0.47,percent of total billed charges,12.84% of total billed charges,0.59,12.84,,0.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.98,65,,2.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,90,,3.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.59,4.13,
ACETABULAR LINER 36MM / 71335756,69162338,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
ACETABULAR LINER 40MM G7 / 110024462,71000021,CDM,278,RC,C1776,HCPCS,Outpatient,,,3484,3484,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.4,60,,1672.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2957.22,84.88,,2365.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2613,75,,2090.4,percent of total billed charges,75% of total billed charges for outpatient setting,1742,50,,1393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2787.2,80,,2229.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3658.2,105,,2926.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.4,35,,975.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2090.4,60,,1672.32,percent of total billed charges,60% of total billed charges for outpatient setting,447.35,3658.2,
ACETABULAR LINER 42MM G7 / 110024464,71000216,CDM,278,RC,C1776,HCPCS,Outpatient,,,3484,3484,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.4,60,,1672.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2957.22,84.88,,2365.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2613,75,,2090.4,percent of total billed charges,75% of total billed charges for outpatient setting,1742,50,,1393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2787.2,80,,2229.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3658.2,105,,2926.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.4,35,,975.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2090.4,60,,1672.32,percent of total billed charges,60% of total billed charges for outpatient setting,447.35,3658.2,
ACETABULAR LINER 44MM G7 / 110024464,71000213,CDM,278,RC,C1776,HCPCS,Outpatient,,,3484,3484,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.4,60,,1672.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2957.22,84.88,,2365.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2613,75,,2090.4,percent of total billed charges,75% of total billed charges for outpatient setting,1742,50,,1393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2787.2,80,,2229.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3658.2,105,,2926.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.4,35,,975.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2090.4,60,,1672.32,percent of total billed charges,60% of total billed charges for outpatient setting,447.35,3658.2,
ACETABULAR LINER 46MM G7 / 110024465,71000148,CDM,278,RC,C1776,HCPCS,Outpatient,,,3484,3484,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.4,60,,1672.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2957.22,84.88,,2365.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2613,75,,2090.4,percent of total billed charges,75% of total billed charges for outpatient setting,1742,50,,1393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2787.2,80,,2229.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,447.35,12.84,,357.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3658.2,105,,2926.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.4,35,,975.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2090.4,60,,1672.32,percent of total billed charges,60% of total billed charges for outpatient setting,447.35,3658.2,
ACETABULAR LINR 36X52MM / 1221-36-452,69169750,CDM,278,RC,C1776,HCPCS,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
ACETABULAR SHELL 52MM / 1217-17-058,69169774,CDM,278,RC,,,Outpatient,,,6765,6765,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4059,60,,3247.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5742.13,84.88,,4593.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,3382.5,50,,2706,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5073.75,75,,4059,percent of total billed charges,75% of total billed charges for outpatient setting,3382.5,50,,2706,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.63,12.84,,694.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5412,80,,4329.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.63,12.84,,694.9,percent of total billed charges,12.84% of total billed charges,868.63,12.84,,694.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7103.25,105,,5682.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,35,,1894.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4059,60,,3247.2,percent of total billed charges,60% of total billed charges for outpatient setting,868.63,7103.25,
ACETABULAR SHELL 56MM 3 HL / 71335556,69162339,CDM,278,RC,,,Outpatient,,,2100,2100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,60,,1008,percent of total billed charges,60% of total Billed charges for outpatient setting,1782.48,84.88,,1425.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1575,75,,1260,percent of total billed charges,75% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,80,,1344,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2205,105,,1764,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,35,,588,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1260,60,,1008,percent of total billed charges,60% of total billed charges for outpatient setting,269.64,2205,
ACETABULAR SHELL 56MM 4 HL / 110010246,71000153,CDM,278,RC,C1776,HCPCS,Outpatient,,,5086,5086,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3051.6,60,,2441.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4317,84.88,,3453.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3814.5,75,,3051.6,percent of total billed charges,75% of total billed charges for outpatient setting,2543,50,,2034.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4068.8,80,,3255.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5340.3,105,,4272.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.1,35,,1424.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3051.6,60,,2441.28,percent of total billed charges,60% of total billed charges for outpatient setting,653.04,5340.3,
ACETABULAR SHELL 58MM 4 HL / 110010247,71000147,CDM,278,RC,C1776,HCPCS,Outpatient,,,5086,5086,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3051.6,60,,2441.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4317,84.88,,3453.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3814.5,75,,3051.6,percent of total billed charges,75% of total billed charges for outpatient setting,2543,50,,2034.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4068.8,80,,3255.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5340.3,105,,4272.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.1,35,,1424.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3051.6,60,,2441.28,percent of total billed charges,60% of total billed charges for outpatient setting,653.04,5340.3,
ACETAM/CODEINE (TYLENOL #3) TAB 300/30MG,3300864,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMIN BUT CAF (FIORICET) TAB :,3300501,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMIN BUT CAF (FIORICET) TAB :,3300502,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMIN BUT CAF (FIORICET) TAB :,3300504,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMIN BUT CAF (FIORICET) TAB:325MG,3300503,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN (genTYLENOL) SUPP  650MG,3300507,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN (genTYLENOL) TAB 325MG,3300516,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN (TYLENOL) CAP: 650MG,3300511,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN (TYLENOL) SUPP: 120MG,3300506,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN (TYLENOL) SUPP: 120MG,3300508,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN (TYLENOL) SUPP: 325 MG,3300509,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN (TYLENOL) SUPP: 650MG,3300515,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN 160MG/5ML SUSP 118ML,3300510,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN 160MG/5ML SUSP 5ML UD CHG,3300505,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN ELIX 130MG/5ML : 25ML UD,3300514,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAMINOPHEN ES (TYLENOL) 500MG TAB,3300517,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN LIQ 500MG/15 ML,3303236,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN OFIRMEV BRAND1000MG/100ML,3306085,CDM,636,RC,J0131,HCPCS,Outpatient,,,220.31,220.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.22,70,,123.38,percent of total billed charges,70% of total billed charges for outpatient setting,187,84.88,,149.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,165.23,75,,132.18,percent of total billed charges,75% of total billed charges for outpatient setting,154.22,70,,123.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.29,12.84,,22.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.25,80,,141,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.29,12.84,,22.63,percent of total billed charges,12.84% of total billed charges,28.29,12.84,,22.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.2,65,,114.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.28,90,,158.62,percent of total billed charges,90% of total billed charges for outpatient setting,0.24,198.28,
ACETAMINOPHEN OFIRMEVgeneric1000MG/100ML,3313809,CDM,636,RC,J0131,HCPCS,Outpatient,,,30.68,30.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,26.04,84.88,,20.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.01,75,,18.41,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.54,80,,19.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.94,65,,15.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.61,90,,22.09,percent of total billed charges,90% of total billed charges for outpatient setting,0.24,27.61,
ACETAMINOPHEN SERUM,200821,CDM,300,RC,80329,HCPCS,Outpatient,,,50.61,45.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.43,70,,28.34,percent of total billed charges,70% of total billed charges for outpatient setting,42.96,84.88,,34.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.31,50,,20.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.96,75,,30.37,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,70,,28.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,12.84,,5.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.49,80,,32.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,12.84,,5.2,percent of total billed charges,12.84% of total billed charges,6.5,12.84,,5.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.55,90,,36.44,percent of total billed charges,90% of total billed charges for outpatient setting,6.5,45.55,
ACETAMINOPHEN SUPP  650MG,3300512,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAMINOPHEN TYLENOL SUSP 80MG/0.8ML,3300513,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ACETAMINOPHEN-CODEINE ELX 120MG-12MG/5ML,3300865,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETAZOLAMIDE (DIAMOX) CAP: 500MG,3300519,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAZOLAMIDE (DIAMOX) TAB: 250 MG,3300518,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACETAZOLAMINE (DIAMOX) INJ: 500MG,3301984,CDM,250,RC,,,Outpatient,,,112.21,112.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.55,70,,62.84,percent of total billed charges,70% of total billed charges for outpatient setting,95.24,84.88,,76.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.11,50,,44.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.16,75,,67.33,percent of total billed charges,75% of total billed charges for outpatient setting,78.55,70,,62.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,12.84,,11.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.77,80,,71.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,12.84,,11.53,percent of total billed charges,12.84% of total billed charges,14.41,12.84,,11.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.94,65,,58.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.27,35,,31.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.99,90,,80.79,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100.99,
ACETAZOLAMINE DIAMOX 250MG TAB,3303237,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ACETAZOLAMINE ER 500MG Generic Diamox,3307866,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETIC (ACETASOL) OTIC SOL 2%: 10ML,3300522,CDM,259,RC,,,Outpatient,,,36.39,36.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,30.89,84.88,,24.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.2,50,,14.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.29,75,,21.83,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.11,80,,23.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.65,65,,18.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,35,,10.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.75,90,,26.2,percent of total billed charges,90% of total billed charges for outpatient setting,4.67,32.75,
ACETIC ACID 0.25 % SOLN: 1000 ML,3302734,CDM,259,RC,,,Outpatient,,,14.53,14.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,70,,8.14,percent of total billed charges,70% of total billed charges for outpatient setting,12.33,84.88,,9.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.27,50,,5.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,75,,8.72,percent of total billed charges,75% of total billed charges for outpatient setting,10.17,70,,8.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.62,80,,9.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.44,65,,7.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,35,,4.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.08,90,,10.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,13.08,
ACETIC ACID 5% SOLN 500 ML chg 1ml,3309611,CDM,259,RC,,,Outpatient,,,14.53,14.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,70,,8.14,percent of total billed charges,70% of total billed charges for outpatient setting,12.33,84.88,,9.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.27,50,,5.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,75,,8.72,percent of total billed charges,75% of total billed charges for outpatient setting,10.17,70,,8.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.62,80,,9.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.44,65,,7.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,35,,4.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.08,90,,10.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,13.08,
ACETIC ACID GLACIAL LIQ : 500ML,3300521,CDM,259,RC,,,Outpatient,,,35.99,35.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,70,,20.15,percent of total billed charges,70% of total billed charges for outpatient setting,30.55,84.88,,24.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,18,50,,14.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.99,75,,21.59,percent of total billed charges,75% of total billed charges for outpatient setting,25.19,70,,20.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,12.84,,3.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.79,80,,23.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,12.84,,3.7,percent of total billed charges,12.84% of total billed charges,4.62,12.84,,3.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.39,65,,18.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,35,,10.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.39,90,,25.91,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,32.39,
ACETIC ACID LIQ 3% :480ML,3300520,CDM,259,RC,,,Outpatient,,,31.53,31.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,70,,17.66,percent of total billed charges,70% of total billed charges for outpatient setting,26.76,84.88,,21.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.77,50,,12.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.65,75,,18.92,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,70,,17.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.22,80,,20.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.49,65,,16.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,35,,8.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.38,90,,22.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.05,28.38,
ACETONE SERUM,200110,CDM,300,RC,82009,HCPCS,Outpatient,,,20.34,18.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,17.26,84.88,,13.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.26,75,,12.21,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.27,80,,13.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of Custom Fee Schedule,18.31,90,,14.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,18.31,
ACETYLCHOLINE MIOCHOL E  20MG VIAL,3300523,CDM,250,RC,,,Outpatient,,,254.69,254.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.28,70,,142.62,percent of total billed charges,70% of total billed charges for outpatient setting,216.18,84.88,,172.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.35,50,,101.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.02,75,,152.82,percent of total billed charges,75% of total billed charges for outpatient setting,178.28,70,,142.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.7,12.84,,26.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.75,80,,163,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.7,12.84,,26.16,percent of total billed charges,12.84% of total billed charges,32.7,12.84,,26.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.55,65,,132.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.14,35,,71.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,229.22,90,,183.38,percent of total billed charges,90% of total billed charges for outpatient setting,32.7,229.22,
ACETYLCHOLINE RECEPTOR BINDING AB,220271,CDM,301,RC,83519,HCPCS,Outpatient,,,82.8,74.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,70.28,84.88,,56.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.1,75,,49.68,percent of total billed charges,75% of total billed charges for outpatient setting,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,80,,52.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,100,,,Fee Schedule,100% of Custom Fee Schedule,74.52,90,,59.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,74.52,
ACETYLCHOLINE RECEPTOR BLOCKING AB,220272,CDM,301,RC,83519,HCPCS,Outpatient,,,82.8,74.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,70.28,84.88,,56.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.1,75,,49.68,percent of total billed charges,75% of total billed charges for outpatient setting,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,80,,52.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,100,,,Fee Schedule,100% of Custom Fee Schedule,74.52,90,,59.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,74.52,
ACETYLCHOLINE RECEPTOR MODULATING AB,220273,CDM,301,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ACETYLCYSTEINE (ACETYLCYSN) INJ: 100 MG,3300526,CDM,250,RC,,,Outpatient,,,14.29,14.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,70,,8,percent of total billed charges,70% of total billed charges for outpatient setting,12.13,84.88,,9.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.15,50,,5.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.72,75,,8.58,percent of total billed charges,75% of total billed charges for outpatient setting,10,70,,8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,80,,9.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.29,65,,7.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,35,,4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.86,90,,10.29,percent of total billed charges,90% of total billed charges for outpatient setting,1.83,12.86,
ACETYLCYSTEINE (MUCOMYST)600MG CAP,3306972,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ACETYLCYSTEINE (MUCOMYST-10)INJ 10%: 4ML,3300525,CDM,250,RC,,,Outpatient,,,12.75,12.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,70,,7.14,percent of total billed charges,70% of total billed charges for outpatient setting,10.82,84.88,,8.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.38,50,,5.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,75,,7.65,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,70,,7.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.2,80,,8.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.29,65,,6.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,35,,3.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.48,90,,9.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.64,11.48,
ACETYLCYSTEINE AMP: 20 %,3300527,CDM,250,RC,,,Outpatient,,,115.38,115.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.77,70,,64.62,percent of total billed charges,70% of total billed charges for outpatient setting,97.93,84.88,,78.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.69,50,,46.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.54,75,,69.23,percent of total billed charges,75% of total billed charges for outpatient setting,80.77,70,,64.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,12.84,,11.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.3,80,,73.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,12.84,,11.85,percent of total billed charges,12.84% of total billed charges,14.81,12.84,,11.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75,65,,60,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.38,35,,32.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.84,90,,83.07,percent of total billed charges,90% of total billed charges for outpatient setting,14.81,103.84,
ACETYLCYSTEINE MUCOMYST 20%  30ML,3300524,CDM,250,RC,,,Outpatient,,,62.79,62.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.95,70,,35.16,percent of total billed charges,70% of total billed charges for outpatient setting,53.3,84.88,,42.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.4,50,,25.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.09,75,,37.67,percent of total billed charges,75% of total billed charges for outpatient setting,43.95,70,,35.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,12.84,,6.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.23,80,,40.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,12.84,,6.45,percent of total billed charges,12.84% of total billed charges,8.06,12.84,,6.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.81,65,,32.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,35,,17.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.51,90,,45.21,percent of total billed charges,90% of total billed charges for outpatient setting,8.06,56.51,
ACHIEVE NEEDLE BIOPSY 16GX15CM / A1615,6150758,CDM,272,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,70,,134.4,percent of total billed charges,70% of total billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,168,70,,134.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,65,,124.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216,90,,172.8,percent of total billed charges,90% of total billed charges for outpatient setting,30.82,216,
ACHILLES MIDSB SPEED BRDG / AR-8929BC-CP,69162519,CDM,278,RC,C1713,HCPCS,Outpatient,,,3690.62,3690.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2214.37,60,,1771.5,percent of total billed charges,60% of total Billed charges for outpatient setting,3132.6,84.88,,2506.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2767.97,75,,2214.38,percent of total billed charges,75% of total billed charges for outpatient setting,1845.31,50,,1476.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2952.5,80,,2362,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3875.15,105,,3100.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.72,35,,1033.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2214.37,60,,1771.5,percent of total billed charges,60% of total billed charges for outpatient setting,473.88,3875.15,
ACHILLS SPEED BRDG W/JMP / AR-8928BCJ-CP,69162775,CDM,278,RC,C1713,HCPCS,Outpatient,,,4189.5,4189.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2513.7,60,,2010.96,percent of total billed charges,60% of total Billed charges for outpatient setting,3556.05,84.88,,2844.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3142.13,75,,2513.7,percent of total billed charges,75% of total billed charges for outpatient setting,2094.75,50,,1675.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.93,12.84,,430.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3351.6,80,,2681.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.93,12.84,,430.34,percent of total billed charges,12.84% of total billed charges,537.93,12.84,,430.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4398.98,105,,3519.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1466.33,35,,1173.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2513.7,60,,2010.96,percent of total billed charges,60% of total billed charges for outpatient setting,537.93,4398.98,
ACID PHOSPHATASE,220855,CDM,300,RC,84060,HCPCS,Outpatient,,,34.38,30.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.07,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,29.18,84.88,,23.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.79,75,,20.63,percent of total billed charges,75% of total billed charges for outpatient setting,24.07,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,80,,22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,100,,,Fee Schedule,100% of Custom Fee Schedule,30.94,90,,24.75,percent of total billed charges,90% of total billed charges for outpatient setting,7.64,30.94,
ACIPHEX TAB 20MG,3302813,CDM,259,RC,,,Outpatient,,,108.65,108.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.06,70,,60.85,percent of total billed charges,70% of total billed charges for outpatient setting,92.22,84.88,,73.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.33,50,,43.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.49,75,,65.19,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,70,,60.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,12.84,,11.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.92,80,,69.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,12.84,,11.16,percent of total billed charges,12.84% of total billed charges,13.95,12.84,,11.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.62,65,,56.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,35,,30.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.79,90,,78.23,percent of total billed charges,90% of total billed charges for outpatient setting,13.95,97.79,
ACL TIGHTROPE / AR-1588RT,69161060,CDM,278,RC,C1713,HCPCS,Outpatient,,,1514.1,1514.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,60,,726.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.17,84.88,,1028.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,75,,908.46,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,80,,969.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.1,65,,1211.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,35,,423.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.46,60,,726.77,percent of total billed charges,60% of total billed charges for outpatient setting,194.41,1514.1,
ACL TIGHTROPE BTB / AR-1588BTB,69161925,CDM,278,RC,C1713,HCPCS,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
ACL TIGHTROPE II BTB / AR-1588BTB-2J,71000417,CDM,278,RC,,,Outpatient,,,2002.87,2002.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.72,60,,961.38,percent of total billed charges,60% of total Billed charges for outpatient setting,1700.04,84.88,,1360.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1001.44,50,,801.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1502.15,75,,1201.72,percent of total billed charges,75% of total billed charges for outpatient setting,1001.44,50,,801.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.17,12.84,,205.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1602.3,80,,1281.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.17,12.84,,205.74,percent of total billed charges,12.84% of total billed charges,257.17,12.84,,205.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2002.87,65,,1602.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701,35,,560.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1201.72,60,,961.38,percent of total billed charges,60% of total billed charges for outpatient setting,257.17,2002.87,
ACL TIGHTROPE II RT / AR-1588RT-2J,71000366,CDM,278,RC,C1713,HCPCS,Outpatient,,,1860,1860,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116,60,,892.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1578.77,84.88,,1263.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1395,75,,1116,percent of total billed charges,75% of total billed charges for outpatient setting,930,50,,744,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.82,12.84,,191.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488,80,,1190.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.82,12.84,,191.06,percent of total billed charges,12.84% of total billed charges,238.82,12.84,,191.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1860,65,,1488,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651,35,,520.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1116,60,,892.8,percent of total billed charges,60% of total billed charges for outpatient setting,238.82,1860,
ACL TIGHTROPE RT DBL SUT/ AR-1588RT-J,69169291,CDM,278,RC,C1713,HCPCS,Outpatient,,,1554,1554,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.4,60,,745.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1319.04,84.88,,1055.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1165.5,75,,932.4,percent of total billed charges,75% of total billed charges for outpatient setting,777,50,,621.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.53,12.84,,159.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1243.2,80,,994.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.53,12.84,,159.62,percent of total billed charges,12.84% of total billed charges,199.53,12.84,,159.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1554,65,,1243.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.9,35,,435.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,932.4,60,,745.92,percent of total billed charges,60% of total billed charges for outpatient setting,199.53,1554,
ACT CLOT TIME,200280,CDM,305,RC,85347,HCPCS,Outpatient,,,19.26,17.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,16.35,84.88,,13.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.45,75,,11.56,percent of total billed charges,75% of total billed charges for outpatient setting,13.48,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,80,,12.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,100,,,Fee Schedule,100% of Custom Fee Schedule,17.33,90,,13.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,17.33,
ACTH,220711,CDM,301,RC,82024,HCPCS,Outpatient,,,173.79,156.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.65,70,,97.32,percent of total billed charges,70% of total billed charges for outpatient setting,147.51,84.88,,118.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,130.34,75,,104.27,percent of total billed charges,75% of total billed charges for outpatient setting,121.65,70,,97.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.03,80,,111.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,56.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.25,100,,,Fee Schedule,100% of Custom Fee Schedule,156.41,90,,125.13,percent of total billed charges,90% of total billed charges for outpatient setting,38.62,156.41,
ACTONEL RISEDRONATE 35 MG,3303200,CDM,259,RC,,,Outpatient,,,39.71,39.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.8,70,,22.24,percent of total billed charges,70% of total billed charges for outpatient setting,33.71,84.88,,26.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.86,50,,15.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.78,75,,23.82,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,70,,22.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.77,80,,25.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.81,65,,20.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.9,35,,11.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.74,90,,28.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,35.74,
ACYCARNITINES QUANTITATIVE EA SPECIMEN,201054,CDM,300,RC,82017,HCPCS,Outpatient,,,75.92,68.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.14,70,,42.51,percent of total billed charges,70% of total billed charges for outpatient setting,64.44,84.88,,51.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.94,75,,45.55,percent of total billed charges,75% of total billed charges for outpatient setting,53.14,70,,42.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.74,80,,48.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.98,100,,,Fee Schedule,100% of Custom Fee Schedule,68.33,90,,54.66,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,68.33,
ACYCLOVIR (genZOVIRAX) INJ 500MG,3300538,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
ACYCLOVIR (ZOVIRAX) CAP : 200MG,3300533,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACYCLOVIR (ZOVIRAX) CAP : 200MG,3300534,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACYCLOVIR (ZOVIRAX) OINT 15GM,3300537,CDM,259,RC,,,Outpatient,,,144.59,144.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.21,70,,80.97,percent of total billed charges,70% of total billed charges for outpatient setting,122.73,84.88,,98.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.3,50,,57.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.44,75,,86.75,percent of total billed charges,75% of total billed charges for outpatient setting,101.21,70,,80.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,12.84,,14.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.67,80,,92.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,12.84,,14.86,percent of total billed charges,12.84% of total billed charges,18.57,12.84,,14.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.98,65,,75.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.61,35,,40.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.13,90,,104.1,percent of total billed charges,90% of total billed charges for outpatient setting,18.57,130.13,
ACYCLOVIR (ZOVIRAX) OINT: 3GM,3300535,CDM,259,RC,,,Outpatient,,,65.37,65.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.76,70,,36.61,percent of total billed charges,70% of total billed charges for outpatient setting,55.49,84.88,,44.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.69,50,,26.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.03,75,,39.22,percent of total billed charges,75% of total billed charges for outpatient setting,45.76,70,,36.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.3,80,,41.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.49,65,,33.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.88,35,,18.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.83,90,,47.06,percent of total billed charges,90% of total billed charges for outpatient setting,8.39,58.83,
ACYCLOVIR (ZOVIRAX) TAB: 800MG,3300536,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ACYCLOVIR ZOVIRAX  INJ  1000MG,3300539,CDM,250,RC,,,Outpatient,,,29.03,29.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,70,,16.26,percent of total billed charges,70% of total billed charges for outpatient setting,24.64,84.88,,19.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,50,,11.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.77,75,,17.42,percent of total billed charges,75% of total billed charges for outpatient setting,20.32,70,,16.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.73,12.84,,2.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.22,80,,18.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.73,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,3.73,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.87,65,,15.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.16,35,,8.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.13,90,,20.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.73,26.13,
ADAPTER 2MM TRTHLN / 5570-S-020,71000371,CDM,278,RC,C1776,HCPCS,Outpatient,,,2292.16,2292.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.3,60,,1100.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1945.59,84.88,,1556.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.12,75,,1375.3,percent of total billed charges,75% of total billed charges for outpatient setting,1146.08,50,,916.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.31,12.84,,235.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.73,80,,1466.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.31,12.84,,235.45,percent of total billed charges,12.84% of total billed charges,294.31,12.84,,235.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2406.77,105,,1925.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.26,35,,641.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1375.3,60,,1100.24,percent of total billed charges,60% of total billed charges for outpatient setting,294.31,2406.77,
ADAPTER 4MM TRTHLN / 5570-S-040,71000517,CDM,278,RC,C1776,HCPCS,Outpatient,,,2292.16,2292.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.3,60,,1100.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1945.59,84.88,,1556.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.12,75,,1375.3,percent of total billed charges,75% of total billed charges for outpatient setting,1146.08,50,,916.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.31,12.84,,235.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.73,80,,1466.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.31,12.84,,235.45,percent of total billed charges,12.84% of total billed charges,294.31,12.84,,235.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2406.77,105,,1925.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.26,35,,641.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1375.3,60,,1100.24,percent of total billed charges,60% of total billed charges for outpatient setting,294.31,2406.77,
ADAPTER ANTI-REFLUX FILTER / 0046000,5150085,CDM,270,RC,,,Outpatient,,,24.88,24.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.42,70,,13.94,percent of total billed charges,70% of total billed charges for outpatient setting,21.12,84.88,,16.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.44,50,,9.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.66,75,,14.93,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,70,,13.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,80,,15.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.17,65,,12.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.71,35,,6.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.39,90,,17.91,percent of total billed charges,90% of total billed charges for outpatient setting,3.19,22.39,
ADAPTER ENDOGATOR CHANNEL / 100136,697064,CDM,272,RC,,,Outpatient,,,32.8,32.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.96,70,,18.37,percent of total billed charges,70% of total billed charges for outpatient setting,27.84,84.88,,22.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.4,50,,13.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.6,75,,19.68,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,70,,18.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.24,80,,20.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.32,65,,17.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,35,,9.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.52,90,,23.62,percent of total billed charges,90% of total billed charges for outpatient setting,4.21,29.52,
ADAPTER SIDE ARM STOPCOCK / G14287,69162776,CDM,272,RC,,,Outpatient,,,141.66,141.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.16,70,,79.33,percent of total billed charges,70% of total billed charges for outpatient setting,120.24,84.88,,96.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.83,50,,56.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.25,75,,85,percent of total billed charges,75% of total billed charges for outpatient setting,99.16,70,,79.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.19,12.84,,14.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.33,80,,90.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.19,12.84,,14.55,percent of total billed charges,12.84% of total billed charges,18.19,12.84,,14.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.08,65,,73.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.58,35,,39.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,90% of total billed charges for outpatient setting,18.19,127.49,
ADAPTER SNAPEVAC / SNAPEVAC20,7080413,CDM,272,RC,,,Outpatient,,,74.97,74.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.48,70,,41.98,percent of total billed charges,70% of total billed charges for outpatient setting,63.63,84.88,,50.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.49,50,,29.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.23,75,,44.98,percent of total billed charges,75% of total billed charges for outpatient setting,52.48,70,,41.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.63,12.84,,7.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.98,80,,47.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.63,12.84,,7.7,percent of total billed charges,12.84% of total billed charges,9.63,12.84,,7.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.73,65,,38.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.24,35,,20.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.47,90,,53.98,percent of total billed charges,90% of total billed charges for outpatient setting,9.63,67.47,
ADAPTER TUOHY BORST / G18814,69162541,CDM,272,RC,,,Outpatient,,,103.7,103.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.59,70,,58.07,percent of total billed charges,70% of total billed charges for outpatient setting,88.02,84.88,,70.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.85,50,,41.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.78,75,,62.22,percent of total billed charges,75% of total billed charges for outpatient setting,72.59,70,,58.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,12.84,,10.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.96,80,,66.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,13.32,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.41,65,,53.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.3,35,,29.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.33,90,,74.66,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,93.33,
ADAPTIC 3X18IN DRESSING / 2015,69159728,CDM,272,RC,A6223,HCPCS,Outpatient,,,5.53,5.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,70,,3.1,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,84.88,,3.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,75,,3.32,percent of total billed charges,75% of total billed charges for outpatient setting,3.87,70,,3.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,80,,3.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.59,65,,2.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,90,,3.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.71,4.98,
ADAPTIC 3X3IN / JJ2012B,5150089,CDM,272,RC,,,Outpatient,,,2.32,2.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,70,,1.3,percent of total billed charges,70% of total billed charges for outpatient setting,1.97,84.88,,1.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.16,50,,0.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.74,75,,1.39,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,70,,1.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,80,,1.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.51,65,,1.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,35,,0.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.09,90,,1.67,percent of total billed charges,90% of total billed charges for outpatient setting,0.3,2.09,
ADAPTIC 3X8 3/PK / CUR250383Z,5150163,CDM,272,RC,A6223,HCPCS,Outpatient,,,16.74,16.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.72,70,,9.38,percent of total billed charges,70% of total billed charges for outpatient setting,14.21,84.88,,11.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.56,75,,10.05,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,70,,9.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,80,,10.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.88,65,,8.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.07,90,,12.06,percent of total billed charges,90% of total billed charges for outpatient setting,2.15,15.07,
ADAPTOR APEX PIN LONG / 4933-1-021,70000668,CDM,278,RC,C1713,HCPCS,Outpatient,,,1757.66,1757.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1054.6,60,,843.68,percent of total billed charges,60% of total Billed charges for outpatient setting,1491.9,84.88,,1193.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1318.25,75,,1054.6,percent of total billed charges,75% of total billed charges for outpatient setting,878.83,50,,703.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.68,12.84,,180.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1406.13,80,,1124.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.68,12.84,,180.54,percent of total billed charges,12.84% of total billed charges,225.68,12.84,,180.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1757.66,65,,1406.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.18,35,,492.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1054.6,60,,843.68,percent of total billed charges,60% of total billed charges for outpatient setting,225.68,1757.66,
ADAPTOR APEX PIN SHORT / 4933-1-020,70000669,CDM,278,RC,C1713,HCPCS,Outpatient,,,1720.89,1720.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.53,60,,826.02,percent of total billed charges,60% of total Billed charges for outpatient setting,1460.69,84.88,,1168.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290.67,75,,1032.54,percent of total billed charges,75% of total billed charges for outpatient setting,860.45,50,,688.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.96,12.84,,176.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1376.71,80,,1101.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.96,12.84,,176.77,percent of total billed charges,12.84% of total billed charges,220.96,12.84,,176.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1720.89,65,,1376.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.31,35,,481.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1032.53,60,,826.02,percent of total billed charges,60% of total billed charges for outpatient setting,220.96,1720.89,
ADAPTOR CABLE RF DISP / DAC-NT,69169627,CDM,272,RC,,,Outpatient,,,315,315,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,267.37,84.88,,213.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,157.5,50,,126,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.25,75,,189,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,80,,201.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,204.75,65,,163.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,35,,88.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,283.5,90,,226.8,percent of total billed charges,90% of total billed charges for outpatient setting,40.45,283.5,
ADENOSINE INTRAVENOUS SOLN 3MG/ML 2ML,3309500,CDM,250,RC,J0150,HCPCS,Outpatient,,,73.5,73.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,62.39,84.88,,49.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.75,50,,29.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.13,75,,44.1,percent of total billed charges,75% of total billed charges for outpatient setting,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,80,,47.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.78,65,,38.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,35,,20.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.15,90,,52.92,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,66.15,
ADENOVIRUS,220857,CDM,302,RC,87798,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
ADHERUS DURAL SEALANT / NUS-109,69162862,CDM,272,RC,,,Outpatient,,,2848.13,2848.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1993.69,70,,1594.95,percent of total billed charges,70% of total billed charges for outpatient setting,2417.49,84.88,,1933.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1424.07,50,,1139.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2136.1,75,,1708.88,percent of total billed charges,75% of total billed charges for outpatient setting,1993.69,70,,1594.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.7,12.84,,292.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2278.5,80,,1822.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.7,12.84,,292.56,percent of total billed charges,12.84% of total billed charges,365.7,12.84,,292.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1851.28,65,,1481.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996.85,35,,797.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2563.32,90,,2050.66,percent of total billed charges,90% of total billed charges for outpatient setting,365.7,2563.32,
ADHESIVE PAD FUSION 9732500XOM,69161835,CDM,272,RC,,,Outpatient,,,37.85,37.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,32.13,84.88,,25.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.93,50,,15.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.39,75,,22.71,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,80,,24.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.6,65,,19.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,35,,10.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.07,90,,27.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,34.07,
ADULT ANES CIRCUIT W/FILTER / M1041112,6152341,CDM,270,RC,,,Outpatient,,,98.89,98.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.22,70,,55.38,percent of total billed charges,70% of total billed charges for outpatient setting,83.94,84.88,,67.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.45,50,,39.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.17,75,,59.34,percent of total billed charges,75% of total billed charges for outpatient setting,69.22,70,,55.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.11,80,,63.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.28,65,,51.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.61,35,,27.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89,90,,71.2,percent of total billed charges,90% of total billed charges for outpatient setting,12.7,89,
ADVAIR 250/50 DISKUS,3302890,CDM,259,RC,,,Outpatient,,,606.3,606.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.41,70,,339.53,percent of total billed charges,70% of total billed charges for outpatient setting,514.63,84.88,,411.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,303.15,50,,242.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.73,75,,363.78,percent of total billed charges,75% of total billed charges for outpatient setting,424.41,70,,339.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.85,12.84,,62.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.04,80,,388.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.85,12.84,,62.28,percent of total billed charges,12.84% of total billed charges,77.85,12.84,,62.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,394.1,65,,315.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.21,35,,169.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.67,90,,436.54,percent of total billed charges,90% of total billed charges for outpatient setting,77.85,545.67,
ADVAIR 500/50DISKUS,3303305,CDM,259,RC,,,Outpatient,,,1008.06,1008.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.64,70,,564.51,percent of total billed charges,70% of total billed charges for outpatient setting,855.64,84.88,,684.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,504.03,50,,403.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,756.05,75,,604.84,percent of total billed charges,75% of total billed charges for outpatient setting,705.64,70,,564.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.45,80,,645.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,655.24,65,,524.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.82,35,,282.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,907.25,90,,725.8,percent of total billed charges,90% of total billed charges for outpatient setting,129.43,907.25,
ADVAIR DISKUS 100-50 MCG/DOSE,3302618,CDM,259,RC,,,Outpatient,,,1299.98,1299.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,909.99,70,,727.99,percent of total billed charges,70% of total billed charges for outpatient setting,1103.42,84.88,,882.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,649.99,50,,519.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,974.99,75,,779.99,percent of total billed charges,75% of total billed charges for outpatient setting,909.99,70,,727.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1039.98,80,,831.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,844.99,65,,675.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.99,35,,363.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1169.98,90,,935.98,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1169.98,
ADVANTAGE FIT SYSTEM 8502110,69162079,CDM,278,RC,C1771,HCPCS,Outpatient,,,2425.5,2425.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.3,60,,1164.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2058.76,84.88,,1647.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1819.13,75,,1455.3,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,50,,970.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.43,12.84,,249.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1940.4,80,,1552.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.43,12.84,,249.14,percent of total billed charges,12.84% of total billed charges,311.43,12.84,,249.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2546.78,105,,2037.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.93,35,,679.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1455.3,60,,1164.24,percent of total billed charges,60% of total billed charges for outpatient setting,311.43,2546.78,
ADVICOR ER 500/20,3302998,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AEROCHAMBER with MASK (LARGE),3314245,CDM,270,RC,,,Outpatient,,,256.96,256.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,70,,143.9,percent of total billed charges,70% of total billed charges for outpatient setting,218.11,84.88,,174.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.48,50,,102.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.72,75,,154.18,percent of total billed charges,75% of total billed charges for outpatient setting,179.87,70,,143.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.57,80,,164.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.02,65,,133.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.94,35,,71.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,231.26,90,,185.01,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,231.26,
AEROCHAMBER with MASK (MEDIUM),3314246,CDM,270,RC,,,Outpatient,,,256.96,256.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,70,,143.9,percent of total billed charges,70% of total billed charges for outpatient setting,218.11,84.88,,174.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.48,50,,102.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.72,75,,154.18,percent of total billed charges,75% of total billed charges for outpatient setting,179.87,70,,143.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.57,80,,164.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.02,65,,133.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.94,35,,71.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,231.26,90,,185.01,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,231.26,
AEROSOL PEDI MASK W/TUBING // 002444,5050223,CDM,270,RC,,,Outpatient,,,23.96,23.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.77,70,,13.42,percent of total billed charges,70% of total billed charges for outpatient setting,20.34,84.88,,16.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.98,50,,9.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.97,75,,14.38,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,70,,13.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.17,80,,15.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.57,65,,12.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,35,,6.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.56,90,,17.25,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,21.56,
AFB CULTURE AND SMEAR,222034,CDM,300,RC,87015,HCPCS,Outpatient,,,30.06,27.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,25.51,84.88,,20.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.55,75,,18.04,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,80,,19.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of Custom Fee Schedule,27.05,90,,21.64,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,27.05,
AFB SUSCEPTIBILITY,201356,CDM,300,RC,87190,HCPCS,Outpatient,,,32.9,29.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,27.93,84.88,,22.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.68,75,,19.74,percent of total billed charges,75% of total billed charges for outpatient setting,23.03,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,80,,21.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.72,100,,,Fee Schedule,100% of Custom Fee Schedule,29.61,90,,23.69,percent of total billed charges,90% of total billed charges for outpatient setting,7.27,29.61,
AFFIRM EXPANDING SCRAPER / 658.216S,69162197,CDM,272,RC,,,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1124.76,65,,899.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1557.36,90,,1245.89,percent of total billed charges,90% of total billed charges for outpatient setting,222.18,1557.36,
AFFIRM VERTEBROPLASTY 10G KIT / 658.720S,69162198,CDM,272,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1430,65,,1144,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,90,,1584,percent of total billed charges,90% of total billed charges for outpatient setting,282.48,1980,
"AFP, MATERNAL",220853,CDM,300,RC,82105,HCPCS,Outpatient,,,75.47,67.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.83,70,,42.26,percent of total billed charges,70% of total billed charges for outpatient setting,64.06,84.88,,51.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.6,75,,45.28,percent of total billed charges,75% of total billed charges for outpatient setting,52.83,70,,42.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.38,80,,48.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,100,,,Fee Schedule,100% of Custom Fee Schedule,67.92,90,,54.34,percent of total billed charges,90% of total billed charges for outpatient setting,16.69,67.92,
AGGRENOX200/25 CAP,3303045,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AGGRESSIVE CUTTER 2.5MM / 275-628,6150584,CDM,270,RC,,,Outpatient,,,355.15,355.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.61,70,,198.89,percent of total billed charges,70% of total billed charges for outpatient setting,301.45,84.88,,241.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,177.58,50,,142.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.36,75,,213.09,percent of total billed charges,75% of total billed charges for outpatient setting,248.61,70,,198.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,12.84,,36.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.12,80,,227.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,12.84,,36.48,percent of total billed charges,12.84% of total billed charges,45.6,12.84,,36.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,230.85,65,,184.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.3,35,,99.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,319.64,90,,255.71,percent of total billed charges,90% of total billed charges for outpatient setting,45.6,319.64,
AHDL,200415,CDM,300,RC,83718,HCPCS,Outpatient,,,36.86,33.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,31.29,84.88,,25.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.65,75,,22.12,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,80,,23.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.96,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,100,,,Fee Schedule,100% of Custom Fee Schedule,33.17,90,,26.54,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,33.17,
AIRWAY BERMAM 40 PINK / DYNJBERM40,6152190,CDM,270,RC,,,Outpatient,,,3.01,3.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,70,,1.69,percent of total billed charges,70% of total billed charges for outpatient setting,2.55,84.88,,2.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,50,,1.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.26,75,,1.81,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,70,,1.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,80,,1.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.96,65,,1.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,35,,0.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.71,90,,2.17,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.71,
AIRWAY BERMAN 100MM PURPLE / 121905,7651085,CDM,272,RC,,,Outpatient,,,1.62,1.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,70,,0.9,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,84.88,,1.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.81,50,,0.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.22,75,,0.98,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,70,,0.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,12.84,,0.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,80,,1.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,12.84,,0.17,percent of total billed charges,12.84% of total billed charges,0.21,12.84,,0.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.05,65,,0.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,35,,0.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.46,90,,1.17,percent of total billed charges,90% of total billed charges for outpatient setting,0.21,1.46,
AIRWAY BERMAN 50MM BLUE // 1-1508-50,6152189,CDM,270,RC,,,Outpatient,,,2.93,2.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,70,,1.64,percent of total billed charges,70% of total billed charges for outpatient setting,2.49,84.88,,1.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.47,50,,1.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.2,75,,1.76,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,70,,1.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,80,,1.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.9,65,,1.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,35,,0.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.64,90,,2.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.38,2.64,
AIRWAY BERMAN 60MM BLACK / 122002,7651070,CDM,272,RC,,,Outpatient,,,1.4,1.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,70,,0.78,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,84.88,,0.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,50,,0.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.05,75,,0.84,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,70,,0.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,12.84,,0.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,80,,0.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,0.18,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.91,65,,0.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,35,,0.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.26,90,,1.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.18,1.26,
AIRWAY BERMAN 70MM WHITE / 3000-070A,3750085,CDM,270,RC,,,Outpatient,,,2.28,2.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,70,,1.28,percent of total billed charges,70% of total billed charges for outpatient setting,1.94,84.88,,1.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.14,50,,0.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.71,75,,1.37,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,70,,1.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,12.84,,0.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,80,,1.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,12.84,,0.23,percent of total billed charges,12.84% of total billed charges,0.29,12.84,,0.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.48,65,,1.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,35,,0.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.05,90,,1.64,percent of total billed charges,90% of total billed charges for outpatient setting,0.29,2.05,
AIRWAY BERMAN 80MM GREEN / 121903,7651075,CDM,272,RC,,,Outpatient,,,1.66,1.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,70,,0.93,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,84.88,,1.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.83,50,,0.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.25,75,,1,percent of total billed charges,75% of total billed charges for outpatient setting,1.16,70,,0.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,12.84,,0.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,80,,1.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,12.84,,0.17,percent of total billed charges,12.84% of total billed charges,0.21,12.84,,0.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.08,65,,0.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,35,,0.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.49,90,,1.19,percent of total billed charges,90% of total billed charges for outpatient setting,0.21,1.49,
AIRWAY BERMAN 90MM YELLOW / 121904,7651080,CDM,272,RC,,,Outpatient,,,1.37,1.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,70,,0.77,percent of total billed charges,70% of total billed charges for outpatient setting,1.16,84.88,,0.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.69,50,,0.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.03,75,,0.82,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,70,,0.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,12.84,,0.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,80,,0.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,0.18,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.89,65,,0.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,35,,0.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.23,90,,0.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.18,1.23,
AIRWAY NASAL 28FR 7MM / 321070,6152191,CDM,272,RC,,,Outpatient,,,23.58,23.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.51,70,,13.21,percent of total billed charges,70% of total billed charges for outpatient setting,20.01,84.88,,16.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.79,50,,9.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.69,75,,14.15,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,70,,13.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.86,80,,15.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.33,65,,12.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.25,35,,6.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.22,90,,16.98,percent of total billed charges,90% of total billed charges for outpatient setting,3.03,21.22,
AIRWAY NASAL 30FR 7.5MM / 8888247049,3750061,CDM,270,RC,,,Outpatient,,,16.16,16.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.31,70,,9.05,percent of total billed charges,70% of total billed charges for outpatient setting,13.72,84.88,,10.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.08,50,,6.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.12,75,,9.7,percent of total billed charges,75% of total billed charges for outpatient setting,11.31,70,,9.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,80,,10.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.5,65,,8.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,35,,4.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.54,90,,11.63,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,14.54,
AIRWAY NASAL 32FR 8.0 / 8888247056,6152192,CDM,272,RC,,,Outpatient,,,15.39,15.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.77,70,,8.62,percent of total billed charges,70% of total billed charges for outpatient setting,13.06,84.88,,10.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.7,50,,6.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.54,75,,9.23,percent of total billed charges,75% of total billed charges for outpatient setting,10.77,70,,8.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.31,80,,9.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10,65,,8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,35,,4.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.85,90,,11.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.98,13.85,
AIRWAY NASAL 34FR / 8.5,6152193,CDM,272,RC,,,Outpatient,,,23.96,23.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.77,70,,13.42,percent of total billed charges,70% of total billed charges for outpatient setting,20.34,84.88,,16.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.98,50,,9.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.97,75,,14.38,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,70,,13.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.17,80,,15.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.57,65,,12.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,35,,6.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.56,90,,17.25,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,21.56,
ALBUMIN (HUMAN) 25% INJ 50 ML,3302656,CDM,636,RC,P9047,HCPCS,Outpatient,,,216.56,216.56,BLJZ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.59,70,,121.27,percent of total billed charges,70% of total billed charges for outpatient setting,183.82,84.88,,147.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.28,50,,86.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.42,75,,129.94,percent of total billed charges,75% of total billed charges for outpatient setting,151.59,70,,121.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,12.84,,22.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.25,80,,138.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,12.84,,22.25,percent of total billed charges,12.84% of total billed charges,27.81,12.84,,22.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.76,65,,112.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.8,35,,60.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.9,90,,155.92,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,194.9,
ALBUMIN (HUMAN) 5% INJ 250 ML,3302657,CDM,636,RC,P9045,HCPCS,Outpatient,,,185.64,185.64,JZ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.95,70,,103.96,percent of total billed charges,70% of total billed charges for outpatient setting,157.57,84.88,,126.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.82,50,,74.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.23,75,,111.38,percent of total billed charges,75% of total billed charges for outpatient setting,129.95,70,,103.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.51,80,,118.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.67,65,,96.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.97,35,,51.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.08,90,,133.66,percent of total billed charges,90% of total billed charges for outpatient setting,23.84,167.08,
ALBUMIN (HUMAN)25% INJ 100MLS,3302959,CDM,386,RC,P9047,HCPCS,Outpatient,,,428.82,428.82,,83.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,300.17,70,,240.14,percent of total billed charges,70% of total billed charges for outpatient setting,363.98,84.88,,291.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,321.62,75,,257.3,percent of total billed charges,75% of total billed charges for outpatient setting,300.17,70,,240.14,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,170,,,Fee Schedule,170% of Medicare OPPS rate,112.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,55.06,12.84,,44.048,percent of total billed charges,12.84% of total billed charges,91.78,175,,,Fee Schedule,175% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,343.06,80,,274.45,percent of total billed charges,80% of total billed charges for outpatient setting,73.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,65.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,55.06,12.84,,44.05,percent of total billed charges,12.84% of total billed charges,55.06,12.84,,44.05,percent of total billed charges,12.84% of total billed charges,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,278.73,65,,222.98,percent of total billed charges,65% of total billed charges for outpatient setting,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.76,100,,,Fee Schedule,100% of Custom Fee Schedule,385.94,90,,308.75,percent of total billed charges,90% of total billed charges for outpatient setting,52.45,385.94,
ALBUMIN 25% INJ 100MLS PROCESSING FEE,3312959,CDM,390,RC,P9047,HCPCS,Outpatient,,,124.99,124.99,,83.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,106.09,84.88,,84.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.74,75,,74.99,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,170,,,Fee Schedule,170% of Medicare OPPS rate,112.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,91.78,175,,,Fee Schedule,175% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.99,80,,79.99,percent of total billed charges,80% of total billed charges for outpatient setting,73.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,65.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.24,65,,64.99,percent of total billed charges,65% of total billed charges for outpatient setting,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.76,100,,,Fee Schedule,100% of Custom Fee Schedule,112.49,90,,89.99,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.76,
ALBUMIN 25% INJ 50 ML PROCESSING FEE,3312656,CDM,636,RC,P9047,HCPCS,Outpatient,,,124.99,124.99,BL,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,106.09,84.88,,84.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.5,50,,50,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.74,75,,74.99,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.99,80,,79.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.24,65,,64.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.75,35,,35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.49,90,,89.99,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.49,
ALBUMIN 5% 250ML PROCESSING FEE,3312657,CDM,636,RC,P9045,HCPCS,Outpatient,,,124.99,124.99,,83.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,106.09,84.88,,84.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.74,75,,74.99,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,170,,,Fee Schedule,170% of Medicare OPPS rate,112.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,91.78,175,,,Fee Schedule,175% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.99,80,,79.99,percent of total billed charges,80% of total billed charges for outpatient setting,73.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,65.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.24,65,,64.99,percent of total billed charges,65% of total billed charges for outpatient setting,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.15,100,,,Fee Schedule,100% of Custom Fee Schedule,112.49,90,,89.99,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.76,
"ALBUMIN, SERUM",200420,CDM,300,RC,82040,HCPCS,Outpatient,,,22.28,20.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,84.88,,15.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.71,75,,13.37,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,80,,14.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,100,,,Fee Schedule,100% of Custom Fee Schedule,20.05,90,,16.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,20.05,
"ALBUMIN, URINE OR OTH SRC, QUANT EA SPEC",200421,CDM,300,RC,82042,HCPCS,Outpatient,,,35.01,31.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.51,70,,19.61,percent of total billed charges,70% of total billed charges for outpatient setting,29.72,84.88,,23.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.26,75,,21.01,percent of total billed charges,75% of total billed charges for outpatient setting,24.51,70,,19.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.01,80,,22.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,31.51,90,,25.21,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,31.51,
"ALBUMIN, URINE OR OTHER SOURCE",202372,CDM,310,RC,82042,HCPCS,Outpatient,,,35.01,31.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.51,70,,19.61,percent of total billed charges,70% of total billed charges for outpatient setting,29.72,84.88,,23.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.26,75,,21.01,percent of total billed charges,75% of total billed charges for outpatient setting,24.51,70,,19.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.01,80,,22.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,31.51,90,,25.21,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,31.51,
"ALBUMIN,URINE,MICROALBUMIN,QUANTITATIVE",202563,CDM,301,RC,82043,HCPCS,Outpatient,,,26.01,23.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,22.08,84.88,,17.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.51,75,,15.61,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,80,,16.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,100,,,Fee Schedule,100% of Custom Fee Schedule,23.41,90,,18.73,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,23.41,
ALBUTEROL (genVENTOLIN) HFA 8GM,3309000,CDM,259,RC,,,Outpatient,,,126.06,126.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.24,70,,70.59,percent of total billed charges,70% of total billed charges for outpatient setting,107,84.88,,85.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.03,50,,50.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.55,75,,75.64,percent of total billed charges,75% of total billed charges for outpatient setting,88.24,70,,70.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.19,12.84,,12.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.85,80,,80.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.19,12.84,,12.95,percent of total billed charges,12.84% of total billed charges,16.19,12.84,,12.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.94,65,,65.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.12,35,,35.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.45,90,,90.76,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,113.45,
ALBUTEROL (genVENTOLIN) INHALER 6.7GM,3300547,CDM,259,RC,,,Outpatient,,,159.39,159.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.57,70,,89.26,percent of total billed charges,70% of total billed charges for outpatient setting,135.29,84.88,,108.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.7,50,,63.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.54,75,,95.63,percent of total billed charges,75% of total billed charges for outpatient setting,111.57,70,,89.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,12.84,,16.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.51,80,,102.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,12.84,,16.38,percent of total billed charges,12.84% of total billed charges,20.47,12.84,,16.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,103.6,65,,82.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.79,35,,44.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.45,90,,114.76,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,143.45,
ALBUTEROL (genVENTOLIN) INHALER 8.5GM,3314127,CDM,259,RC,,,Outpatient,,,167.25,167.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.08,70,,93.66,percent of total billed charges,70% of total billed charges for outpatient setting,141.96,84.88,,113.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,83.63,50,,66.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.44,75,,100.35,percent of total billed charges,75% of total billed charges for outpatient setting,117.08,70,,93.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,12.84,,17.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,80,,107.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,12.84,,17.18,percent of total billed charges,12.84% of total billed charges,21.47,12.84,,17.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,108.71,65,,86.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.54,35,,46.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.53,90,,120.42,percent of total billed charges,90% of total billed charges for outpatient setting,21.47,150.53,
ALBUTEROL INH 0.083% 3ML,3300545,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALBUTEROL PROVENTIL NEB SOL 5MG/ML 20ML,3300542,CDM,259,RC,,,Outpatient,,,44.48,44.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,37.75,84.88,,30.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.24,50,,17.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.36,75,,26.69,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.58,80,,28.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.91,65,,23.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.57,35,,12.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.03,90,,32.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.71,40.03,
ALBUTEROL PROVENTIL TAB  2 MG,3300543,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ALBUTEROL PROVENTIL TAB 4MG REP,3300546,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALBUTEROL PROVETIL NEB SOL 5MG/ML 1ML,3300544,CDM,259,RC,,,Outpatient,,,44.48,44.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,37.75,84.88,,30.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.24,50,,17.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.36,75,,26.69,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.58,80,,28.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.91,65,,23.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.57,35,,12.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.03,90,,32.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.71,40.03,
ALBUTEROL VENTOLIN INH 90 MCG 6.8 GM,3300541,CDM,259,RC,,,Outpatient,,,47.65,47.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,70,,26.69,percent of total billed charges,70% of total billed charges for outpatient setting,40.45,84.88,,32.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.83,50,,19.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.74,75,,28.59,percent of total billed charges,75% of total billed charges for outpatient setting,33.36,70,,26.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,12.84,,4.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.12,80,,30.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,6.12,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.97,65,,24.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.68,35,,13.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.89,90,,34.31,percent of total billed charges,90% of total billed charges for outpatient setting,6.12,42.89,
ALDOLASE,220474,CDM,300,RC,82085,HCPCS,Outpatient,,,43.7,39.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,37.09,84.88,,29.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.78,75,,26.22,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,80,,27.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,100,,,Fee Schedule,100% of Custom Fee Schedule,39.33,90,,31.46,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,39.33,
ALDOSTERONE,220111,CDM,301,RC,82088,HCPCS,Outpatient,,,183.38,165.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.37,70,,102.7,percent of total billed charges,70% of total billed charges for outpatient setting,155.65,84.88,,124.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,137.54,75,,110.03,percent of total billed charges,75% of total billed charges for outpatient setting,128.37,70,,102.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.7,80,,117.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,59.5,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.28,100,,,Fee Schedule,100% of Custom Fee Schedule,165.04,90,,132.03,percent of total billed charges,90% of total billed charges for outpatient setting,40.75,165.04,
ALDOSTERONE 24 HR URINE,220240,CDM,301,RC,82088,HCPCS,Outpatient,,,183.38,165.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.37,70,,102.7,percent of total billed charges,70% of total billed charges for outpatient setting,155.65,84.88,,124.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,137.54,75,,110.03,percent of total billed charges,75% of total billed charges for outpatient setting,128.37,70,,102.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.7,80,,117.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,59.5,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.28,100,,,Fee Schedule,100% of Custom Fee Schedule,165.04,90,,132.03,percent of total billed charges,90% of total billed charges for outpatient setting,40.75,165.04,
ALENDRONATE FOSAMAX TAB 10 MG,3300548,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALENDRONATE SODIUM TAB 70MG TAB,3303151,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ALENIC ALKA SUSPENSION:95MG/15ML-358MG/1,3303067,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALFENTANIL  ALFENTA  INJ 500 MCG,3300550,CDM,250,RC,,,Outpatient,,,124.49,124.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.14,70,,69.71,percent of total billed charges,70% of total billed charges for outpatient setting,105.67,84.88,,84.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.25,50,,49.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.37,75,,74.7,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,70,,69.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,12.84,,12.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.59,80,,79.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,12.84,,12.78,percent of total billed charges,12.84% of total billed charges,15.98,12.84,,12.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.92,65,,64.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.57,35,,34.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.04,90,,89.63,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,112.04,
ALFENTANIL ALFENTA INJ  500 MCG,3300549,CDM,250,RC,,,Outpatient,,,22.65,22.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,70,,12.69,percent of total billed charges,70% of total billed charges for outpatient setting,19.23,84.88,,15.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.33,50,,9.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.99,75,,13.59,percent of total billed charges,75% of total billed charges for outpatient setting,15.86,70,,12.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.12,80,,14.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.72,65,,11.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,35,,6.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.39,90,,16.31,percent of total billed charges,90% of total billed charges for outpatient setting,2.91,20.39,
ALFENTANIL ALFENTA INJ 500 MCG,3300551,CDM,250,RC,,,Outpatient,,,39.17,39.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,70,,21.94,percent of total billed charges,70% of total billed charges for outpatient setting,33.25,84.88,,26.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.59,50,,15.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.38,75,,23.5,percent of total billed charges,75% of total billed charges for outpatient setting,27.42,70,,21.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,12.84,,4.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,80,,25.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,12.84,,4.02,percent of total billed charges,12.84% of total billed charges,5.03,12.84,,4.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.46,65,,20.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,35,,10.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.25,90,,28.2,percent of total billed charges,90% of total billed charges for outpatient setting,5.03,35.25,
ALFUZOSIN (UROXATRAL) 10MG TABS,3303778,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALK PHOS,200675,CDM,300,RC,84075,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
ALK PHOS ISOENZYMES,200887,CDM,302,RC,84080,HCPCS,Outpatient,,,66.51,59.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.56,70,,37.25,percent of total billed charges,70% of total billed charges for outpatient setting,56.45,84.88,,45.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.88,75,,39.9,percent of total billed charges,75% of total billed charges for outpatient setting,46.56,70,,37.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.21,80,,42.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,100,,,Fee Schedule,100% of Custom Fee Schedule,59.86,90,,47.89,percent of total billed charges,90% of total billed charges for outpatient setting,14.78,59.86,
ALKALINE PHOSPHATASE,200425,CDM,300,RC,84075,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
ALLANTOIN CARRASYN GEL,3300552,CDM,259,RC,,,Outpatient,,,49.28,49.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.5,70,,27.6,percent of total billed charges,70% of total billed charges for outpatient setting,41.83,84.88,,33.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.64,50,,19.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.96,75,,29.57,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,70,,27.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,12.84,,5.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.42,80,,31.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,12.84,,5.06,percent of total billed charges,12.84% of total billed charges,6.33,12.84,,5.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.03,65,,25.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,35,,13.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.35,90,,35.48,percent of total billed charges,90% of total billed charges for outpatient setting,6.33,44.35,
ALLEGRA (FEXOFENADINE)180 MG TAB,3302963,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALLEGRA 180 MG: FEXOFENADINE,3302833,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
"ALLERGEN PROFILE W IGE, AREA 6",220869,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
ALLODERM 12x20CM / 15201220,70000234,CDM,278,RC,Q4116,HCPCS,Outpatient,,,14248,14248,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8548.8,60,,6839.04,percent of total billed charges,60% of total Billed charges for outpatient setting,12093.7,84.88,,9674.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10686,75,,8548.8,percent of total billed charges,75% of total billed charges for outpatient setting,7124,50,,5699.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1829.44,12.84,,1463.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11398.4,80,,9118.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1829.44,12.84,,1463.55,percent of total billed charges,12.84% of total billed charges,1829.44,12.84,,1463.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14960.4,105,,11968.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8548.8,60,,6839.04,percent of total billed charges,60% of total billed charges for outpatient setting,34.22,14960.4,
ALLODERM 19.3X9.6CM MED / CM1518P,69162854,CDM,278,RC,C1821,HCPCS,Outpatient,,,7908,7908,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4744.8,60,,3795.84,percent of total billed charges,60% of total Billed charges for outpatient setting,6712.31,84.88,,5369.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5931,75,,4744.8,percent of total billed charges,75% of total billed charges for outpatient setting,3954,50,,3163.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.39,12.84,,812.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6326.4,80,,5061.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.39,12.84,,812.31,percent of total billed charges,12.84% of total billed charges,1015.39,12.84,,812.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8303.4,105,,6642.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2767.8,35,,2214.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4744.8,60,,3795.84,percent of total billed charges,60% of total billed charges for outpatient setting,1015.39,8303.4,
ALLODERM 8x16CM / 102128,69161195,CDM,278,RC,Q4116,HCPCS,Outpatient,,,9494,9494,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5696.4,60,,4557.12,percent of total billed charges,60% of total Billed charges for outpatient setting,8058.51,84.88,,6446.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,7120.5,75,,5696.4,percent of total billed charges,75% of total billed charges for outpatient setting,4747,50,,3797.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.03,12.84,,975.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7595.2,80,,6076.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.03,12.84,,975.22,percent of total billed charges,12.84% of total billed charges,1219.03,12.84,,975.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9968.7,105,,7974.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5696.4,60,,4557.12,percent of total billed charges,60% of total billed charges for outpatient setting,34.22,9968.7,
ALLODERM SM CONTOUR TISSUE / CS1516,69162545,CDM,278,RC,Q4116,HCPCS,Outpatient,,,4568,4568,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2740.8,60,,2192.64,percent of total billed charges,60% of total Billed charges for outpatient setting,3877.32,84.88,,3101.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3426,75,,2740.8,percent of total billed charges,75% of total billed charges for outpatient setting,2284,50,,1827.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.53,12.84,,469.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3654.4,80,,2923.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.53,12.84,,469.22,percent of total billed charges,12.84% of total billed charges,586.53,12.84,,469.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4796.4,105,,3837.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2740.8,60,,2192.64,percent of total billed charges,60% of total billed charges for outpatient setting,34.22,4796.4,
ALLOGRAFT 11X14MM 5DEG CERV / 8109.1208S,69162853,CDM,278,RC,C1821,HCPCS,Outpatient,,,2208,2208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.8,60,,1059.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1874.15,84.88,,1499.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1656,75,,1324.8,percent of total billed charges,75% of total billed charges for outpatient setting,1104,50,,883.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1766.4,80,,1413.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2318.4,105,,1854.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.8,35,,618.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1324.8,60,,1059.84,percent of total billed charges,60% of total billed charges for outpatient setting,283.51,2318.4,
ALLOGRAFT 11X14MM 6MM CERV / 8109.1206S,69162857,CDM,278,RC,C1821,HCPCS,Outpatient,,,2208,2208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.8,60,,1059.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1874.15,84.88,,1499.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1656,75,,1324.8,percent of total billed charges,75% of total billed charges for outpatient setting,1104,50,,883.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1766.4,80,,1413.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2318.4,105,,1854.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.8,35,,618.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1324.8,60,,1059.84,percent of total billed charges,60% of total billed charges for outpatient setting,283.51,2318.4,
ALLOGRAFT 11X14MM 7MM CERV / 8109.1207S,69162856,CDM,278,RC,C1821,HCPCS,Outpatient,,,2208,2208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.8,60,,1059.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1874.15,84.88,,1499.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1656,75,,1324.8,percent of total billed charges,75% of total billed charges for outpatient setting,1104,50,,883.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1766.4,80,,1413.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,283.51,12.84,,226.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2318.4,105,,1854.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.8,35,,618.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1324.8,60,,1059.84,percent of total billed charges,60% of total billed charges for outpatient setting,283.51,2318.4,
ALLOGRAFT 4X7CM ACELLULAR / AD.090.0407,71000908,CDM,278,RC,C1762,HCPCS,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
ALLOGRAFT 4X8CM ACELLULAR / EVD483,71000870,CDM,278,RC,C1762,HCPCS,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,60,,3840,percent of total billed charges,60% of total Billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8400,105,,6720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4800,60,,3840,percent of total billed charges,60% of total billed charges for outpatient setting,1027.2,8400,
ALLOGRAFT 8X14MM 7DEG 9MM AGX/8128.1279S,69162833,CDM,278,RC,C1821,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ALLOGRAFT 8X14MM 7DEG AGX / 8128.1278S,69162809,CDM,278,RC,C1821,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ALLOGRAFT EVOPATCH DL / EAP-46,71000306,CDM,278,RC,V2790,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
ALLOMAX  GRAFT 2X3.1 / 1180020,69161036,CDM,272,RC,C1781,HCPCS,Outpatient,,,2108,2108,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1475.6,70,,1180.48,percent of total billed charges,70% of total billed charges for outpatient setting,1789.27,84.88,,1431.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1581,75,,1264.8,percent of total billed charges,75% of total billed charges for outpatient setting,1475.6,70,,1180.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.67,12.84,,216.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.4,80,,1349.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.67,12.84,,216.54,percent of total billed charges,12.84% of total billed charges,270.67,12.84,,216.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1370.2,65,,1096.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,737.8,35,,590.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1897.2,90,,1517.76,percent of total billed charges,90% of total billed charges for outpatient setting,270.67,1897.2,
ALLOPURINOL (ZYLOPRIM) 300 MG,3303009,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALLOPURINOL genericZYLOPRIM TAB  100 MG,3300553,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALLOPURINOL ZYLOPRIM TAB  300 MG,3300554,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALLOPURINOL ZYLOPRIM TAB  300 MG,3300555,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALLOWRAP 4X4CM DS WET / 3102-2006,70000528,CDM,278,RC,Q4150,HCPCS,Outpatient,,,8160,8160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4896,60,,3916.8,percent of total billed charges,60% of total Billed charges for outpatient setting,6926.21,84.88,,5540.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,4080,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,6120,75,,4896,percent of total billed charges,75% of total billed charges for outpatient setting,4080,50,,3264,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.74,12.84,,838.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528,80,,5222.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.74,12.84,,838.19,percent of total billed charges,12.84% of total billed charges,1047.74,12.84,,838.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8568,105,,6854.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2856,35,,2284.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4896,60,,3916.8,percent of total billed charges,60% of total billed charges for outpatient setting,1047.74,8568,
ALOE VESTA OINTMENT 2OZ / MSC092B02,69169024,CDM,272,RC,A6250,HCPCS,Outpatient,,,6.8,6.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,70,,3.81,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,84.88,,4.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,75,,4.08,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,70,,3.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.44,80,,4.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.42,65,,3.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,35,,1.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.12,90,,4.9,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.12,
ALPHA 1-ANTITRYPSIN,200963,CDM,301,RC,82103,HCPCS,Outpatient,,,40.39,36.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.27,70,,22.62,percent of total billed charges,70% of total billed charges for outpatient setting,34.28,84.88,,27.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.29,75,,24.23,percent of total billed charges,75% of total billed charges for outpatient setting,28.27,70,,22.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.31,80,,25.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.61,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.48,100,,,Fee Schedule,100% of Custom Fee Schedule,36.35,90,,29.08,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,36.35,
"ALPHA 2 MACROGLOBULINS, QNT",220843,CDM,301,RC,83883,HCPCS,Outpatient,,,61.2,55.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,70,,34.27,percent of total billed charges,70% of total billed charges for outpatient setting,51.95,84.88,,41.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.9,75,,36.72,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,70,,34.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,80,,39.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,55.08,90,,44.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,55.08,
ALPHA FETOPROTEIN TUMOR MARKER,220852,CDM,300,RC,82105,HCPCS,Outpatient,,,75.47,67.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.83,70,,42.26,percent of total billed charges,70% of total billed charges for outpatient setting,64.06,84.88,,51.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.6,75,,45.28,percent of total billed charges,75% of total billed charges for outpatient setting,52.83,70,,42.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.38,80,,48.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,100,,,Fee Schedule,100% of Custom Fee Schedule,67.92,90,,54.34,percent of total billed charges,90% of total billed charges for outpatient setting,16.69,67.92,
ALPHA GALACTOS BEANO TAB,3300556,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALPHA SUBUNIT,220898,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
ALPHA-1- ANTITRYPSIN PHENOTYPES,220850,CDM,302,RC,82104,HCPCS,Outpatient,,,65.07,58.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.55,70,,36.44,percent of total billed charges,70% of total billed charges for outpatient setting,55.23,84.88,,44.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.8,75,,39.04,percent of total billed charges,75% of total billed charges for outpatient setting,45.55,70,,36.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.06,80,,41.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.11,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,100,,,Fee Schedule,100% of Custom Fee Schedule,58.56,90,,46.85,percent of total billed charges,90% of total billed charges for outpatient setting,14.46,58.56,
ALPHA-GAL  IGE  FOOD ALLERGEN,220165,CDM,301,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
ALPRAZOLAM (genericXANAX) TAB 0.25 MG,3300557,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALPRAZOLAM (genericXANAX) TAB 0.5 MG,3300558,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALPRAZOLAM XANAX TAB 0.5 MG,3300559,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ALTEPLASE ACTIVASE INJ 100 MG,3300561,CDM,250,RC,,,Outpatient,,,10214.09,10214.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7149.86,70,,5719.89,percent of total billed charges,70% of total billed charges for outpatient setting,8669.72,84.88,,6935.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,5107.05,50,,4085.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7660.57,75,,6128.46,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.49,12.84,,1049.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8171.27,80,,6537.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.49,12.84,,1049.19,percent of total billed charges,12.84% of total billed charges,1311.49,12.84,,1049.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6639.16,65,,5311.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3574.93,35,,2859.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9192.68,90,,7354.14,percent of total billed charges,90% of total billed charges for outpatient setting,1311.49,9192.68,
ALTEPLASE CATHFLO INJ 2 MG,3300560,CDM,250,RC,,,Outpatient,,,226.84,226.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.79,70,,127.03,percent of total billed charges,70% of total billed charges for outpatient setting,192.54,84.88,,154.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.42,50,,90.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.13,75,,136.1,percent of total billed charges,75% of total billed charges for outpatient setting,158.79,70,,127.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.13,12.84,,23.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.47,80,,145.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.13,12.84,,23.3,percent of total billed charges,12.84% of total billed charges,29.13,12.84,,23.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.45,65,,117.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.39,35,,63.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.16,90,,163.33,percent of total billed charges,90% of total billed charges for outpatient setting,29.13,204.16,
ALTIS SLING SYSTEM SINGLE I INC / 519650,69162522,CDM,278,RC,C1771,HCPCS,Outpatient,,,4395.6,4395.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2637.36,60,,2109.89,percent of total billed charges,60% of total Billed charges for outpatient setting,3730.99,84.88,,2984.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3296.7,75,,2637.36,percent of total billed charges,75% of total billed charges for outpatient setting,2197.8,50,,1758.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.4,12.84,,451.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3516.48,80,,2813.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.4,12.84,,451.52,percent of total billed charges,12.84% of total billed charges,564.4,12.84,,451.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4615.38,105,,3692.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1538.46,35,,1230.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2637.36,60,,2109.89,percent of total billed charges,60% of total billed charges for outpatient setting,564.4,4615.38,
ALU/MAG/SIMETHICONE LIQ 355MLS,3300562,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ALUMINUM,200969,CDM,300,RC,82108,HCPCS,Outpatient,,,114.66,103.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,70,,64.21,percent of total billed charges,70% of total billed charges for outpatient setting,97.32,84.88,,77.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,86,75,,68.8,percent of total billed charges,75% of total billed charges for outpatient setting,80.26,70,,64.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.73,80,,73.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.2,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of Custom Fee Schedule,103.19,90,,82.55,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,103.19,
AMANTADINE SYMMETREL CAP 100 MG,3300563,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AMANTADINE SYMMETREL SYRUP 50MG/5ML 5ML,3300564,CDM,259,RC,,,Outpatient,,,220.26,220.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.18,70,,123.34,percent of total billed charges,70% of total billed charges for outpatient setting,186.96,84.88,,149.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.13,50,,88.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.2,75,,132.16,percent of total billed charges,75% of total billed charges for outpatient setting,154.18,70,,123.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,12.84,,22.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.21,80,,140.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,12.84,,22.62,percent of total billed charges,12.84% of total billed charges,28.28,12.84,,22.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.09,35,,61.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198.23,90,,158.58,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,198.23,
AMBLUANCE - CC,5100045,CDM,542,RC,,,Outpatient,,,1704.55,1704.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.19,70,,954.55,percent of total billed charges,70% of total billed charges for outpatient setting,1446.82,84.88,,1157.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,852.28,50,,681.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1278.41,75,,1022.73,percent of total billed charges,75% of total billed charges for outpatient setting,1193.19,70,,954.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.86,12.84,,175.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.64,80,,1090.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.86,12.84,,175.09,percent of total billed charges,12.84% of total billed charges,218.86,12.84,,175.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.59,35,,477.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1534.1,90,,1227.28,percent of total billed charges,90% of total billed charges for outpatient setting,218.86,1534.1,
AMBLUANCE-BASIC,5100050,CDM,540,RC,,,Outpatient,,,568.18,568.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.73,70,,318.18,percent of total billed charges,70% of total billed charges for outpatient setting,482.27,84.88,,385.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.09,50,,227.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.14,75,,340.91,percent of total billed charges,75% of total billed charges for outpatient setting,397.73,70,,318.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.54,80,,363.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.86,35,,159.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,511.36,90,,409.09,percent of total billed charges,90% of total billed charges for outpatient setting,72.95,511.36,
AMIKACIN AMIKIN  INJ 250 MG/ML 2ML,3300566,CDM,250,RC,,,Outpatient,,,103.69,103.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.58,70,,58.06,percent of total billed charges,70% of total billed charges for outpatient setting,88.01,84.88,,70.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.85,50,,41.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.77,75,,62.22,percent of total billed charges,75% of total billed charges for outpatient setting,72.58,70,,58.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,12.84,,10.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.95,80,,66.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,12.84,,10.65,percent of total billed charges,12.84% of total billed charges,13.31,12.84,,10.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.4,65,,53.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,35,,29.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.32,90,,74.66,percent of total billed charges,90% of total billed charges for outpatient setting,13.31,93.32,
AMIKACIN AMIKIN SF INJ 250MG/ML 2ML,3300565,CDM,250,RC,,,Outpatient,,,117.95,117.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.57,70,,66.06,percent of total billed charges,70% of total billed charges for outpatient setting,100.12,84.88,,80.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.98,50,,47.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.46,75,,70.77,percent of total billed charges,75% of total billed charges for outpatient setting,82.57,70,,66.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.14,12.84,,12.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.36,80,,75.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.14,12.84,,12.11,percent of total billed charges,12.84% of total billed charges,15.14,12.84,,12.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.67,65,,61.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,35,,33.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.16,90,,84.93,percent of total billed charges,90% of total billed charges for outpatient setting,15.14,106.16,
AMIKACIN PEAK,200035,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMIKACIN PEAK,220018,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMIKACIN QUANT,200040,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMIKACIN RANDOM,220023,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMIKACIN TROUGH,200045,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMIKACIN TROUGH,220024,CDM,300,RC,80150,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,61.07,
AMILORIDE HCT MODURETIC TAB  5 50 MG,3300567,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMINO ACID TRAVASOL 8.5%LYTES SOL 500ML,3300568,CDM,259,RC,,,Outpatient,,,481.19,481.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.83,70,,269.46,percent of total billed charges,70% of total billed charges for outpatient setting,408.43,84.88,,326.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.6,50,,192.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.89,75,,288.71,percent of total billed charges,75% of total billed charges for outpatient setting,336.83,70,,269.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.78,12.84,,49.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.95,80,,307.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.78,12.84,,49.42,percent of total billed charges,12.84% of total billed charges,61.78,12.84,,49.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,312.77,65,,250.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.42,35,,134.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,433.07,90,,346.46,percent of total billed charges,90% of total billed charges for outpatient setting,61.78,433.07,
AMINOACID (CLINISOL)15% 500 ML,3303104,CDM,250,RC,,,Outpatient,,,493.69,493.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.58,70,,276.46,percent of total billed charges,70% of total billed charges for outpatient setting,419.04,84.88,,335.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,246.85,50,,197.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.27,75,,296.22,percent of total billed charges,75% of total billed charges for outpatient setting,345.58,70,,276.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.39,12.84,,50.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.95,80,,315.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.39,12.84,,50.71,percent of total billed charges,12.84% of total billed charges,63.39,12.84,,50.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,320.9,65,,256.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.79,35,,138.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,444.32,90,,355.46,percent of total billed charges,90% of total billed charges for outpatient setting,63.39,444.32,
AMINOCAPROIC AMICAR  INJ 250MG/ML 20ML,3300569,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMINOCAPROIC AMICAR TAB 500 MG,3300570,CDM,259,RC,,,Outpatient,,,79.72,79.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,70,,44.64,percent of total billed charges,70% of total billed charges for outpatient setting,67.67,84.88,,54.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.86,50,,31.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.79,75,,47.83,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,70,,44.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.24,12.84,,8.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.78,80,,51.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.24,12.84,,8.19,percent of total billed charges,12.84% of total billed charges,10.24,12.84,,8.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.82,65,,41.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,35,,22.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.75,90,,57.4,percent of total billed charges,90% of total billed charges for outpatient setting,10.24,71.75,
AMINOPHYLLINE AMINOPHYLL 500MG 20ML INJ,3300571,CDM,636,RC,J0280,HCPCS,Outpatient,,,48.37,48.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.86,70,,27.09,percent of total billed charges,70% of total billed charges for outpatient setting,41.06,84.88,,32.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.28,75,,29.02,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,70,,27.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,12.84,,4.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,80,,30.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,12.84,,4.97,percent of total billed charges,12.84% of total billed charges,6.21,12.84,,4.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.44,65,,25.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,100,,,Fee Schedule,100% of Custom Fee Schedule,43.53,90,,34.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.21,43.53,
AMINOSYN 10%: 500 ML,3303099,CDM,250,RC,,,Outpatient,,,484.02,484.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.81,70,,271.05,percent of total billed charges,70% of total billed charges for outpatient setting,410.84,84.88,,328.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,242.01,50,,193.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,363.02,75,,290.42,percent of total billed charges,75% of total billed charges for outpatient setting,338.81,70,,271.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.15,12.84,,49.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.22,80,,309.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.15,12.84,,49.72,percent of total billed charges,12.84% of total billed charges,62.15,12.84,,49.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,314.61,65,,251.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.41,35,,135.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,435.62,90,,348.5,percent of total billed charges,90% of total billed charges for outpatient setting,62.15,435.62,
AMIODARONE,200568,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
AMIODARONE (genCORDARONE)50MG/ML 18MLinj,3303057,CDM,636,RC,J0282,HCPCS,Outpatient,,,83.79,83.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.65,70,,46.92,percent of total billed charges,70% of total billed charges for outpatient setting,71.12,84.88,,56.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.84,75,,50.27,percent of total billed charges,75% of total billed charges for outpatient setting,58.65,70,,46.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,12.84,,8.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.03,80,,53.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,12.84,,8.61,percent of total billed charges,12.84% of total billed charges,10.76,12.84,,8.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.46,65,,43.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.41,90,,60.33,percent of total billed charges,90% of total billed charges for outpatient setting,0.5,75.41,
AMIODARONE (genPACERONE) 200MG TAB,3300573,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMIODARONE CORDARONE INJ 50MG/ML 3ML,3300574,CDM,636,RC,J0282,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMIODARONE CORDARONE TAB  200 MG,3300572,CDM,259,RC,,,Outpatient,,,8.03,8.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.62,70,,4.5,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,84.88,,5.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.02,50,,3.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.02,75,,4.82,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,70,,4.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,80,,5.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.22,65,,4.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,35,,2.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.23,90,,5.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,7.23,
AMISULPRIDE (BARHEMSYS) 2.5MG/ML  4ML,3313961,CDM,636,RC,J3490,HCPCS,Outpatient,,,320.44,320.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.31,70,,179.45,percent of total billed charges,70% of total billed charges for outpatient setting,271.99,84.88,,217.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,240.33,75,,192.26,percent of total billed charges,75% of total billed charges for outpatient setting,224.31,70,,179.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.14,12.84,,32.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.35,80,,205.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.14,12.84,,32.91,percent of total billed charges,12.84% of total billed charges,41.14,12.84,,32.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208.29,65,,166.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.15,35,,89.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288.4,90,,230.72,percent of total billed charges,90% of total billed charges for outpatient setting,41.14,288.4,
AMITRIP HCL (ELAVIL) TAB 75MG,3303091,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMITRIP HCL ELAVIL TAB 25 MG,3300576,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMITRIPTYLINE,220025,CDM,300,RC,80335,HCPCS,Outpatient,,,171.81,154.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.27,70,,96.22,percent of total billed charges,70% of total billed charges for outpatient setting,145.83,84.88,,116.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.91,50,,68.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.86,75,,103.09,percent of total billed charges,75% of total billed charges for outpatient setting,120.27,70,,96.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.06,12.84,,17.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.45,80,,109.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.06,12.84,,17.65,percent of total billed charges,12.84% of total billed charges,22.06,12.84,,17.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.63,90,,123.7,percent of total billed charges,90% of total billed charges for outpatient setting,22.06,154.63,
AMITRIPTYLINE HCL(genELAVIL) 25MG TAB,3300575,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMITRIPTYLINE(ELAVIL) : 50 MG,3302831,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMITRIPTYLINE(genericELAVIL)TAB  10 MG,3300577,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AMLODIPINE (genericNORVASC) TAB 10MG,3302700,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMLODIPINE (genericNORVASC) TAB 2.5 MG,3300579,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AMLODIPINE (genericNORVASC) TAB 5 MG,3300580,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AMLODIPINE/BENAZEPRIL(LOTREL)5/10 CAP,3302866,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMMONIA,220830,CDM,301,RC,82140,HCPCS,Outpatient,,,65.57,59.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,55.66,84.88,,44.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.18,75,,39.34,percent of total billed charges,75% of total billed charges for outpatient setting,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.46,80,,41.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.63,100,,,Fee Schedule,100% of Custom Fee Schedule,59.01,90,,47.21,percent of total billed charges,90% of total billed charges for outpatient setting,14.57,59.01,
AMMONIA INHALANTS,3300581,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMMONIUM L AMLACTIN LOT 225 GM,3300583,CDM,259,RC,,,Outpatient,,,26.57,26.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,70,,14.88,percent of total billed charges,70% of total billed charges for outpatient setting,22.55,84.88,,18.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.29,50,,10.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.93,75,,15.94,percent of total billed charges,75% of total billed charges for outpatient setting,18.6,70,,14.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,12.84,,2.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.26,80,,17.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,12.84,,2.73,percent of total billed charges,12.84% of total billed charges,3.41,12.84,,2.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.27,65,,13.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,35,,7.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.91,90,,19.13,percent of total billed charges,90% of total billed charges for outpatient setting,3.41,23.91,
AMMONIUM L LAC HYDRIN LOTION 4 OZ,3300582,CDM,259,RC,,,Outpatient,,,15.71,15.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11,70,,8.8,percent of total billed charges,70% of total billed charges for outpatient setting,13.33,84.88,,10.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.86,50,,6.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.78,75,,9.42,percent of total billed charges,75% of total billed charges for outpatient setting,11,70,,8.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.57,80,,10.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.21,65,,8.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,35,,4.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.14,90,,11.31,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.14,
AMNIOGRAFT 1.5X1.0CM OCULAR / AG-1510F,69169874,CDM,278,RC,V2790,HCPCS,Outpatient,,,22576,22576,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13545.6,60,,10836.48,percent of total billed charges,60% of total Billed charges for outpatient setting,19162.51,84.88,,15330.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,11288,50,,9030.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16932,75,,13545.6,percent of total billed charges,75% of total billed charges for outpatient setting,11288,50,,9030.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2898.76,12.84,,2319.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18060.8,80,,14448.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2898.76,12.84,,2319.01,percent of total billed charges,12.84% of total billed charges,2898.76,12.84,,2319.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23704.8,105,,18963.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7901.6,35,,6321.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13545.6,60,,10836.48,percent of total billed charges,60% of total billed charges for outpatient setting,2898.76,23704.8,
AMNIOGRAFT 2.0X1.5CM OCULAR / AG-2015,71000244,CDM,278,RC,V2790,HCPCS,Outpatient,,,2411.5,2411.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.9,60,,1157.52,percent of total billed charges,60% of total Billed charges for outpatient setting,2046.88,84.88,,1637.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1205.75,50,,964.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1808.63,75,,1446.9,percent of total billed charges,75% of total billed charges for outpatient setting,1205.75,50,,964.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.64,12.84,,247.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.2,80,,1543.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.64,12.84,,247.71,percent of total billed charges,12.84% of total billed charges,309.64,12.84,,247.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2532.08,105,,2025.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.03,35,,675.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1446.9,60,,1157.52,percent of total billed charges,60% of total billed charges for outpatient setting,309.64,2532.08,
AMOXAPINE ASENDIN TAB 50 MG,3300584,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMOXICILLIN (TRIMOX) CAP :250MG  U/D,3300586,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMOXICILLIN AUGMENTIN TAB  250MG U/D,3300596,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMOXICILLIN AUGMENTIN TAB 500MG U/D,3300597,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMOXICILLIN CAP 250 MG,3302870,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMOXICILLIN CAP 500MG UD,3300593,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMOXICILLIN PED DROPS 50MG/ML 15ML,3300587,CDM,259,RC,,,Outpatient,,,4.85,4.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,84.88,,3.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.43,50,,1.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.64,75,,2.91,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,80,,3.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.15,65,,2.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,35,,1.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.37,90,,3.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.37,
AMOXICILLIN SUSP 250MG/5ML100,3300588,CDM,259,RC,,,Outpatient,,,29.57,29.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,70,,16.56,percent of total billed charges,70% of total billed charges for outpatient setting,25.1,84.88,,20.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.79,50,,11.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.18,75,,17.74,percent of total billed charges,75% of total billed charges for outpatient setting,20.7,70,,16.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,80,,18.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.22,65,,15.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,35,,8.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.61,90,,21.29,percent of total billed charges,90% of total billed charges for outpatient setting,3.8,26.61,
AMOXICILLIN SUSP 250MG/5ML80ML,3300589,CDM,259,RC,,,Outpatient,,,14.43,14.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,70,,8.08,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,84.88,,9.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.22,50,,5.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.82,75,,8.66,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,70,,8.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.54,80,,9.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.38,65,,7.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,35,,4.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.99,90,,10.39,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,12.99,
AMOXICILLIN TRIMOX CAP 250 MG,3300585,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMOXICILLIN TRIMOX CAP 250MG UD,3300591,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
AMOXICILLIN TRIMOX CAP 500 MG,3300590,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AMOXICILLIN TRIMOX CAP 500MG  UD,3300592,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
AMOXICILLIN/POT CLAVU 875-125MG TAB,3302812,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMP 10ML ELEVIEW 5 / 9000020,71000088,CDM,272,RC,,,Outpatient,,,334.4,334.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.08,70,,187.26,percent of total billed charges,70% of total billed charges for outpatient setting,283.84,84.88,,227.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.2,50,,133.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.8,75,,200.64,percent of total billed charges,75% of total billed charges for outpatient setting,234.08,70,,187.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,12.84,,34.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.52,80,,214.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,12.84,,34.35,percent of total billed charges,12.84% of total billed charges,42.94,12.84,,34.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.36,65,,173.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.04,35,,93.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.96,90,,240.77,percent of total billed charges,90% of total billed charges for outpatient setting,42.94,300.96,
AMP PROBE TECHNIQUE QUALITATIVE,201508,CDM,306,RC,87521,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
AMPHOTERICIN B FUNGIZONE INJ  50 MG,3300599,CDM,636,RC,J0285,HCPCS,Outpatient,,,103.47,103.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.43,70,,57.94,percent of total billed charges,70% of total billed charges for outpatient setting,87.83,84.88,,70.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.95,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.6,75,,62.08,percent of total billed charges,75% of total billed charges for outpatient setting,72.43,70,,57.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.29,12.84,,10.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.78,80,,66.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.29,12.84,,10.63,percent of total billed charges,12.84% of total billed charges,13.29,12.84,,10.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.26,65,,53.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,100,,,Fee Schedule,100% of Custom Fee Schedule,93.12,90,,74.5,percent of total billed charges,90% of total billed charges for outpatient setting,13.29,93.12,
AMPHOTERICIN B FUNGIZONE INJ 50 MG,3300598,CDM,636,RC,J0285,HCPCS,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.95,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,100,,,Fee Schedule,100% of Custom Fee Schedule,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,50.95,
AMPICILLIN  POLYCILLIN INJ 2GM,3300601,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMPICILLIN & SULB 1.5GM / 50 ML NS IVPB,3302727,CDM,250,RC,,,Outpatient,,,113.43,113.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,96.28,84.88,,77.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.72,50,,45.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.07,75,,68.06,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,80,,72.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.73,65,,58.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,35,,31.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.09,90,,81.67,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.09,
AMPICILLIN (genericPOLYCILLIN) 1GM INJ,3300600,CDM,250,RC,J0290,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMPICILLIN POLYCILLIN INJ  10GM,3300602,CDM,250,RC,,,Outpatient,,,345.6,345.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.92,70,,193.54,percent of total billed charges,70% of total billed charges for outpatient setting,293.35,84.88,,234.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,172.8,50,,138.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.2,75,,207.36,percent of total billed charges,75% of total billed charges for outpatient setting,241.92,70,,193.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.38,12.84,,35.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.48,80,,221.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.38,12.84,,35.5,percent of total billed charges,12.84% of total billed charges,44.38,12.84,,35.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.64,65,,179.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,35,,96.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.04,90,,248.83,percent of total billed charges,90% of total billed charges for outpatient setting,44.38,311.04,
AMPICILLIN PRINCIPEN CAP  250 MG,3300603,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AMPICILLIN SULB genUNASYN 3 GM VIAL,3300605,CDM,636,RC,J0295,HCPCS,Outpatient,,,57.19,57.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.03,70,,32.02,percent of total billed charges,70% of total billed charges for outpatient setting,48.54,84.88,,38.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.89,75,,34.31,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,70,,32.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.34,12.84,,5.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.75,80,,36.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.34,12.84,,5.87,percent of total billed charges,12.84% of total billed charges,7.34,12.84,,5.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.17,65,,29.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.71,100,,,Fee Schedule,100% of Custom Fee Schedule,51.47,90,,41.18,percent of total billed charges,90% of total billed charges for outpatient setting,2.65,51.47,
AMPICILLIN SULBUNASYNINJ 1.5 GM,3300604,CDM,636,RC,J0295,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.71,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AMVISC PLUS .8ML / 60081L,69162905,CDM,270,RC,,,Outpatient,,,205.49,205.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.84,70,,115.07,percent of total billed charges,70% of total billed charges for outpatient setting,174.42,84.88,,139.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.75,50,,82.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.12,75,,123.3,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,70,,115.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,12.84,,21.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.39,80,,131.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,26.38,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.57,65,,106.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.92,35,,57.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.94,90,,147.95,percent of total billed charges,90% of total billed charges for outpatient setting,26.38,184.94,
AMYLASE,200120,CDM,300,RC,82150,HCPCS,Outpatient,,,29.16,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,24.75,84.88,,19.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.87,75,,17.5,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,80,,18.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of Custom Fee Schedule,26.24,90,,20.99,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,26.24,
AMYLASE L P PANCREASE CAP 4500UN,3300606,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
AMYLASE/LIPASE/PROTEASE:VIOKASE 8000 U,3303270,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
ANA TITER BY IFA,222002,CDM,300,RC,86038,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.92,100,,,Fee Schedule,100% of Custom Fee Schedule,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,48.97,
ANA W/REFLEX TO CONFIRMATORY TESTS,222003,CDM,302,RC,86038,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.92,100,,,Fee Schedule,100% of Custom Fee Schedule,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,48.97,
ANAEROBIC BACTERIA SUSCEPTIBILITY,201358,CDM,300,RC,87184,HCPCS,Outpatient,,,33.66,30.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,84.88,,22.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.25,75,,20.2,percent of total billed charges,75% of total billed charges for outpatient setting,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.93,80,,21.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.07,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,100,,,Fee Schedule,100% of Custom Fee Schedule,30.29,90,,24.23,percent of total billed charges,90% of total billed charges for outpatient setting,7.48,30.29,
ANAFRANIL (CLOMIPRAMINE): 25 MG,3303167,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
ANALPRAM HC CREAM:,3303034,CDM,259,RC,,,Outpatient,,,24.09,24.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,20.45,84.88,,16.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.05,50,,9.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.07,75,,14.46,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,80,,15.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.66,65,,12.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.43,35,,6.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.68,90,,17.34,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,21.68,
ANASTROZOLE ARIMIDEX TAB 1 MG,3300607,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ANCA SCREEN PROFILE,220453,CDM,302,RC,86256,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.85,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANCHOR 1.8MM FIBERTAK / AR-3636,71000596,CDM,278,RC,C1713,HCPCS,Outpatient,,,1848,1848,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.8,60,,887.04,percent of total billed charges,60% of total Billed charges for outpatient setting,1568.58,84.88,,1254.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,75,,1108.8,percent of total billed charges,75% of total billed charges for outpatient setting,924,50,,739.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.28,12.84,,189.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1478.4,80,,1182.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.28,12.84,,189.82,percent of total billed charges,12.84% of total billed charges,237.28,12.84,,189.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1848,65,,1478.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,35,,517.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1108.8,60,,887.04,percent of total billed charges,60% of total billed charges for outpatient setting,237.28,1848,
ANCHOR 2 SUTURE FIBERTAK / AR-8991,71000262,CDM,278,RC,C1713,HCPCS,Outpatient,,,2186.62,2186.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.97,60,,1049.58,percent of total billed charges,60% of total Billed charges for outpatient setting,1856,84.88,,1484.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.97,75,,1311.98,percent of total billed charges,75% of total billed charges for outpatient setting,1093.31,50,,874.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.76,12.84,,224.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.3,80,,1399.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.76,12.84,,224.61,percent of total billed charges,12.84% of total billed charges,280.76,12.84,,224.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2295.95,105,,1836.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.32,35,,612.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1311.97,60,,1049.58,percent of total billed charges,60% of total billed charges for outpatient setting,280.76,2295.95,
ANCHOR 2.5X10MM SONIC /1910-1272S,69169141,CDM,278,RC,C1713,HCPCS,Outpatient,,,1946,1946,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.6,60,,934.08,percent of total billed charges,60% of total Billed charges for outpatient setting,1651.76,84.88,,1321.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1459.5,75,,1167.6,percent of total billed charges,75% of total billed charges for outpatient setting,973,50,,778.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.87,12.84,,199.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1556.8,80,,1245.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.87,12.84,,199.9,percent of total billed charges,12.84% of total billed charges,249.87,12.84,,199.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1946,65,,1556.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.1,35,,544.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1167.6,60,,934.08,percent of total billed charges,60% of total billed charges for outpatient setting,249.87,1946,
ANCHOR 2.6 FBRTK TIGER LP / AR-3652SP,71000496,CDM,278,RC,C1713,HCPCS,Outpatient,,,1974.5,1974.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1184.7,60,,947.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1675.96,84.88,,1340.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.88,75,,1184.7,percent of total billed charges,75% of total billed charges for outpatient setting,987.25,50,,789.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.53,12.84,,202.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1579.6,80,,1263.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.53,12.84,,202.82,percent of total billed charges,12.84% of total billed charges,253.53,12.84,,202.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1974.5,65,,1579.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.08,35,,552.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1184.7,60,,947.76,percent of total billed charges,60% of total billed charges for outpatient setting,253.53,1974.5,
ANCHOR 2.6 FBRTK TRIPLE LOAD / AR-3633SP,71000554,CDM,278,RC,C1713,HCPCS,Outpatient,,,1722,1722,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1033.2,60,,826.56,percent of total billed charges,60% of total Billed charges for outpatient setting,1461.63,84.88,,1169.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.5,75,,1033.2,percent of total billed charges,75% of total billed charges for outpatient setting,861,50,,688.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.1,12.84,,176.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1377.6,80,,1102.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.1,12.84,,176.88,percent of total billed charges,12.84% of total billed charges,221.1,12.84,,176.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1722,65,,1377.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.7,35,,482.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1033.2,60,,826.56,percent of total billed charges,60% of total billed charges for outpatient setting,221.1,1722,
ANCHOR 2.6 FBRTK WH/BLK / AR-3652TSP,71000559,CDM,278,RC,C1713,HCPCS,Outpatient,,,1974.5,1974.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1184.7,60,,947.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1675.96,84.88,,1340.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.88,75,,1184.7,percent of total billed charges,75% of total billed charges for outpatient setting,987.25,50,,789.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.53,12.84,,202.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1579.6,80,,1263.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.53,12.84,,202.82,percent of total billed charges,12.84% of total billed charges,253.53,12.84,,202.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1974.5,65,,1579.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.08,35,,552.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1184.7,60,,947.76,percent of total billed charges,60% of total billed charges for outpatient setting,253.53,1974.5,
ANCHOR 2.9X15.5MM PK PSHLCK / AR-1923PS,69161712,CDM,278,RC,C1713,HCPCS,Outpatient,,,1512,1512,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.2,60,,725.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1283.39,84.88,,1026.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,75,,907.2,percent of total billed charges,75% of total billed charges for outpatient setting,756,50,,604.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.14,12.84,,155.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.6,80,,967.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.14,12.84,,155.31,percent of total billed charges,12.84% of total billed charges,194.14,12.84,,155.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1512,65,,1209.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.2,35,,423.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,907.2,60,,725.76,percent of total billed charges,60% of total billed charges for outpatient setting,194.14,1512,
ANCHOR 3.5X10MM CORKSCRW  / AR-1915FT,69169456,CDM,278,RC,C1713,HCPCS,Outpatient,,,1197,1197,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.2,60,,574.56,percent of total billed charges,60% of total Billed charges for outpatient setting,1016.01,84.88,,812.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.75,75,,718.2,percent of total billed charges,75% of total billed charges for outpatient setting,598.5,50,,478.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.69,12.84,,122.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.6,80,,766.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.69,12.84,,122.95,percent of total billed charges,12.84% of total billed charges,153.69,12.84,,122.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1197,65,,957.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.95,35,,335.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,718.2,60,,574.56,percent of total billed charges,60% of total billed charges for outpatient setting,153.69,1197,
ANCHOR 3.9X17.9MM MPFL / AR-1360FT-BC,71000626,CDM,278,RC,C1713,HCPCS,Outpatient,,,4189.5,4189.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2513.7,60,,2010.96,percent of total billed charges,60% of total Billed charges for outpatient setting,3556.05,84.88,,2844.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3142.13,75,,2513.7,percent of total billed charges,75% of total billed charges for outpatient setting,2094.75,50,,1675.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.93,12.84,,430.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3351.6,80,,2681.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.93,12.84,,430.34,percent of total billed charges,12.84% of total billed charges,537.93,12.84,,430.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4398.98,105,,3519.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1466.33,35,,1173.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2513.7,60,,2010.96,percent of total billed charges,60% of total billed charges for outpatient setting,537.93,4398.98,
ANCHOR 3X12.7MM FIBERWIRE / AR-1938BC,71000491,CDM,278,RC,C1713,HCPCS,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
ANCHOR 4.5 MM HEALICOIL / 72203378,69169110,CDM,278,RC,C1713,HCPCS,Outpatient,,,1604.95,1604.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.97,60,,770.38,percent of total billed charges,60% of total Billed charges for outpatient setting,1362.28,84.88,,1089.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.71,75,,962.97,percent of total billed charges,75% of total billed charges for outpatient setting,802.48,50,,641.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.08,12.84,,164.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1283.96,80,,1027.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.08,12.84,,164.86,percent of total billed charges,12.84% of total billed charges,206.08,12.84,,164.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1604.95,65,,1283.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.73,35,,449.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,962.97,60,,770.38,percent of total billed charges,60% of total billed charges for outpatient setting,206.08,1604.95,
ANCHOR 4.5 MM PK SUTURE / 72202901,69162902,CDM,278,RC,C1713,HCPCS,Outpatient,,,1661.18,1661.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996.71,60,,797.37,percent of total billed charges,60% of total Billed charges for outpatient setting,1410.01,84.88,,1128.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.89,75,,996.71,percent of total billed charges,75% of total billed charges for outpatient setting,830.59,50,,664.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.3,12.84,,170.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1328.94,80,,1063.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.3,12.84,,170.64,percent of total billed charges,12.84% of total billed charges,213.3,12.84,,170.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1661.18,65,,1328.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.41,35,,465.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,996.71,60,,797.37,percent of total billed charges,60% of total billed charges for outpatient setting,213.3,1661.18,
ANCHOR 4.5X28MM PUSHLOCK / AR-1922BCM,71000492,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681.62,1681.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.97,60,,807.18,percent of total billed charges,60% of total Billed charges for outpatient setting,1427.36,84.88,,1141.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.22,75,,1008.98,percent of total billed charges,75% of total billed charges for outpatient setting,840.81,50,,672.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.92,12.84,,172.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.3,80,,1076.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.92,12.84,,172.74,percent of total billed charges,12.84% of total billed charges,215.92,12.84,,172.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1681.62,65,,1345.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.57,35,,470.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1008.97,60,,807.18,percent of total billed charges,60% of total billed charges for outpatient setting,215.92,1681.62,
ANCHOR BIO CORKSCREW 5.5mm AR-1927BCF,69161457,CDM,278,RC,C1713,HCPCS,Outpatient,,,1448.13,1448.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.88,60,,695.1,percent of total billed charges,60% of total Billed charges for outpatient setting,1229.17,84.88,,983.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1086.1,75,,868.88,percent of total billed charges,75% of total billed charges for outpatient setting,724.07,50,,579.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.94,12.84,,148.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.5,80,,926.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.94,12.84,,148.75,percent of total billed charges,12.84% of total billed charges,185.94,12.84,,148.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1448.13,65,,1158.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.85,35,,405.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.88,60,,695.1,percent of total billed charges,60% of total billed charges for outpatient setting,185.94,1448.13,
ANCHOR BIO-SUTURE TAK 3MM AR-1934BCF-2,69161047,CDM,278,RC,,,Outpatient,,,1454.37,1454.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.62,60,,698.1,percent of total billed charges,60% of total Billed charges for outpatient setting,1234.47,84.88,,987.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,727.19,50,,581.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090.78,75,,872.62,percent of total billed charges,75% of total billed charges for outpatient setting,727.19,50,,581.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.74,12.84,,149.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.5,80,,930.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.74,12.84,,149.39,percent of total billed charges,12.84% of total billed charges,186.74,12.84,,149.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1454.37,65,,1163.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.03,35,,407.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,872.62,60,,698.1,percent of total billed charges,60% of total billed charges for outpatient setting,186.74,1454.37,
ANCHOR CLIK X MRI / SC-4319,70000135,CDM,278,RC,C1713,HCPCS,Outpatient,,,1460.03,1460.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.02,60,,700.82,percent of total billed charges,60% of total Billed charges for outpatient setting,1239.27,84.88,,991.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.02,75,,876.02,percent of total billed charges,75% of total billed charges for outpatient setting,730.02,50,,584.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.47,12.84,,149.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.02,80,,934.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.47,12.84,,149.98,percent of total billed charges,12.84% of total billed charges,187.47,12.84,,149.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1460.03,65,,1168.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.01,35,,408.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,876.02,60,,700.82,percent of total billed charges,60% of total billed charges for outpatient setting,187.47,1460.03,
ANCHOR CORKSCREW 4.5x14MM / AR-1928SF-45,69169334,CDM,278,RC,C1713,HCPCS,Outpatient,,,966,966,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.6,60,,463.68,percent of total billed charges,60% of total Billed charges for outpatient setting,819.94,84.88,,655.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.5,75,,579.6,percent of total billed charges,75% of total billed charges for outpatient setting,483,50,,386.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.03,12.84,,99.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.8,80,,618.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.03,12.84,,99.22,percent of total billed charges,12.84% of total billed charges,124.03,12.84,,99.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,966,65,,772.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.1,35,,270.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,579.6,60,,463.68,percent of total billed charges,60% of total billed charges for outpatient setting,124.03,966,
ANCHOR CORKSCREW 5MM / AR-1920SF,69161149,CDM,278,RC,C1713,HCPCS,Outpatient,,,868.88,868.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.33,60,,417.06,percent of total billed charges,60% of total Billed charges for outpatient setting,737.51,84.88,,590.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.66,75,,521.33,percent of total billed charges,75% of total billed charges for outpatient setting,434.44,50,,347.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.56,12.84,,89.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.1,80,,556.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.56,12.84,,89.25,percent of total billed charges,12.84% of total billed charges,111.56,12.84,,89.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,868.88,65,,695.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.11,35,,243.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,521.33,60,,417.06,percent of total billed charges,60% of total billed charges for outpatient setting,111.56,868.88,
ANCHOR CORKSCREW 6.5MM / AR-1929SF-3,69161448,CDM,278,RC,C1713,HCPCS,Outpatient,,,1059.87,1059.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.92,60,,508.74,percent of total billed charges,60% of total Billed charges for outpatient setting,899.62,84.88,,719.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.9,75,,635.92,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,50,,423.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.09,12.84,,108.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.9,80,,678.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.09,12.84,,108.87,percent of total billed charges,12.84% of total billed charges,136.09,12.84,,108.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1059.87,65,,847.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.95,35,,296.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,635.92,60,,508.74,percent of total billed charges,60% of total billed charges for outpatient setting,136.09,1059.87,
ANCHOR CORKSCREW FTIII / AR-1928SF-3,69160525,CDM,278,RC,C1713,HCPCS,Outpatient,,,1029,1029,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.4,60,,493.92,percent of total billed charges,60% of total Billed charges for outpatient setting,873.42,84.88,,698.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.75,75,,617.4,percent of total billed charges,75% of total billed charges for outpatient setting,514.5,50,,411.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.12,12.84,,105.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.2,80,,658.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.12,12.84,,105.7,percent of total billed charges,12.84% of total billed charges,132.12,12.84,,105.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1029,65,,823.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.15,35,,288.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,617.4,60,,493.92,percent of total billed charges,60% of total billed charges for outpatient setting,132.12,1029,
ANCHOR FIBER TAK 2.6  / AR-3633,69169588,CDM,278,RC,C1713,HCPCS,Outpatient,,,1617,1617,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.2,60,,776.16,percent of total billed charges,60% of total Billed charges for outpatient setting,1372.51,84.88,,1098.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.75,75,,970.2,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,50,,646.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.62,12.84,,166.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.6,80,,1034.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.62,12.84,,166.1,percent of total billed charges,12.84% of total billed charges,207.62,12.84,,166.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1617,65,,1293.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.95,35,,452.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,970.2,60,,776.16,percent of total billed charges,60% of total billed charges for outpatient setting,207.62,1617,
ANCHOR FIBER TAK 2.6 TRIPLE / AR-3631-1,71000045,CDM,278,RC,C1713,HCPCS,Outpatient,,,1420,1420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,852,60,,681.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1205.3,84.88,,964.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065,75,,852,percent of total billed charges,75% of total billed charges for outpatient setting,710,50,,568,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.33,12.84,,145.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136,80,,908.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.33,12.84,,145.86,percent of total billed charges,12.84% of total billed charges,182.33,12.84,,145.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1420,65,,1136,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497,35,,397.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,852,60,,681.6,percent of total billed charges,60% of total billed charges for outpatient setting,182.33,1420,
ANCHOR FIBERTAK SUTURE / AR-8990ST,71000025,CDM,272,RC,C1713,HCPCS,Outpatient,,,1860,1860,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1302,70,,1041.6,percent of total billed charges,70% of total billed charges for outpatient setting,1578.77,84.88,,1263.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1395,75,,1116,percent of total billed charges,75% of total billed charges for outpatient setting,1302,70,,1041.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.82,12.84,,191.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488,80,,1190.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.82,12.84,,191.06,percent of total billed charges,12.84% of total billed charges,238.82,12.84,,191.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1209,65,,967.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651,35,,520.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1674,90,,1339.2,percent of total billed charges,90% of total billed charges for outpatient setting,238.82,1674,
ANCHOR GENESYS PRESSFT 2.6w/2 sut NB262,69161559,CDM,278,RC,,,Outpatient,,,1403.57,1403.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.14,60,,673.71,percent of total billed charges,60% of total Billed charges for outpatient setting,1191.35,84.88,,953.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,701.79,50,,561.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1052.68,75,,842.14,percent of total billed charges,75% of total billed charges for outpatient setting,701.79,50,,561.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.22,12.84,,144.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122.86,80,,898.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.22,12.84,,144.18,percent of total billed charges,12.84% of total billed charges,180.22,12.84,,144.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1403.57,65,,1122.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.25,35,,393,percent of total billed charges,35% of total Billed charges for Outpatient Setting,842.14,60,,673.71,percent of total billed charges,60% of total billed charges for outpatient setting,180.22,1403.57,
ANCHOR Genesys w/suture  CFBC-5502,69161595,CDM,278,RC,,,Outpatient,,,1269.9,1269.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.94,60,,609.55,percent of total billed charges,60% of total Billed charges for outpatient setting,1077.89,84.88,,862.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.95,50,,507.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,952.43,75,,761.94,percent of total billed charges,75% of total billed charges for outpatient setting,634.95,50,,507.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,12.84,,130.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.92,80,,812.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,12.84,,130.45,percent of total billed charges,12.84% of total billed charges,163.06,12.84,,130.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1269.9,65,,1015.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.47,35,,355.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,761.94,60,,609.55,percent of total billed charges,60% of total billed charges for outpatient setting,163.06,1269.9,
ANCHOR GII QUICK PLUS / 222983,69162443,CDM,278,RC,,,Outpatient,,,1747.7,1747.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1048.62,60,,838.9,percent of total billed charges,60% of total Billed charges for outpatient setting,1483.45,84.88,,1186.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,873.85,50,,699.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1310.78,75,,1048.62,percent of total billed charges,75% of total billed charges for outpatient setting,873.85,50,,699.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.4,12.84,,179.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.16,80,,1118.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.4,12.84,,179.52,percent of total billed charges,12.84% of total billed charges,224.4,12.84,,179.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1747.7,65,,1398.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.7,35,,489.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1048.62,60,,838.9,percent of total billed charges,60% of total billed charges for outpatient setting,224.4,1747.7,
ANCHOR MICRO CORKSCREW FT AR-1318FT,69161760,CDM,278,RC,C1713,HCPCS,Outpatient,,,1269.9,1269.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.94,60,,609.55,percent of total billed charges,60% of total Billed charges for outpatient setting,1077.89,84.88,,862.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.43,75,,761.94,percent of total billed charges,75% of total billed charges for outpatient setting,634.95,50,,507.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,12.84,,130.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.92,80,,812.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,12.84,,130.45,percent of total billed charges,12.84% of total billed charges,163.06,12.84,,130.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1269.9,65,,1015.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.47,35,,355.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,761.94,60,,609.55,percent of total billed charges,60% of total billed charges for outpatient setting,163.06,1269.9,
ANCHOR MINI QUICK PLUS #0 SUT / 212038,69162742,CDM,278,RC,C1713,HCPCS,Outpatient,,,1830.76,1830.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.46,60,,878.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1553.95,84.88,,1243.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1373.07,75,,1098.46,percent of total billed charges,75% of total billed charges for outpatient setting,915.38,50,,732.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.07,12.84,,188.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.61,80,,1171.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.07,12.84,,188.06,percent of total billed charges,12.84% of total billed charges,235.07,12.84,,188.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1830.76,65,,1464.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.77,35,,512.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1098.46,60,,878.77,percent of total billed charges,60% of total billed charges for outpatient setting,235.07,1830.76,
ANCHOR MINILOK QUICK PLS #2\0 SUT 212853,69162295,CDM,278,RC,,,Outpatient,,,1903.99,1903.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.39,60,,913.91,percent of total billed charges,60% of total Billed charges for outpatient setting,1616.11,84.88,,1292.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,952,50,,761.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1427.99,75,,1142.39,percent of total billed charges,75% of total billed charges for outpatient setting,952,50,,761.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.47,12.84,,195.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1523.19,80,,1218.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.47,12.84,,195.58,percent of total billed charges,12.84% of total billed charges,244.47,12.84,,195.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1903.99,65,,1523.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.4,35,,533.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1142.39,60,,913.91,percent of total billed charges,60% of total billed charges for outpatient setting,244.47,1903.99,
ANCHOR MULTIFIX P4.5 KNOTLESS OM-1300,69161560,CDM,278,RC,,,Outpatient,,,1648.64,1648.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.18,60,,791.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1399.37,84.88,,1119.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,824.32,50,,659.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1236.48,75,,989.18,percent of total billed charges,75% of total billed charges for outpatient setting,824.32,50,,659.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.69,12.84,,169.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1318.91,80,,1055.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.69,12.84,,169.35,percent of total billed charges,12.84% of total billed charges,211.69,12.84,,169.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1648.64,65,,1318.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.02,35,,461.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,989.18,60,,791.34,percent of total billed charges,60% of total billed charges for outpatient setting,211.69,1648.64,
ANCHOR NANO CORKSCREW FT / AR-1317FT,71000836,CDM,278,RC,C1713,HCPCS,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
ANCHOR PUSHLOCK SP 4.5X18.5 AR-1922PSM,69160926,CDM,278,RC,,,Outpatient,,,1681.62,1681.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.97,60,,807.18,percent of total billed charges,60% of total Billed charges for outpatient setting,1427.36,84.88,,1141.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,840.81,50,,672.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1261.22,75,,1008.98,percent of total billed charges,75% of total billed charges for outpatient setting,840.81,50,,672.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.92,12.84,,172.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.3,80,,1076.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.92,12.84,,172.74,percent of total billed charges,12.84% of total billed charges,215.92,12.84,,172.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1681.62,65,,1345.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.57,35,,470.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1008.97,60,,807.18,percent of total billed charges,60% of total billed charges for outpatient setting,215.92,1681.62,
ANCHOR REVO-FT W/2 SUTURES / CF6140H,69161535,CDM,278,RC,,,Outpatient,,,1345.61,1345.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.37,60,,645.9,percent of total billed charges,60% of total Billed charges for outpatient setting,1142.15,84.88,,913.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,672.81,50,,538.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1009.21,75,,807.37,percent of total billed charges,75% of total billed charges for outpatient setting,672.81,50,,538.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.78,12.84,,138.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1076.49,80,,861.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.78,12.84,,138.22,percent of total billed charges,12.84% of total billed charges,172.78,12.84,,138.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1345.61,65,,1076.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.96,35,,376.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,807.37,60,,645.9,percent of total billed charges,60% of total billed charges for outpatient setting,172.78,1345.61,
ANCHOR SAFFRON / 520350,7100315,CDM,278,RC,C2631,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,60,,108,percent of total billed charges,60% of total Billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,225,65,,180,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135,60,,108,percent of total billed charges,60% of total billed charges for outpatient setting,28.89,225,
ANCHOR SONIC FORCE FIBER 2 / 1910-1273S,70000529,CDM,278,RC,C1713,HCPCS,Outpatient,,,2407.42,2407.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.45,60,,1155.56,percent of total billed charges,60% of total Billed charges for outpatient setting,2043.42,84.88,,1634.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1805.57,75,,1444.46,percent of total billed charges,75% of total billed charges for outpatient setting,1203.71,50,,962.97,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.11,12.84,,247.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1925.94,80,,1540.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.11,12.84,,247.29,percent of total billed charges,12.84% of total billed charges,309.11,12.84,,247.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2527.79,105,,2022.23,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.6,35,,674.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1444.45,60,,1155.56,percent of total billed charges,60% of total billed charges for outpatient setting,309.11,2527.79,
ANCHOR SPEEDBRG SWVLK / AR-2600SBS-10,71000498,CDM,278,RC,C1713,HCPCS,Outpatient,,,4515,4515,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2709,60,,2167.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3832.33,84.88,,3065.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3386.25,75,,2709,percent of total billed charges,75% of total billed charges for outpatient setting,2257.5,50,,1806,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.73,12.84,,463.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3612,80,,2889.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.73,12.84,,463.78,percent of total billed charges,12.84% of total billed charges,579.73,12.84,,463.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4740.75,105,,3792.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.25,35,,1264.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2709,60,,2167.2,percent of total billed charges,60% of total billed charges for outpatient setting,579.73,4740.75,
ANCHOR SPEEDBRG SWVLK / AR-2600SBS-9,71000495,CDM,278,RC,C1713,HCPCS,Outpatient,,,4011,4011,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2406.6,60,,1925.28,percent of total billed charges,60% of total Billed charges for outpatient setting,3404.54,84.88,,2723.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3008.25,75,,2406.6,percent of total billed charges,75% of total billed charges for outpatient setting,2005.5,50,,1604.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.01,12.84,,412.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3208.8,80,,2567.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.01,12.84,,412.01,percent of total billed charges,12.84% of total billed charges,515.01,12.84,,412.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4211.55,105,,3369.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1403.85,35,,1123.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2406.6,60,,1925.28,percent of total billed charges,60% of total billed charges for outpatient setting,515.01,4211.55,
ANCHOR SPEEDBRG SYS SWVLK/AR-2600SBS-4,69162514,CDM,278,RC,,,Outpatient,,,3480,3480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2088,60,,1670.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2953.82,84.88,,2363.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,1740,50,,1392,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2610,75,,2088,percent of total billed charges,75% of total billed charges for outpatient setting,1740,50,,1392,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.83,12.84,,357.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2784,80,,2227.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.83,12.84,,357.46,percent of total billed charges,12.84% of total billed charges,446.83,12.84,,357.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3654,105,,2923.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218,35,,974.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2088,60,,1670.4,percent of total billed charges,60% of total billed charges for outpatient setting,446.83,3654,
ANCHOR THREVO-FT W/3 SUTURES / CF6160H,69161753,CDM,278,RC,,,Outpatient,,,1520.95,1520.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,912.57,60,,730.06,percent of total billed charges,60% of total Billed charges for outpatient setting,1290.98,84.88,,1032.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,760.48,50,,608.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1140.71,75,,912.57,percent of total billed charges,75% of total billed charges for outpatient setting,760.48,50,,608.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.29,12.84,,156.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.76,80,,973.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.29,12.84,,156.23,percent of total billed charges,12.84% of total billed charges,195.29,12.84,,156.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1520.95,65,,1216.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.33,35,,425.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,912.57,60,,730.06,percent of total billed charges,60% of total billed charges for outpatient setting,195.29,1520.95,
ANCHORSURE / A-SURE 02,69169502,CDM,278,RC,C1713,HCPCS,Outpatient,,,861,861,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.6,60,,413.28,percent of total billed charges,60% of total Billed charges for outpatient setting,730.82,84.88,,584.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.75,75,,516.6,percent of total billed charges,75% of total billed charges for outpatient setting,430.5,50,,344.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.8,80,,551.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,861,65,,688.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.35,35,,241.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,516.6,60,,413.28,percent of total billed charges,60% of total billed charges for outpatient setting,110.55,861,
ANCHORSURE SYSTEM / A-SURE,69169501,CDM,278,RC,,,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
ANCHOR-TWIN FIX(SHLDR) 2.8MM,8370032,CDM,272,RC,,,Outpatient,,,536.01,536.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,454.97,84.88,,363.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,268.01,50,,214.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.01,75,,321.61,percent of total billed charges,75% of total billed charges for outpatient setting,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.81,80,,343.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.41,65,,278.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.41,90,,385.93,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.41,
ANCHOR-TWIN FIX(SHLDR) 3.5MM,8370031,CDM,272,RC,,,Outpatient,,,536.01,536.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,454.97,84.88,,363.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,268.01,50,,214.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.01,75,,321.61,percent of total billed charges,75% of total billed charges for outpatient setting,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.81,80,,343.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.41,65,,278.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.41,90,,385.93,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.41,
ANCHOR-TWIN FIX(SHLDR) 5.0MM,8370030,CDM,272,RC,,,Outpatient,,,536.01,536.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,454.97,84.88,,363.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,268.01,50,,214.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.01,75,,321.61,percent of total billed charges,75% of total billed charges for outpatient setting,375.21,70,,300.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.81,80,,343.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.41,65,,278.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.41,90,,385.93,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.41,
ANCHR 4.75X19 PEEK SWIVEL / AR-2324PSLC,69162237,CDM,278,RC,,,Outpatient,,,1622.25,1622.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,60,,778.68,percent of total billed charges,60% of total Billed charges for outpatient setting,1376.97,84.88,,1101.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,811.13,50,,648.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1216.69,75,,973.35,percent of total billed charges,75% of total billed charges for outpatient setting,811.13,50,,648.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.3,12.84,,166.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1297.8,80,,1038.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.3,12.84,,166.64,percent of total billed charges,12.84% of total billed charges,208.3,12.84,,166.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1622.25,65,,1297.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.79,35,,454.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,973.35,60,,778.68,percent of total billed charges,60% of total billed charges for outpatient setting,208.3,1622.25,
ANCHR 4.75X19 SWIVEL KNTL / AR-2324KBCC,71000635,CDM,278,RC,C1713,HCPCS,Outpatient,,,1932,1932,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.2,60,,927.36,percent of total billed charges,60% of total Billed charges for outpatient setting,1639.88,84.88,,1311.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449,75,,1159.2,percent of total billed charges,75% of total billed charges for outpatient setting,966,50,,772.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1545.6,80,,1236.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1932,65,,1545.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.2,35,,540.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1159.2,60,,927.36,percent of total billed charges,60% of total billed charges for outpatient setting,248.07,1932,
ANCHR 4.75X19 SWIVEL KNTL / AR-2324KBCCT,71000470,CDM,278,RC,,,Outpatient,,,1947.75,1947.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.65,60,,934.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1653.25,84.88,,1322.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,973.88,50,,779.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1460.81,75,,1168.65,percent of total billed charges,75% of total billed charges for outpatient setting,973.88,50,,779.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.09,12.84,,200.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1558.2,80,,1246.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.09,12.84,,200.07,percent of total billed charges,12.84% of total billed charges,250.09,12.84,,200.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1947.75,65,,1558.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.71,35,,545.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1168.65,60,,934.92,percent of total billed charges,60% of total billed charges for outpatient setting,250.09,1947.75,
ANCHR 4.75X22 BIOCOMP DBL / AR-2324BCT-2,69169536,CDM,278,RC,C1713,HCPCS,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
ANCHR 5.5X19 SWIVEL KNTL / AR-2323KBCC,71000847,CDM,278,RC,C1713,HCPCS,Outpatient,,,1932,1932,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.2,60,,927.36,percent of total billed charges,60% of total Billed charges for outpatient setting,1639.88,84.88,,1311.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449,75,,1159.2,percent of total billed charges,75% of total billed charges for outpatient setting,966,50,,772.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1545.6,80,,1236.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1932,65,,1545.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.2,35,,540.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1159.2,60,,927.36,percent of total billed charges,60% of total billed charges for outpatient setting,248.07,1932,
ANCHR 6.25X19.1MM SWIVEL  AR-1662BC,69162599,CDM,278,RC,,,Outpatient,,,1782.31,1782.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.39,60,,855.51,percent of total billed charges,60% of total Billed charges for outpatient setting,1512.82,84.88,,1210.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,891.16,50,,712.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1336.73,75,,1069.38,percent of total billed charges,75% of total billed charges for outpatient setting,891.16,50,,712.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.85,12.84,,183.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.85,80,,1140.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.85,12.84,,183.08,percent of total billed charges,12.84% of total billed charges,228.85,12.84,,183.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1782.31,65,,1425.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.81,35,,499.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1069.39,60,,855.51,percent of total billed charges,60% of total billed charges for outpatient setting,228.85,1782.31,
ANCHR BIO COMP SWIVEL / AR-2324BCC,69161768,CDM,278,RC,,,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,60,,830.59,percent of total billed charges,60% of total Billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1730.4,65,,1384.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1038.24,60,,830.59,percent of total billed charges,60% of total billed charges for outpatient setting,222.18,1730.4,
ANCHR BIO COMP SWIVEL DBL / AR-2324BCC-2,69162727,CDM,278,RC,C1713,HCPCS,Outpatient,,,1803.94,1803.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.36,60,,865.89,percent of total billed charges,60% of total Billed charges for outpatient setting,1531.18,84.88,,1224.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.96,75,,1082.37,percent of total billed charges,75% of total billed charges for outpatient setting,901.97,50,,721.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.63,12.84,,185.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.15,80,,1154.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.63,12.84,,185.3,percent of total billed charges,12.84% of total billed charges,231.63,12.84,,185.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1803.94,65,,1443.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.38,35,,505.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1082.36,60,,865.89,percent of total billed charges,60% of total billed charges for outpatient setting,231.63,1803.94,
ANCHR BIO CRKSCR 5.5MM TRPL AR-1927BCF-3,69161458,CDM,278,RC,,,Outpatient,,,1514.96,1514.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.98,60,,727.18,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.9,84.88,,1028.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,757.48,50,,605.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1136.22,75,,908.98,percent of total billed charges,75% of total billed charges for outpatient setting,757.48,50,,605.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.52,12.84,,155.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.97,80,,969.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.52,12.84,,155.62,percent of total billed charges,12.84% of total billed charges,194.52,12.84,,155.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.96,65,,1211.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.24,35,,424.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.98,60,,727.18,percent of total billed charges,60% of total billed charges for outpatient setting,194.52,1514.96,
ANCHR BIO SVLK C 4.75X19.1 / AR-2324BCCT,69162412,CDM,278,RC,C1713,HCPCS,Outpatient,,,2033.22,2033.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.93,60,,975.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1725.8,84.88,,1380.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.92,75,,1219.94,percent of total billed charges,75% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.58,80,,1301.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2033.22,65,,1626.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.63,35,,569.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1219.93,60,,975.94,percent of total billed charges,60% of total billed charges for outpatient setting,261.07,2033.22,
ANCHR BIO SWVLK 4.75X19.1 / AR-2324BCCTT,69162454,CDM,278,RC,C1713,HCPCS,Outpatient,,,2033.22,2033.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.93,60,,975.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1725.8,84.88,,1380.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.92,75,,1219.94,percent of total billed charges,75% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.58,80,,1301.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2033.22,65,,1626.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.63,35,,569.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1219.93,60,,975.94,percent of total billed charges,60% of total billed charges for outpatient setting,261.07,2033.22,
ANCHR PSHLK 2.9X12.5MM BIO/ AR-2923BC,69162851,CDM,278,RC,C1713,HCPCS,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,60,,830.59,percent of total billed charges,60% of total Billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1730.4,65,,1384.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1038.24,60,,830.59,percent of total billed charges,60% of total billed charges for outpatient setting,222.18,1730.4,
ANCHR PSHLK 2.9X15.5MM BIO/ AR-1923BC,69162399,CDM,278,RC,,,Outpatient,,,1680,1680,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,60,,806.4,percent of total billed charges,60% of total Billed charges for outpatient setting,1425.98,84.88,,1140.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,840,50,,672,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1260,75,,1008,percent of total billed charges,75% of total billed charges for outpatient setting,840,50,,672,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.71,12.84,,172.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,80,,1075.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.71,12.84,,172.57,percent of total billed charges,12.84% of total billed charges,215.71,12.84,,172.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1680,65,,1344,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,35,,470.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1008,60,,806.4,percent of total billed charges,60% of total billed charges for outpatient setting,215.71,1680,
ANDROSTENEDIONE,201569,CDM,301,RC,82157,HCPCS,Outpatient,,,131.76,118.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.23,70,,73.78,percent of total billed charges,70% of total billed charges for outpatient setting,111.84,84.88,,89.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,98.82,75,,79.06,percent of total billed charges,75% of total billed charges for outpatient setting,92.23,70,,73.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.41,80,,84.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,42.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.52,100,,,Fee Schedule,100% of Custom Fee Schedule,118.58,90,,94.86,percent of total billed charges,90% of total billed charges for outpatient setting,29.28,118.58,
ANES CIRCUIT ADULT CUST PK / 450963-NL,69160745,CDM,271,RC,,,Outpatient,,,38.77,38.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,32.91,84.88,,26.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.39,50,,15.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.08,75,,23.26,percent of total billed charges,75% of total billed charges for outpatient setting,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.2,65,,20.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,35,,10.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.89,90,,27.91,percent of total billed charges,90% of total billed charges for outpatient setting,4.98,34.89,
ANES CIRCUIT/MASK/ADULT / ANE436625B,70000033,CDM,271,RC,,,Outpatient,,,45.43,45.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.8,70,,25.44,percent of total billed charges,70% of total billed charges for outpatient setting,38.56,84.88,,30.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.72,50,,18.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.07,75,,27.26,percent of total billed charges,75% of total billed charges for outpatient setting,31.8,70,,25.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,80,,29.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.53,65,,23.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.9,35,,12.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.89,90,,32.71,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.89,
ANES. BREATHING CIRCUIT/650904,6152054,CDM,271,RC,,,Outpatient,,,37.45,37.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,84.88,,25.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.73,50,,14.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.09,75,,22.47,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.96,80,,23.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.34,65,,19.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,35,,10.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.71,90,,26.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,33.71,
ANESTHESIA A-LINE,3700020,CDM,360,RC,,,Outpatient,,,232.51,232.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.76,70,,130.21,percent of total billed charges,70% of total billed charges for outpatient setting,197.35,84.88,,157.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.26,50,,93.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.38,75,,139.5,percent of total billed charges,75% of total billed charges for outpatient setting,162.76,70,,130.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,12.84,,23.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.01,80,,148.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,12.84,,23.88,percent of total billed charges,12.84% of total billed charges,29.85,12.84,,23.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.38,35,,65.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,209.26,90,,167.41,percent of total billed charges,90% of total billed charges for outpatient setting,29.85,209.26,
ANESTHESIA BU EA 15 MINUTES,3700006,CDM,370,RC,,,Outpatient,,,93,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.1,70,,52.08,percent of total billed charges,70% of total billed charges for outpatient setting,78.94,84.88,,63.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.5,50,,37.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.75,75,,55.8,percent of total billed charges,75% of total billed charges for outpatient setting,65.1,70,,52.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.4,80,,59.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.45,65,,48.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,35,,26.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.7,90,,66.96,percent of total billed charges,90% of total billed charges for outpatient setting,11.94,83.7,
ANESTHESIA BU PER 15 MINUTES,370006,CDM,370,RC,,,Outpatient,,,93,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.1,70,,52.08,percent of total billed charges,70% of total billed charges for outpatient setting,78.94,84.88,,63.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.5,50,,37.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.75,75,,55.8,percent of total billed charges,75% of total billed charges for outpatient setting,65.1,70,,52.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.4,80,,59.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.45,65,,48.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,35,,26.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.7,90,,66.96,percent of total billed charges,90% of total billed charges for outpatient setting,11.94,83.7,
ANESTHESIA CENTRAL LINE,3700025,CDM,360,RC,,,Outpatient,,,387.52,387.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.26,70,,217.01,percent of total billed charges,70% of total billed charges for outpatient setting,328.93,84.88,,263.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,193.76,50,,155.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.64,75,,232.51,percent of total billed charges,75% of total billed charges for outpatient setting,271.26,70,,217.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.76,12.84,,39.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.02,80,,248.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.76,12.84,,39.81,percent of total billed charges,12.84% of total billed charges,49.76,12.84,,39.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.63,35,,108.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348.77,90,,279.02,percent of total billed charges,90% of total billed charges for outpatient setting,49.76,348.77,
ANESTHESIA FOR PATIENT <1YR OR>70YR,3700015,CDM,370,RC,99100,HCPCS,Outpatient,,,465.01,465.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.51,70,,260.41,percent of total billed charges,70% of total billed charges for outpatient setting,394.7,84.88,,315.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,232.51,50,,186.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.76,75,,279.01,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,70,,260.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.71,12.84,,47.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.01,80,,297.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.71,12.84,,47.77,percent of total billed charges,12.84% of total billed charges,59.71,12.84,,47.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.26,65,,241.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.75,35,,130.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,418.51,90,,334.81,percent of total billed charges,90% of total billed charges for outpatient setting,59.71,418.51,
ANGIOMAX (BIVALIRUDIN) 250 MG,3303181,CDM,636,RC,J0583,HCPCS,Outpatient,,,1753.36,1753.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1227.35,70,,981.88,percent of total billed charges,70% of total billed charges for outpatient setting,1488.25,84.88,,1190.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1315.02,75,,1052.02,percent of total billed charges,75% of total billed charges for outpatient setting,1227.35,70,,981.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.13,12.84,,180.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1402.69,80,,1122.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.13,12.84,,180.1,percent of total billed charges,12.84% of total billed charges,225.13,12.84,,180.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1139.68,65,,911.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.6,100,,,Fee Schedule,100% of Custom Fee Schedule,1578.02,90,,1262.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,1578.02,
ANGIOTENSIN CONVERTING ENZYME,220396,CDM,300,RC,82164,HCPCS,Outpatient,,,65.7,59.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,55.77,84.88,,44.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.28,75,,39.42,percent of total billed charges,75% of total billed charges for outpatient setting,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.56,80,,42.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.31,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.69,100,,,Fee Schedule,100% of Custom Fee Schedule,59.13,90,,47.3,percent of total billed charges,90% of total billed charges for outpatient setting,14.6,59.13,
ANKLE 3+ VWS BILATERAL,2400427,CDM,320,RC,73610,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
ANKLE 3+ VWS LEFT,2400426,CDM,320,RC,73610,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ANKLE 3+ VWS RIGHT,2400425,CDM,320,RC,73610,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ANKLE ARTHROGRAPHY LEFT,2400431,CDM,322,RC,73615,HCPCS,Outpatient,,,1141.31,855.98,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
ANKLE ARTHROGRAPHY RIGHT,2400430,CDM,322,RC,73615,HCPCS,Outpatient,,,1141.31,855.98,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
ANKLE TWO VWS LEFT,2400421,CDM,320,RC,73600,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ANKLE TWO VWS RIGHT,2400420,CDM,320,RC,73600,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ANNA,200462,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANNA TITER,200463,CDM,301,RC,86256,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.85,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANOSPEC 103X18MM BEVELED / C060120,71000631,CDM,271,RC,,,Outpatient,,,35.04,35.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.53,70,,19.62,percent of total billed charges,70% of total billed charges for outpatient setting,29.74,84.88,,23.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.52,50,,14.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.28,75,,21.02,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,70,,19.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.03,80,,22.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.78,65,,18.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.26,35,,9.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.54,90,,25.23,percent of total billed charges,90% of total billed charges for outpatient setting,4.5,31.54,
ANTACIDS LIQUI CHAR LIQ  25 GM,3300608,CDM,259,RC,,,Outpatient,,,16.65,16.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.66,70,,9.33,percent of total billed charges,70% of total billed charges for outpatient setting,14.13,84.88,,11.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.33,50,,6.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.49,75,,9.99,percent of total billed charges,75% of total billed charges for outpatient setting,11.66,70,,9.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,80,,10.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.82,65,,8.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,35,,4.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.99,90,,11.99,percent of total billed charges,90% of total billed charges for outpatient setting,2.14,14.99,
ANTERIOR TIBIALIS GRAFT 9X250,69162050,CDM,278,RC,,,Outpatient,,,3900,3900,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2340,60,,1872,percent of total billed charges,60% of total Billed charges for outpatient setting,3310.32,84.88,,2648.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1950,50,,1560,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2925,75,,2340,percent of total billed charges,75% of total billed charges for outpatient setting,1950,50,,1560,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.76,12.84,,400.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,80,,2496,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.76,12.84,,400.61,percent of total billed charges,12.84% of total billed charges,500.76,12.84,,400.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4095,105,,3276,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,35,,1092,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2340,60,,1872,percent of total billed charges,60% of total billed charges for outpatient setting,500.76,4095,
ANTERIOR VIT PACK CENTURION/ 8065752134,69160689,CDM,272,RC,,,Outpatient,,,734.12,734.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.88,70,,411.1,percent of total billed charges,70% of total billed charges for outpatient setting,623.12,84.88,,498.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,367.06,50,,293.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,550.59,75,,440.47,percent of total billed charges,75% of total billed charges for outpatient setting,513.88,70,,411.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.26,12.84,,75.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.3,80,,469.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.26,12.84,,75.41,percent of total billed charges,12.84% of total billed charges,94.26,12.84,,75.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,477.18,65,,381.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.94,35,,205.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,660.71,90,,528.57,percent of total billed charges,90% of total billed charges for outpatient setting,94.26,660.71,
ANTI INTRINSIC FACTOR BLOCK AB,220021,CDM,302,RC,86340,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,61.07,
ANTI JO 1,200603,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
ANTI MULLERIAN HORMONE,222040,CDM,301,RC,82397,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,69.95,
ANTI RNP,220835,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
ANTIADRENAL CORTEX ANTIBODY,201247,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANTIBODY REFLEX,200806,CDM,302,RC,86039,HCPCS,Outpatient,,,50.22,45.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.15,70,,28.12,percent of total billed charges,70% of total billed charges for outpatient setting,42.63,84.88,,34.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.67,75,,30.14,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,70,,28.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,80,,32.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,100,,,Fee Schedule,100% of Custom Fee Schedule,45.2,90,,36.16,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,45.2,
ANTICARDIOLIPIN AB,220844,CDM,302,RC,86147,HCPCS,Outpatient,,,114.53,103.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.17,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,97.21,84.88,,77.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.9,75,,68.72,percent of total billed charges,75% of total billed charges for outpatient setting,80.17,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.62,80,,73.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,100% of Custom Fee Schedule,103.08,90,,82.46,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,103.08,
ANTI-CCP CYCLIC CITRULLINATED PEPTIDE,220788,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
ANTICENTROMERE AB,220888,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
ANTICHROMATIN AB,220886,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
ANTI-DNA SINGLE-STRANDED AB,220887,CDM,302,RC,86226,HCPCS,Outpatient,,,54.5,49.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,46.26,84.88,,37.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.88,75,,32.7,percent of total billed charges,75% of total billed charges for outpatient setting,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.6,80,,34.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.96,100,,,Fee Schedule,100% of Custom Fee Schedule,49.05,90,,39.24,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,49.05,
ANTI-DNASE B ANTIBODIES,201063,CDM,300,RC,86215,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.13,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
ANTI-DSDNA AB,220513,CDM,302,RC,86225,HCPCS,Outpatient,,,61.83,55.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.28,70,,34.62,percent of total billed charges,70% of total billed charges for outpatient setting,52.48,84.88,,41.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.37,75,,37.1,percent of total billed charges,75% of total billed charges for outpatient setting,43.28,70,,34.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.46,80,,39.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.05,100,,,Fee Schedule,100% of Custom Fee Schedule,55.65,90,,44.52,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,55.65,
ANTIENDOMYSIAL AB,201502,CDM,301,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANTIENDOMYSIAL ANTIBODY,200615,CDM,300,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANTI-GAD AB,203258,CDM,310,RC,86341,HCPCS,Outpatient,,,106.07,95.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,90.03,84.88,,72.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.55,75,,63.64,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.86,80,,67.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.52,100,,,Fee Schedule,100% of Custom Fee Schedule,95.46,90,,76.37,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,95.46,
ANTI-GBM GLOMERULAR BASEMENT MEMBRANE,202265,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
ANTIGLIADIN AB,200600,CDM,300,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
ANTIGLIADIN AB,220243,CDM,300,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
ANTIGLIADIN AB IGG,220702,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
ANTIHISTONE ANTIBODIES,220870,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
ANTIMITOCHONDRIAL ANTIBODY,220448,CDM,302,RC,86381,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,35,,15.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,18.98,48.81,
ANTIPARIETAL CELL AB,220842,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANTIPYRINE AURALGAN OTIC SOL  15ML,3300610,CDM,259,RC,,,Outpatient,,,5.92,5.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.96,50,,2.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.44,75,,3.55,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.33,90,,4.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.33,
ANTIPYRINE AURALGAN OTIC SOL15ML,3300609,CDM,259,RC,,,Outpatient,,,9.1,9.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,7.72,84.88,,6.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.55,50,,3.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.83,75,,5.46,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,80,,5.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.92,65,,4.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,35,,2.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.19,90,,6.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.17,8.19,
ANTISCLERODERMA-70 ANTIBODIES,220906,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
"ANTISKIN AUTOANTIBODIES, QUANT",220907,CDM,301,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
ANTISMOOTH MUSCLE ANTIBODY,220449,CDM,302,RC,86015,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,35,,15.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,48.81,
ANTISPAMODIC ELX 16.2MG/5ML : 5ML,3300661,CDM,259,RC,,,Outpatient,,,38.27,38.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.79,70,,21.43,percent of total billed charges,70% of total billed charges for outpatient setting,32.48,84.88,,25.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.14,50,,15.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.7,75,,22.96,percent of total billed charges,75% of total billed charges for outpatient setting,26.79,70,,21.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,12.84,,3.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,80,,24.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,12.84,,3.93,percent of total billed charges,12.84% of total billed charges,4.91,12.84,,3.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.88,65,,19.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,35,,10.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.44,90,,27.55,percent of total billed charges,90% of total billed charges for outpatient setting,4.91,34.44,
ANTITHROMBIN III  ANTIGEN,220016,CDM,301,RC,85301,HCPCS,Outpatient,,,48.65,43.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.06,70,,27.25,percent of total billed charges,70% of total billed charges for outpatient setting,41.29,84.88,,33.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.49,75,,29.19,percent of total billed charges,75% of total billed charges for outpatient setting,34.06,70,,27.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.92,80,,31.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.5,100,,,Fee Schedule,100% of Custom Fee Schedule,43.79,90,,35.03,percent of total billed charges,90% of total billed charges for outpatient setting,10.81,43.79,
ANTITHROMBIN III  ANTIGEN ASSAY,200019,CDM,301,RC,85301,HCPCS,Outpatient,,,48.65,43.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.06,70,,27.25,percent of total billed charges,70% of total billed charges for outpatient setting,41.29,84.88,,33.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.49,75,,29.19,percent of total billed charges,75% of total billed charges for outpatient setting,34.06,70,,27.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.92,80,,31.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.5,100,,,Fee Schedule,100% of Custom Fee Schedule,43.79,90,,35.03,percent of total billed charges,90% of total billed charges for outpatient setting,10.81,43.79,
ANTITHROMBIN III ACTIVITY,220006,CDM,301,RC,85300,HCPCS,Outpatient,,,53.33,48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.33,70,,29.86,percent of total billed charges,70% of total billed charges for outpatient setting,45.27,84.88,,36.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40,75,,32,percent of total billed charges,75% of total billed charges for outpatient setting,37.33,70,,29.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.66,80,,34.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,100,,,Fee Schedule,100% of Custom Fee Schedule,48,90,,38.4,percent of total billed charges,90% of total billed charges for outpatient setting,11.85,48,
ANTITHYROGLOBULIN AB,220353,CDM,302,RC,86800,HCPCS,Outpatient,,,71.6,64.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,60.77,84.88,,48.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.7,75,,42.96,percent of total billed charges,75% of total billed charges for outpatient setting,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,80,,45.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,100,,,Fee Schedule,100% of Custom Fee Schedule,64.44,90,,51.55,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,64.44,
ANTIVENIN POLYVALNT INJ 1 CMB,3300611,CDM,259,RC,,,Outpatient,,,526.21,526.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.35,70,,294.68,percent of total billed charges,70% of total billed charges for outpatient setting,446.65,84.88,,357.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,263.11,50,,210.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.66,75,,315.73,percent of total billed charges,75% of total billed charges for outpatient setting,368.35,70,,294.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.57,12.84,,54.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.97,80,,336.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.57,12.84,,54.06,percent of total billed charges,12.84% of total billed charges,67.57,12.84,,54.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,342.04,65,,273.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.17,35,,147.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.59,90,,378.87,percent of total billed charges,90% of total billed charges for outpatient setting,67.57,473.59,
ANZEMET(DOLASETRON) 12.5 MG/0.625 ML,3302689,CDM,250,RC,,,Outpatient,,,137.42,137.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.19,70,,76.95,percent of total billed charges,70% of total billed charges for outpatient setting,116.64,84.88,,93.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.71,50,,54.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.07,75,,82.46,percent of total billed charges,75% of total billed charges for outpatient setting,96.19,70,,76.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,80,,87.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.32,65,,71.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.1,35,,38.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.68,90,,98.94,percent of total billed charges,90% of total billed charges for outpatient setting,17.64,123.68,
APAP/BTB/CA 325-50-40MG (FIORICET)TAB,3304488,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
APC RESISTANCE PROFILE,200018,CDM,301,RC,85307,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
APC RESISTANCE PROFILE,220015,CDM,301,RC,85307,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
API CHEMISTRY SURVEY,200901,CDM,300,RC,80048,HCPCS,Outpatient,,,38.07,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,32.31,84.88,,25.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.55,75,,22.84,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,80,,24.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,100,,,Fee Schedule,100% of Custom Fee Schedule,34.26,90,,27.41,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,34.26,
API FECAL OCCULT BLOOD SURVEY,201911,CDM,300,RC,82272,HCPCS,Outpatient,,,19.04,17.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,16.16,84.88,,12.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.28,75,,11.42,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,80,,12.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.14,90,,13.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,17.14,
API HCG SERUM SURVEY,200903,CDM,300,RC,84703,HCPCS,Outpatient,,,33.84,30.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.69,70,,18.95,percent of total billed charges,70% of total billed charges for outpatient setting,28.72,84.88,,22.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.38,75,,20.3,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,70,,18.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,80,,21.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.26,100,,,Fee Schedule,100% of Custom Fee Schedule,30.46,90,,24.37,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,30.46,
API IMMUNOASSAY SURVEY,200904,CDM,300,RC,G0103,HCPCS,Outpatient,,,86.9,78.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,73.76,84.88,,59.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.18,75,,52.14,percent of total billed charges,75% of total billed charges for outpatient setting,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.52,80,,55.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,78.21,90,,62.57,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,78.21,
API IMMUNOASSAY-SPECIAL SURVEY,200906,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
API INFLUENZA A&B,200908,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
API SARS-CoV-2 AG SURVEY (BINAXNOW),200909,CDM,306,RC,87811,HCPCS,Outpatient,,,62.07,55.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,52.69,84.88,,42.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.55,75,,37.24,percent of total billed charges,75% of total billed charges for outpatient setting,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.66,80,,39.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of Custom Fee Schedule,55.86,90,,44.69,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,55.86,
APIXABAN (ELIQUIS) 2.5MG TAB,3307979,CDM,259,RC,,,Outpatient,,,61.47,61.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.03,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,52.18,84.88,,41.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.74,50,,24.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.1,75,,36.88,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.18,80,,39.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,65,,31.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.51,35,,17.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.32,90,,44.26,percent of total billed charges,90% of total billed charges for outpatient setting,7.89,55.32,
"APPLICATION OF CAST, LONG ARM",69160724,CDM,360,RC,,,Outpatient,,,318.15,318.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,270.05,84.88,,216.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.08,50,,127.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.61,75,,190.89,percent of total billed charges,75% of total billed charges for outpatient setting,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.52,80,,203.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.35,35,,89.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.34,90,,229.07,percent of total billed charges,90% of total billed charges for outpatient setting,40.85,286.34,
"APPLICATION OF CAST, LONG ARM",7650881,CDM,360,RC,,,Outpatient,,,340.91,340.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,289.36,84.88,,231.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.46,50,,136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.68,75,,204.54,percent of total billed charges,75% of total billed charges for outpatient setting,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.73,80,,218.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.32,35,,95.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.82,90,,245.46,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.82,
"APPLICATION OF CAST, LONG LEG",7650883,CDM,360,RC,,,Outpatient,,,340.91,340.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,289.36,84.88,,231.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.46,50,,136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.68,75,,204.54,percent of total billed charges,75% of total billed charges for outpatient setting,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.73,80,,218.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.32,35,,95.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.82,90,,245.46,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.82,
"APPLICATION OF CAST, SHORT ARM",7650882,CDM,360,RC,,,Outpatient,,,340.91,340.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,289.36,84.88,,231.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.46,50,,136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.68,75,,204.54,percent of total billed charges,75% of total billed charges for outpatient setting,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.73,80,,218.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.32,35,,95.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.82,90,,245.46,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.82,
"APPLICATION OF CAST, SHORT LEG",7650884,CDM,360,RC,,,Outpatient,,,340.91,340.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,289.36,84.88,,231.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.46,50,,136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.68,75,,204.54,percent of total billed charges,75% of total billed charges for outpatient setting,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.73,80,,218.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.32,35,,95.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.82,90,,245.46,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.82,
"APPLICATION OF CAST,LONG ARM",69160970,CDM,360,RC,,,Outpatient,,,318.15,318.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,270.05,84.88,,216.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.08,50,,127.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.61,75,,190.89,percent of total billed charges,75% of total billed charges for outpatient setting,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.52,80,,203.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.35,35,,89.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.34,90,,229.07,percent of total billed charges,90% of total billed charges for outpatient setting,40.85,286.34,
"APPLICATION OF SPLINT, LONG ARM",7650887,CDM,360,RC,,,Outpatient,,,136.35,136.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.18,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.08,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.72,90,,98.18,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.72,
"APPLICATION OF SPLINT, LONG LEG",7650889,CDM,360,RC,,,Outpatient,,,136.35,136.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.18,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.08,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.72,90,,98.18,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.72,
"APPLICATION OF SPLINT, SHORT LEG",7650891,CDM,360,RC,,,Outpatient,,,136.35,136.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.18,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.08,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.72,90,,98.18,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.72,
"APPLICATION OF SPLINT,SHORT ARM,STATIC",7650888,CDM,360,RC,,,Outpatient,,,136.35,136.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.18,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.45,70,,76.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.08,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.72,90,,98.18,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.72,
APPLICATION OF WALKING CAST,7650886,CDM,360,RC,,,Outpatient,,,340.91,340.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,289.36,84.88,,231.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.46,50,,136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.68,75,,204.54,percent of total billed charges,75% of total billed charges for outpatient setting,238.64,70,,190.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.73,80,,218.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.32,35,,95.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.82,90,,245.46,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.82,
APPLIER 2300MM CLIP / HX-202UR.A,1596498,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406,70,,324.8,percent of total billed charges,70% of total billed charges for outpatient setting,492.3,84.88,,393.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,290,50,,232,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,435,75,,348,percent of total billed charges,75% of total billed charges for outpatient setting,406,70,,324.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464,80,,371.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,377,65,,301.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,35,,162.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,522,90,,417.6,percent of total billed charges,90% of total billed charges for outpatient setting,74.47,522,
APPLIER CLIP LARGE / MCL20,6150423,CDM,272,RC,,,Outpatient,,,145,145,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.5,70,,81.2,percent of total billed charges,70% of total billed charges for outpatient setting,123.08,84.88,,98.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.5,50,,58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.75,75,,87,percent of total billed charges,75% of total billed charges for outpatient setting,101.5,70,,81.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,12.84,,14.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116,80,,92.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,12.84,,14.9,percent of total billed charges,12.84% of total billed charges,18.62,12.84,,14.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.25,65,,75.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.75,35,,40.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.5,90,,104.4,percent of total billed charges,90% of total billed charges for outpatient setting,18.62,130.5,
AQUACEL 3.5 X 9.75  SILVER /412011A,69161966,CDM,272,RC,,,Outpatient,,,202.79,202.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,172.13,84.88,,137.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.4,50,,81.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.09,75,,121.67,percent of total billed charges,75% of total billed charges for outpatient setting,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,80,,129.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.81,65,,105.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.98,35,,56.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.51,90,,146.01,percent of total billed charges,90% of total billed charges for outpatient setting,26.04,182.51,
AQUACEL SURGICAL 3.5X10 DRSG / 422605,69162858,CDM,272,RC,,,Outpatient,,,136.65,136.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.66,70,,76.53,percent of total billed charges,70% of total billed charges for outpatient setting,115.99,84.88,,92.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.33,50,,54.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.49,75,,81.99,percent of total billed charges,75% of total billed charges for outpatient setting,95.66,70,,76.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,12.84,,14.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.32,80,,87.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,12.84,,14.04,percent of total billed charges,12.84% of total billed charges,17.55,12.84,,14.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.82,65,,71.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.83,35,,38.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.99,90,,98.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.55,122.99,
AQUACEL SURGICAL 3.5X12 DRSG / 422606,69169221,CDM,272,RC,,,Outpatient,,,150.7,150.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.49,70,,84.39,percent of total billed charges,70% of total billed charges for outpatient setting,127.91,84.88,,102.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.35,50,,60.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.03,75,,90.42,percent of total billed charges,75% of total billed charges for outpatient setting,105.49,70,,84.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,12.84,,15.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.56,80,,96.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,12.84,,15.48,percent of total billed charges,12.84% of total billed charges,19.35,12.84,,15.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.96,65,,78.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.75,35,,42.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.63,90,,108.5,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,135.63,
AQUACEL SURGICAL 3.5X6 DRSG / 422604,69162859,CDM,272,RC,,,Outpatient,,,130.92,130.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.64,70,,73.31,percent of total billed charges,70% of total billed charges for outpatient setting,111.12,84.88,,88.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.46,50,,52.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.19,75,,78.55,percent of total billed charges,75% of total billed charges for outpatient setting,91.64,70,,73.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.81,12.84,,13.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.74,80,,83.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.81,12.84,,13.45,percent of total billed charges,12.84% of total billed charges,16.81,12.84,,13.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.1,65,,68.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.82,35,,36.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,117.83,90,,94.26,percent of total billed charges,90% of total billed charges for outpatient setting,16.81,117.83,
AQUAMANTYS 6.0 BIPOLAR SEALR / 23-112-1,69161846,CDM,272,RC,,,Outpatient,,,1380,1380,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966,70,,772.8,percent of total billed charges,70% of total billed charges for outpatient setting,1171.34,84.88,,937.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,690,50,,552,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1035,75,,828,percent of total billed charges,75% of total billed charges for outpatient setting,966,70,,772.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,12.84,,141.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104,80,,883.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,12.84,,141.75,percent of total billed charges,12.84% of total billed charges,177.19,12.84,,141.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,897,65,,717.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483,35,,386.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1242,90,,993.6,percent of total billed charges,90% of total billed charges for outpatient setting,177.19,1242,
AQUAMANTYS EPIDURAL VEIN SEAL / 23-121-1,69162176,CDM,272,RC,,,Outpatient,,,1958.78,1958.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1371.15,70,,1096.92,percent of total billed charges,70% of total billed charges for outpatient setting,1662.61,84.88,,1330.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,979.39,50,,783.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1469.09,75,,1175.27,percent of total billed charges,75% of total billed charges for outpatient setting,1371.15,70,,1096.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.51,12.84,,201.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1567.02,80,,1253.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.51,12.84,,201.21,percent of total billed charges,12.84% of total billed charges,251.51,12.84,,201.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1273.21,65,,1018.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.57,35,,548.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1762.9,90,,1410.32,percent of total billed charges,90% of total billed charges for outpatient setting,251.51,1762.9,
ARAVA 10MG TAB,3302911,CDM,259,RC,,,Outpatient,,,35.74,35.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,70,,20.02,percent of total billed charges,70% of total billed charges for outpatient setting,30.34,84.88,,24.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.87,50,,14.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.81,75,,21.45,percent of total billed charges,75% of total billed charges for outpatient setting,25.02,70,,20.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,12.84,,3.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.59,80,,22.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,12.84,,3.67,percent of total billed charges,12.84% of total billed charges,4.59,12.84,,3.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.23,65,,18.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.51,35,,10.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.17,90,,25.74,percent of total billed charges,90% of total billed charges for outpatient setting,4.59,32.17,
"ARBOVIRUS AB IGG AND IGM, SERUM",220885,CDM,302,RC,86651,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
ARCH FOOT 180MM / 4934-6-180,70000663,CDM,278,RC,C1713,HCPCS,Outpatient,,,3502,3502,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2101.2,60,,1680.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2972.5,84.88,,2378,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2626.5,75,,2101.2,percent of total billed charges,75% of total billed charges for outpatient setting,1751,50,,1400.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.66,12.84,,359.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.6,80,,2241.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.66,12.84,,359.73,percent of total billed charges,12.84% of total billed charges,449.66,12.84,,359.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3677.1,105,,2941.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225.7,35,,980.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2101.2,60,,1680.96,percent of total billed charges,60% of total billed charges for outpatient setting,449.66,3677.1,
ARIPIPRAZOLE (ABILIFY) 10MG TAB,3303235,CDM,259,RC,,,Outpatient,,,52.96,52.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.07,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,44.95,84.88,,35.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.48,50,,21.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.72,75,,31.78,percent of total billed charges,75% of total billed charges for outpatient setting,37.07,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.37,80,,33.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.42,65,,27.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,35,,14.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.66,90,,38.13,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.66,
ARISTA 3 GRAM / SM0002-USA,69161384,CDM,272,RC,,,Outpatient,,,694.4,694.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.08,70,,388.86,percent of total billed charges,70% of total billed charges for outpatient setting,589.41,84.88,,471.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,347.2,50,,277.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.8,75,,416.64,percent of total billed charges,75% of total billed charges for outpatient setting,486.08,70,,388.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,12.84,,71.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.52,80,,444.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,12.84,,71.33,percent of total billed charges,12.84% of total billed charges,89.16,12.84,,71.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,451.36,65,,361.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.04,35,,194.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,624.96,90,,499.97,percent of total billed charges,90% of total billed charges for outpatient setting,89.16,624.96,
ARISTA FLEXITIP APPLICATOR / AM0005,69161389,CDM,272,RC,,,Outpatient,,,99.6,99.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.72,70,,55.78,percent of total billed charges,70% of total billed charges for outpatient setting,84.54,84.88,,67.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.8,50,,39.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,75,,59.76,percent of total billed charges,75% of total billed charges for outpatient setting,69.72,70,,55.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.79,12.84,,10.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,80,,63.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.79,12.84,,10.23,percent of total billed charges,12.84% of total billed charges,12.79,12.84,,10.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.74,65,,51.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.86,35,,27.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.64,90,,71.71,percent of total billed charges,90% of total billed charges for outpatient setting,12.79,89.64,
ARM CANOE SHLDR TRCT LONG / 020801,69161411,CDM,272,RC,,,Outpatient,,,255.23,255.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.66,70,,142.93,percent of total billed charges,70% of total billed charges for outpatient setting,216.64,84.88,,173.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.62,50,,102.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.42,75,,153.14,percent of total billed charges,75% of total billed charges for outpatient setting,178.66,70,,142.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,12.84,,26.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.18,80,,163.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,12.84,,26.22,percent of total billed charges,12.84% of total billed charges,32.77,12.84,,26.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.9,65,,132.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.33,35,,71.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,229.71,90,,183.77,percent of total billed charges,90% of total billed charges for outpatient setting,32.77,229.71,
ARMSTRG FLUOROPLASTIC Tube/Single1010030,69161349,CDM,272,RC,,,Outpatient,,,183.8,183.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.66,70,,102.93,percent of total billed charges,70% of total billed charges for outpatient setting,156.01,84.88,,124.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.9,50,,73.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.85,75,,110.28,percent of total billed charges,75% of total billed charges for outpatient setting,128.66,70,,102.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.6,12.84,,18.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.04,80,,117.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.6,12.84,,18.88,percent of total billed charges,12.84% of total billed charges,23.6,12.84,,18.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.47,65,,95.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,35,,51.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,165.42,90,,132.34,percent of total billed charges,90% of total billed charges for outpatient setting,23.6,165.42,
ARMSTRONG GROMMET TUBE/dbl 1046055,69161068,CDM,272,RC,,,Outpatient,,,273.83,273.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.68,70,,153.34,percent of total billed charges,70% of total billed charges for outpatient setting,232.43,84.88,,185.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.92,50,,109.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.37,75,,164.3,percent of total billed charges,75% of total billed charges for outpatient setting,191.68,70,,153.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.16,12.84,,28.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.06,80,,175.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.16,12.84,,28.13,percent of total billed charges,12.84% of total billed charges,35.16,12.84,,28.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.99,65,,142.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.84,35,,76.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,246.45,90,,197.16,percent of total billed charges,90% of total billed charges for outpatient setting,35.16,246.45,
ARSENIC BLOOD,220878,CDM,301,RC,82175,HCPCS,Outpatient,,,85.37,76.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.76,70,,47.81,percent of total billed charges,70% of total billed charges for outpatient setting,72.46,84.88,,57.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,64.03,75,,51.22,percent of total billed charges,75% of total billed charges for outpatient setting,59.76,70,,47.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.3,80,,54.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.99,100,,,Fee Schedule,100% of Custom Fee Schedule,76.83,90,,61.46,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,76.83,
ARTCL SURFCE 12MM LT MC / 42-5121-003-12,71000194,CDM,272,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1300,65,,1040,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,90,,1440,percent of total billed charges,90% of total billed charges for outpatient setting,256.8,1800,
ARTCL SURFCE 14MM LT MC  /42-5121-003-14,69169748,CDM,272,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1300,65,,1040,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,90,,1440,percent of total billed charges,90% of total billed charges for outpatient setting,256.8,1800,
ARTERIAL BLOOD GAS,200165,CDM,300,RC,82805,HCPCS,Outpatient,,,354.47,319.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.13,70,,198.5,percent of total billed charges,70% of total billed charges for outpatient setting,300.87,84.88,,240.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,265.85,75,,212.68,percent of total billed charges,75% of total billed charges for outpatient setting,248.13,70,,198.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.58,80,,226.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,41.43,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,100,,,Fee Schedule,100% of Custom Fee Schedule,319.02,90,,255.22,percent of total billed charges,90% of total billed charges for outpatient setting,11.03,319.02,
ARTERIAL PUNCTURE,200123,CDM,360,RC,36600,HCPCS,Outpatient,,,446.25,446.25,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,378.78,84.88,,303.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,334.69,75,,267.75,percent of total billed charges,75% of total billed charges for outpatient setting,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,57.3,12.84,,45.84,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,357,80,,285.6,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,57.3,12.84,,45.84,percent of total billed charges,12.84% of total billed charges,57.3,12.84,,45.84,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,401.63,90,,321.3,percent of total billed charges,90% of total billed charges for outpatient setting,57.3,490,
ARTERIAL PUNCTURE,1300080,CDM,300,RC,36600,HCPCS,Outpatient,,,446.25,401.63,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,378.78,84.88,,303.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,334.69,75,,267.75,percent of total billed charges,75% of total billed charges for outpatient setting,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,357,80,,285.6,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,401.63,90,,321.3,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,401.63,
ARTHROFLEX PATCH /AFLEX201,69162267,CDM,278,RC,,,Outpatient,,,6646.5,6646.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3987.9,60,,3190.32,percent of total billed charges,60% of total Billed charges for outpatient setting,5641.55,84.88,,4513.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3323.25,50,,2658.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4984.88,75,,3987.9,percent of total billed charges,75% of total billed charges for outpatient setting,3323.25,50,,2658.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.41,12.84,,682.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.2,80,,4253.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.41,12.84,,682.73,percent of total billed charges,12.84% of total billed charges,853.41,12.84,,682.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6978.83,105,,5583.06,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2326.28,35,,1861.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3987.9,60,,3190.32,percent of total billed charges,60% of total billed charges for outpatient setting,853.41,6978.83,
ARTICLR SURFCE 10MM LT MC/42-5121-009-10,69169517,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 10MM RT MC/42-5221-008-10,69169490,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 11MM L / 42-5121-008-11,71000316,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 11MM RT MC/42-5221-008-11,69169668,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 12MM RT / 42-5221-008-12,71000162,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 13MM LT MC/42-5121-008-13,69169756,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 13MM RT MC/42-5221-008-13,71000170,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 14MM LT MC/42-5121-008-14,69169491,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 14MM RT MC/42-5221-008-14,69169580,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICLR SURFCE 18MM LT / 42-5121-008-18,71000136,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICR INSRT POST ST  5-6/ 21MM 71420840,69161877,CDM,278,RC,,,Outpatient,,,2036.1,2036.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1221.66,60,,977.33,percent of total billed charges,60% of total Billed charges for outpatient setting,1728.24,84.88,,1382.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,1018.05,50,,814.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1527.08,75,,1221.66,percent of total billed charges,75% of total billed charges for outpatient setting,1018.05,50,,814.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.44,12.84,,209.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1628.88,80,,1303.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.44,12.84,,209.15,percent of total billed charges,12.84% of total billed charges,261.44,12.84,,209.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2036.1,65,,1628.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.64,35,,570.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1221.66,60,,977.33,percent of total billed charges,60% of total billed charges for outpatient setting,261.44,2036.1,
ARTICULAR INSERT 11MM/SZ 3-4,69161176,CDM,278,RC,C1776,HCPCS,Outpatient,,,2571.4,2571.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.84,60,,1234.27,percent of total billed charges,60% of total Billed charges for outpatient setting,2182.6,84.88,,1746.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1928.55,75,,1542.84,percent of total billed charges,75% of total billed charges for outpatient setting,1285.7,50,,1028.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.17,12.84,,264.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2057.12,80,,1645.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.17,12.84,,264.14,percent of total billed charges,12.84% of total billed charges,330.17,12.84,,264.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2699.97,105,,2159.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.99,35,,719.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1542.84,60,,1234.27,percent of total billed charges,60% of total billed charges for outpatient setting,330.17,2699.97,
ARTICULAR INSERT 11MM/SZ 3-4 /71420524,69161235,CDM,278,RC,C1776,HCPCS,Outpatient,,,4140,4140,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484,60,,1987.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3514.03,84.88,,2811.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3105,75,,2484,percent of total billed charges,75% of total billed charges for outpatient setting,2070,50,,1656,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3312,80,,2649.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4347,105,,3477.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449,35,,1159.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2484,60,,1987.2,percent of total billed charges,60% of total billed charges for outpatient setting,531.58,4347,
ARTICULAR INSERT 11MM/SZ 5-6 / 71453122,69162391,CDM,278,RC,,,Outpatient,,,3256,3256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1953.6,60,,1562.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2763.69,84.88,,2210.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,1628,50,,1302.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2442,75,,1953.6,percent of total billed charges,75% of total billed charges for outpatient setting,1628,50,,1302.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.07,12.84,,334.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2604.8,80,,2083.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.07,12.84,,334.46,percent of total billed charges,12.84% of total billed charges,418.07,12.84,,334.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3418.8,105,,2735.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.6,35,,911.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1953.6,60,,1562.88,percent of total billed charges,60% of total billed charges for outpatient setting,418.07,3418.8,
ARTICULAR INSERT 13mm/SZ 1-2   71453103,69161586,CDM,278,RC,,,Outpatient,,,2699.98,2699.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.99,60,,1295.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.74,84.88,,1833.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349.99,50,,1079.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2024.99,75,,1619.99,percent of total billed charges,75% of total billed charges for outpatient setting,1349.99,50,,1079.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2159.98,80,,1727.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2834.98,105,,2267.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.99,35,,755.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1619.99,60,,1295.99,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2834.98,
ARTICULAR INSERT 13MM/SZ 5-6,69161106,CDM,278,RC,,,Outpatient,,,2663.4,2663.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.04,60,,1278.43,percent of total billed charges,60% of total Billed charges for outpatient setting,2260.69,84.88,,1808.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1331.7,50,,1065.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1997.55,75,,1598.04,percent of total billed charges,75% of total billed charges for outpatient setting,1331.7,50,,1065.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.98,12.84,,273.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.72,80,,1704.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.98,12.84,,273.58,percent of total billed charges,12.84% of total billed charges,341.98,12.84,,273.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2796.57,105,,2237.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.19,35,,745.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1598.04,60,,1278.43,percent of total billed charges,60% of total billed charges for outpatient setting,341.98,2796.57,
ARTICULAR INSERT 15mm/SZ 1-2   71453104,69162097,CDM,278,RC,,,Outpatient,,,2699.98,2699.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.99,60,,1295.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.74,84.88,,1833.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349.99,50,,1079.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2024.99,75,,1619.99,percent of total billed charges,75% of total billed charges for outpatient setting,1349.99,50,,1079.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2159.98,80,,1727.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2834.98,105,,2267.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.99,35,,755.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1619.99,60,,1295.99,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2834.98,
ARTICULAR INSERT 15MM/SZ 1-2 /71420808,69169200,CDM,278,RC,,,Outpatient,,,2312.48,2312.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.49,60,,1109.99,percent of total billed charges,60% of total Billed charges for outpatient setting,1962.83,84.88,,1570.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1156.24,50,,924.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1734.36,75,,1387.49,percent of total billed charges,75% of total billed charges for outpatient setting,1156.24,50,,924.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.92,12.84,,237.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.98,80,,1479.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.92,12.84,,237.54,percent of total billed charges,12.84% of total billed charges,296.92,12.84,,237.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2428.1,105,,1942.48,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.37,35,,647.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1387.49,60,,1109.99,percent of total billed charges,60% of total billed charges for outpatient setting,296.92,2428.1,
ARTICULAR INSERT 15MM/SZ 3-4  71420528,69161371,CDM,278,RC,,,Outpatient,,,4140,4140,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484,60,,1987.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3514.03,84.88,,2811.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,2070,50,,1656,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3105,75,,2484,percent of total billed charges,75% of total billed charges for outpatient setting,2070,50,,1656,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3312,80,,2649.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4347,105,,3477.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449,35,,1159.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2484,60,,1987.2,percent of total billed charges,60% of total billed charges for outpatient setting,531.58,4347,
ARTICULAR INSERT 15MM/SZ 7-8 71453234,69161482,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
ARTICULAR INSERT 18MM/SZ 3-4 / 71420814,69169534,CDM,278,RC,C1776,HCPCS,Outpatient,,,2312.48,2312.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.49,60,,1109.99,percent of total billed charges,60% of total Billed charges for outpatient setting,1962.83,84.88,,1570.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.36,75,,1387.49,percent of total billed charges,75% of total billed charges for outpatient setting,1156.24,50,,924.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.92,12.84,,237.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.98,80,,1479.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.92,12.84,,237.54,percent of total billed charges,12.84% of total billed charges,296.92,12.84,,237.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2428.1,105,,1942.48,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.37,35,,647.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1387.49,60,,1109.99,percent of total billed charges,60% of total billed charges for outpatient setting,296.92,2428.1,
ARTICULAR INSERT 18MM/SZ 3-4 /71420824,69161288,CDM,278,RC,,,Outpatient,,,3474.39,3474.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2084.63,60,,1667.7,percent of total billed charges,60% of total Billed charges for outpatient setting,2949.06,84.88,,2359.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,1737.2,50,,1389.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2605.79,75,,2084.63,percent of total billed charges,75% of total billed charges for outpatient setting,1737.2,50,,1389.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.11,12.84,,356.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2779.51,80,,2223.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.11,12.84,,356.89,percent of total billed charges,12.84% of total billed charges,446.11,12.84,,356.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3648.11,105,,2918.49,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.04,35,,972.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2084.63,60,,1667.7,percent of total billed charges,60% of total billed charges for outpatient setting,446.11,3648.11,
ARTICULAR INSERT 18MM/SZ 3-4/71420530,69161113,CDM,278,RC,,,Outpatient,,,4140,4140,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484,60,,1987.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3514.03,84.88,,2811.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,2070,50,,1656,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3105,75,,2484,percent of total billed charges,75% of total billed charges for outpatient setting,2070,50,,1656,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3312,80,,2649.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,531.58,12.84,,425.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4347,105,,3477.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449,35,,1159.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2484,60,,1987.2,percent of total billed charges,60% of total billed charges for outpatient setting,531.58,4347,
ARTICULAR INSERT 18MM/SZ 5-6 /71420838,69161236,CDM,278,RC,,,Outpatient,,,3474.39,3474.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2084.63,60,,1667.7,percent of total billed charges,60% of total Billed charges for outpatient setting,2949.06,84.88,,2359.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,1737.2,50,,1389.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2605.79,75,,2084.63,percent of total billed charges,75% of total billed charges for outpatient setting,1737.2,50,,1389.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.11,12.84,,356.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2779.51,80,,2223.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.11,12.84,,356.89,percent of total billed charges,12.84% of total billed charges,446.11,12.84,,356.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3648.11,105,,2918.49,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.04,35,,972.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2084.63,60,,1667.7,percent of total billed charges,60% of total billed charges for outpatient setting,446.11,3648.11,
ARTICULAR INSERT 21MM/SZ 3-4 /71420826,69161496,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
ARTICULAR INSERT 9 mm/SZ 1-2   71453101,69162201,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT 9MM SZ 3-4 / 71420816,71000696,CDM,278,RC,C1776,HCPCS,Outpatient,,,2029.24,2029.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1217.54,60,,974.03,percent of total billed charges,60% of total Billed charges for outpatient setting,1722.42,84.88,,1377.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1521.93,75,,1217.54,percent of total billed charges,75% of total billed charges for outpatient setting,1014.62,50,,811.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1623.39,80,,1298.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2029.24,65,,1623.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.23,35,,568.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1217.54,60,,974.03,percent of total billed charges,60% of total billed charges for outpatient setting,260.55,2029.24,
ARTICULAR INSERT 9MM SZ 3-4 / 71453111,69161145,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT 9MM/SZ 5-6 / 71453121,69162358,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT SZ 1-2 15MM / 71453204,69162602,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"ARTICULAR INSERT SZ 1-2, 9MM  71453201",69161721,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
ARTICULAR INSERT SZ 3-4 13MM / 71453213,69161215,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT SZ 3-4 9MM  71453211,69161292,CDM,278,RC,C1776,HCPCS,Outpatient,,,3007.77,3007.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1804.66,60,,1443.73,percent of total billed charges,60% of total Billed charges for outpatient setting,2553,84.88,,2042.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2255.83,75,,1804.66,percent of total billed charges,75% of total billed charges for outpatient setting,1503.89,50,,1203.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.2,12.84,,308.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2406.22,80,,1924.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.2,12.84,,308.96,percent of total billed charges,12.84% of total billed charges,386.2,12.84,,308.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3158.16,105,,2526.53,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.72,35,,842.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1804.66,60,,1443.73,percent of total billed charges,60% of total billed charges for outpatient setting,386.2,3158.16,
"ARTICULAR INSERT SZ 3-4, 11MM  71453212",69161437,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
"ARTICULAR INSERT SZ 3-4, 15MM 71453214",69161243,CDM,278,RC,,,Outpatient,,,5451.67,5451.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3271,60,,2616.8,percent of total billed charges,60% of total Billed charges for outpatient setting,4627.38,84.88,,3701.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,2725.84,50,,2180.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4088.75,75,,3271,percent of total billed charges,75% of total billed charges for outpatient setting,2725.84,50,,2180.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.99,12.84,,559.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4361.34,80,,3489.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.99,12.84,,559.99,percent of total billed charges,12.84% of total billed charges,699.99,12.84,,559.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5724.25,105,,4579.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1908.08,35,,1526.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3271,60,,2616.8,percent of total billed charges,60% of total billed charges for outpatient setting,699.99,5724.25,
ARTICULAR INSERT SZ 5-6 13MM / 71453223,6916117,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT SZ 5-6 9MM / 71453221,69161103,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"ARTICULAR INSERT SZ 5-6, 11MM  71453222",69161120,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
"ARTICULAR INSERT SZ 5-6, 13MM  71453223",69161117,CDM,278,RC,,,Outpatient,,,2663.4,2663.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.04,60,,1278.43,percent of total billed charges,60% of total Billed charges for outpatient setting,2260.69,84.88,,1808.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1331.7,50,,1065.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1997.55,75,,1598.04,percent of total billed charges,75% of total billed charges for outpatient setting,1331.7,50,,1065.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.98,12.84,,273.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.72,80,,1704.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.98,12.84,,273.58,percent of total billed charges,12.84% of total billed charges,341.98,12.84,,273.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2796.57,105,,2237.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.19,35,,745.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1598.04,60,,1278.43,percent of total billed charges,60% of total billed charges for outpatient setting,341.98,2796.57,
"ARTICULAR INSERT SZ 5-6, 15MM  71453224",69161257,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
ARTICULAR INSERT SZ 7-8 11MM / 71453132,70000160,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT SZ 7-8 15MM / 71453134,69161214,CDM,278,RC,,,Outpatient,,,2571.4,2571.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.84,60,,1234.27,percent of total billed charges,60% of total Billed charges for outpatient setting,2182.6,84.88,,1746.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1285.7,50,,1028.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1928.55,75,,1542.84,percent of total billed charges,75% of total billed charges for outpatient setting,1285.7,50,,1028.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.17,12.84,,264.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2057.12,80,,1645.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.17,12.84,,264.14,percent of total billed charges,12.84% of total billed charges,330.17,12.84,,264.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2699.97,105,,2159.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.99,35,,719.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1542.84,60,,1234.27,percent of total billed charges,60% of total billed charges for outpatient setting,330.17,2699.97,
ARTICULAR INSERT SZ 7-8 9MM / 71453231,69161094,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT SZ 7-8 9MM 71453131,69161130,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"ARTICULAR INSERT SZ 7-8, 11MM  71453232",69161169,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
ARTICULAR INSERT13MM/SZ3-4 / 71453113,69162633,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR INSERT15MM/SZ3-4 / 71453114,69162200,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 10MM LT / 42-5121-005-10,72000000,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 11MM LT / 42-5121-004-11,71000058,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 12MM LT / 42-5121-004-12,71000219,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 14MM LT / 42-5121-004-14,71000129,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 16MM LT / 42-5121-004-16,71000624,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SRFCE 18MM LT / 42-5121-004-18,71000072,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM L / 42-5121-004-10,69169473,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM L / 42-5121-007-10,69169500,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM L / 42-5126-010-10,71000112,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM LT /42-5121-003-10,71000054,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM LT /42-5121-008-10,69169223,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5214-004-10,71000174,CDM,278,RC,C1776,HCPCS,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,60,,1092,percent of total billed charges,60% of total Billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2388.75,105,,1911,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1365,60,,1092,percent of total billed charges,60% of total billed charges for outpatient setting,292.11,2388.75,
ARTICULAR SURFCE 10MM R / 42-5214-010-10,71000182,CDM,278,RC,C1776,HCPCS,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,60,,1092,percent of total billed charges,60% of total Billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2388.75,105,,1911,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1365,60,,1092,percent of total billed charges,60% of total billed charges for outpatient setting,292.11,2388.75,
ARTICULAR SURFCE 10MM R / 42-5221-003-10,71000521,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5221-004-10,69169692,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5221-005-10,71000493,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5221-007-10,71000282,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5221-010-10,69169825,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM R / 42-5222-004-10,71000524,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM RT /42-5221-009-10,69169726,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 10MM RT /42-5224-008-10,69169420,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
ARTICULAR SURFCE 11MM L / 42-5122-005-11,71000234,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM LT /42-5121-009-1,71000142,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM R / 42-5221-003-11,72000006,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM R / 42-5221-004-11,69169693,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM R / 42-5221-007-11,69169516,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM R / 42-5222-005-11,71000097,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM RT /42-5221-005-11,69169532,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 11MM RT /42-5221-009-12,71000157,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM L / 42-5121-007-12,71000296,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM L / 42-5121-009-12,71000210,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM R / 42-5221-003-12,69169436,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM R / 42-5221-005-12,71000057,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM R / 42-5221-006-12,71000202,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM R / 42-5221-009-12,71000107,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 12MM R / 42-5224-007-12,69169399,CDM,278,RC,C1776,HCPCS,Outpatient,,,2100,2100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,60,,1008,percent of total billed charges,60% of total Billed charges for outpatient setting,1782.48,84.88,,1425.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,75,,1260,percent of total billed charges,75% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,80,,1344,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2205,105,,1764,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,35,,588,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1260,60,,1008,percent of total billed charges,60% of total billed charges for outpatient setting,269.64,2205,
ARTICULAR SURFCE 13MM L / 42-5121-009-13,69169731,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM L / 42-5122-005-13,71000242,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM L / 42-5122-006-13,71000297,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM R / 42-5221-003-13,71000476,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM R / 42-5221-004-13,71000475,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM R / 42-5221-007-13,69169895,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 13MM R / 42-5221-010-13,69169515,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM L / 42-5121-005-14,71000092,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM L / 42-5121-007-14,69169471,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM L / 42-5121-009-14,69169684,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM L / 42-5122-004-14,71000206,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM L / 42-5122-006-14,71000143,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5221-003-14,71000104,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5221-004-14,71000041,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5221-007-14,71000102,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5221-009-14,69169583,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5222-004-14,71000247,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5222-006-14,71000211,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 14MM R / 42-5224-007-14,69169416,CDM,278,RC,C1776,HCPCS,Outpatient,,,2100,2100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,60,,1008,percent of total billed charges,60% of total Billed charges for outpatient setting,1782.48,84.88,,1425.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,75,,1260,percent of total billed charges,75% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,80,,1344,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2205,105,,1764,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,35,,588,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1260,60,,1008,percent of total billed charges,60% of total billed charges for outpatient setting,269.64,2205,
ARTICULAR SURFCE 16MM L / 42-5114-007-16,71000184,CDM,278,RC,C1776,HCPCS,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,60,,1092,percent of total billed charges,60% of total Billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2388.75,105,,1911,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1365,60,,1092,percent of total billed charges,60% of total billed charges for outpatient setting,292.11,2388.75,
ARTICULAR SURFCE 16MM L / 42-5121-003-16,71000069,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM L / 42-5121-009-16,71000474,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM L / 42-5126-004-16,71000302,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM R / 42-5221-004-16,71000012,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM R / 42-5221-008-16,71000044,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM R / 42-5221-009-16,69169662,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 16MM R / 42-5222-005-16,69169370,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM L / 42-5121-003-18,69169564,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM L / 42-5121-009-18,69169808,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM L / 42-5122-005-18,71000108,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM L / 42-5126-004-18,71000135,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM L / 42-5126-006-18,71000318,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 18MM R / 42-5221-004-18,69169681,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 20MM / 5994-32-20,69169576,CDM,278,RC,C1776,HCPCS,Outpatient,,,4114,4114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2468.4,60,,1974.72,percent of total billed charges,60% of total Billed charges for outpatient setting,3491.96,84.88,,2793.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3085.5,75,,2468.4,percent of total billed charges,75% of total billed charges for outpatient setting,2057,50,,1645.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.24,12.84,,422.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3291.2,80,,2632.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.24,12.84,,422.59,percent of total billed charges,12.84% of total billed charges,528.24,12.84,,422.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4319.7,105,,3455.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1439.9,35,,1151.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2468.4,60,,1974.72,percent of total billed charges,60% of total billed charges for outpatient setting,528.24,4319.7,
ARTICULAR SURFCE 20MM L / 42-5121-005-20,69169665,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTICULAR SURFCE 20MM L / 42-5126-004-20,71000186,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
ARTIFICIAL TEARS OPHTH DROPS 15ML,3303280,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
ASCA ANTIBODIES,220900,CDM,302,RC,86671,HCPCS,Outpatient,,,55.13,49.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.59,70,,30.87,percent of total billed charges,70% of total billed charges for outpatient setting,46.79,84.88,,37.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.35,75,,33.08,percent of total billed charges,75% of total billed charges for outpatient setting,38.59,70,,30.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,80,,35.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.24,100,,,Fee Schedule,100% of Custom Fee Schedule,49.62,90,,39.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,49.62,
ASCORBIC ACID  C  TAB 250 MG,3300612,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ASCORBIC ACID  C  TAB 500 MG,3300613,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASCORBIC ACID 500 MG/ML 2ML,3303248,CDM,250,RC,,,Outpatient,,,28.05,28.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.64,70,,15.71,percent of total billed charges,70% of total billed charges for outpatient setting,23.81,84.88,,19.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.03,50,,11.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.04,75,,16.83,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,70,,15.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.44,80,,17.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.23,65,,14.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.82,35,,7.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.25,90,,20.2,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,25.25,
ASCORBIC ACID TAB 500 MG,3300614,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ASCORBIC ACID TAB 500 MG,3300615,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASEPTO SYRINGE / 67000,6150460,CDM,270,RC,,,Outpatient,,,13.32,13.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,70,,7.46,percent of total billed charges,70% of total billed charges for outpatient setting,11.31,84.88,,9.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.66,50,,5.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.99,75,,7.99,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,70,,7.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,80,,8.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.66,65,,6.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,35,,3.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.99,90,,9.59,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.99,
ASO ANTIBODY,220872,CDM,302,RC,86060,HCPCS,Outpatient,,,32.85,29.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,27.88,84.88,,22.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.64,75,,19.71,percent of total billed charges,75% of total billed charges for outpatient setting,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.28,80,,21.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of Custom Fee Schedule,29.57,90,,23.66,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,29.57,
ASPERGILLUS,220601,CDM,302,RC,86606,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
ASPERGILLUS AB,220865,CDM,302,RC,86603,HCPCS,Outpatient,,,57.92,52.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,49.16,84.88,,39.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.44,75,,34.75,percent of total billed charges,75% of total billed charges for outpatient setting,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,80,,37.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.39,100,,,Fee Schedule,100% of Custom Fee Schedule,52.13,90,,41.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,52.13,
ASPERGILLUS GALACTOMANNAN AG,220875,CDM,302,RC,87305,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
ASPIRIN (ENTERIC COATED) 325 MG TAB,3302749,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ASPIRIN ACETAMIN  GENACED TAB,3300626,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN CHEW 81 MG,3300617,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN CHEW TAB 81MG,3300625,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
ASPIRIN EC 81 MG TAB,3300622,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ASPIRIN SUPP 300 MG,3300618,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ASPIRIN SUPP 600 MG,3300620,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ASPIRIN TAB 325 MG,3300624,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ASPIRIN TAB 325 MG,3300616,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN TAB 325 MG,3300619,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN TAB 325 MG,3300621,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN TAB 325 MG,3300623,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ASPIRIN TAB 81MG CHEWABLE,3303774,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ASTELIN(AZELASTINE): NASAL,3303127,CDM,259,RC,,,Outpatient,,,272.6,272.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.82,70,,152.66,percent of total billed charges,70% of total billed charges for outpatient setting,231.38,84.88,,185.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.3,50,,109.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.45,75,,163.56,percent of total billed charges,75% of total billed charges for outpatient setting,190.82,70,,152.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,12.84,,28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.08,80,,174.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,12.84,,28,percent of total billed charges,12.84% of total billed charges,35,12.84,,28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.19,65,,141.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.41,35,,76.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,245.34,90,,196.27,percent of total billed charges,90% of total billed charges for outpatient setting,35,245.34,
ATACAND HCT16/12.5 TAB,3302865,CDM,259,RC,,,Outpatient,,,59.51,59.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,70,,33.33,percent of total billed charges,70% of total billed charges for outpatient setting,50.51,84.88,,40.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.76,50,,23.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.63,75,,35.7,percent of total billed charges,75% of total billed charges for outpatient setting,41.66,70,,33.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,12.84,,6.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.61,80,,38.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,12.84,,6.11,percent of total billed charges,12.84% of total billed charges,7.64,12.84,,6.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.68,65,,30.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,35,,16.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.56,90,,42.85,percent of total billed charges,90% of total billed charges for outpatient setting,7.64,53.56,
ATAZANAVIR (REYATAZ) 100MG CAP,3303274,CDM,259,RC,,,Outpatient,,,66.53,66.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.57,70,,37.26,percent of total billed charges,70% of total billed charges for outpatient setting,56.47,84.88,,45.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.27,50,,26.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.9,75,,39.92,percent of total billed charges,75% of total billed charges for outpatient setting,46.57,70,,37.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,12.84,,6.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.22,80,,42.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,12.84,,6.83,percent of total billed charges,12.84% of total billed charges,8.54,12.84,,6.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.24,65,,34.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.29,35,,18.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.88,90,,47.9,percent of total billed charges,90% of total billed charges for outpatient setting,8.54,59.88,
ATENOLOL (genTENORMIN) 50MG,3300629,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ATENOLOL TENORMIN TAB  25 MG,3300630,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ATENOLOL TENORMIN TAB  50 MG,3300627,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ATENOLOL TENORMIN TAB 50 MG U/D,3300628,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ATORVASTATIN (genericLIPITOR) 10MG TAB,3300631,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ATORVASTATIN (genericLIPITOR) 40MG TAB,3303224,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ATORVASTATIN (genericLIPITOR) 80MG TAB,3313691,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ATORVASTATIN (genericLIPITOR) TAB 20MG,3303261,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ATORVASTATIN (LIPITOR) TAB 40MG,3304127,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ATORVASTATIN LIPITOR TAB 10MG,3300632,CDM,259,RC,,,Outpatient,,,6.27,6.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,70,,3.51,percent of total billed charges,70% of total billed charges for outpatient setting,5.32,84.88,,4.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.14,50,,2.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.7,75,,3.76,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,70,,3.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.02,80,,4.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.08,65,,3.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,35,,1.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.64,90,,4.51,percent of total billed charges,90% of total billed charges for outpatient setting,0.81,5.64,
ATRACURIUM BESYLATE10 MG/ML 5 ML,3302724,CDM,250,RC,,,Outpatient,,,45.2,45.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.64,70,,25.31,percent of total billed charges,70% of total billed charges for outpatient setting,38.37,84.88,,30.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.6,50,,18.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.9,75,,27.12,percent of total billed charges,75% of total billed charges for outpatient setting,31.64,70,,25.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,12.84,,4.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.16,80,,28.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,12.84,,4.64,percent of total billed charges,12.84% of total billed charges,5.8,12.84,,4.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.38,65,,23.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.82,35,,12.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.68,90,,32.54,percent of total billed charges,90% of total billed charges for outpatient setting,5.8,40.68,
ATROPINE 1% 5ML OPHTHALMIC:,3302671,CDM,259,RC,,,Outpatient,,,7.95,7.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,84.88,,5.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.98,50,,3.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.96,75,,4.77,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.36,80,,5.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.17,65,,4.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,35,,2.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.16,90,,5.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,7.16,
ATROPINE 1% OPHTH SOLN 2ML,3302670,CDM,259,RC,,,Outpatient,,,147.15,147.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,70,,82.41,percent of total billed charges,70% of total billed charges for outpatient setting,124.9,84.88,,99.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.58,50,,58.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.36,75,,88.29,percent of total billed charges,75% of total billed charges for outpatient setting,103.01,70,,82.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.72,80,,94.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.65,65,,76.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.5,35,,41.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.44,90,,105.95,percent of total billed charges,90% of total billed charges for outpatient setting,18.89,132.44,
ATROPINE 1% OPHTH SOLN 5ML,3310577,CDM,259,RC,,,Outpatient,,,237.98,237.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.59,70,,133.27,percent of total billed charges,70% of total billed charges for outpatient setting,202,84.88,,161.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.99,50,,95.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.49,75,,142.79,percent of total billed charges,75% of total billed charges for outpatient setting,166.59,70,,133.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,12.84,,24.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.38,80,,152.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,12.84,,24.45,percent of total billed charges,12.84% of total billed charges,30.56,12.84,,24.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.69,65,,123.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.29,35,,66.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.18,90,,171.34,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,214.18,
ATROPINE SULF INFANT INJ 0.05MG/ML 5ML,3300638,CDM,250,RC,,,Outpatient,,,95.48,95.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.84,70,,53.47,percent of total billed charges,70% of total billed charges for outpatient setting,81.04,84.88,,64.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.74,50,,38.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.61,75,,57.29,percent of total billed charges,75% of total billed charges for outpatient setting,66.84,70,,53.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.26,12.84,,9.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.38,80,,61.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.26,12.84,,9.81,percent of total billed charges,12.84% of total billed charges,12.26,12.84,,9.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.06,65,,49.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.42,35,,26.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.93,90,,68.74,percent of total billed charges,90% of total billed charges for outpatient setting,12.26,85.93,
ATROPINE SULF INJ 0.1MG/ML 10ML SYRINGE,3300637,CDM,250,RC,,,Outpatient,,,46.24,46.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.37,70,,25.9,percent of total billed charges,70% of total billed charges for outpatient setting,39.25,84.88,,31.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.12,50,,18.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.68,75,,27.74,percent of total billed charges,75% of total billed charges for outpatient setting,32.37,70,,25.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.94,12.84,,4.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.99,80,,29.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.94,12.84,,4.75,percent of total billed charges,12.84% of total billed charges,5.94,12.84,,4.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.06,65,,24.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,35,,12.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.62,90,,33.3,percent of total billed charges,90% of total billed charges for outpatient setting,5.94,41.62,
ATROPINE SULFATE INJ 0.4 MG/ML 1ML,3300635,CDM,636,RC,J0461,HCPCS,Outpatient,,,33.85,33.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,70,,18.96,percent of total billed charges,70% of total billed charges for outpatient setting,28.73,84.88,,22.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.39,75,,20.31,percent of total billed charges,75% of total billed charges for outpatient setting,23.7,70,,18.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,12.84,,3.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.08,80,,21.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,12.84,,3.48,percent of total billed charges,12.84% of total billed charges,4.35,12.84,,3.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22,65,,17.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.08,100,,,Fee Schedule,100% of Custom Fee Schedule,30.47,90,,24.38,percent of total billed charges,90% of total billed charges for outpatient setting,0.08,30.47,
ATROPINE SULFATE INJ 0.4MG/ML 1ML,3300634,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ATROPINE SULFATE INJ 1 MG/ML 1ML,3306297,CDM,636,RC,J0461,HCPCS,Outpatient,,,41.19,41.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,34.96,84.88,,27.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.89,75,,24.71,percent of total billed charges,75% of total billed charges for outpatient setting,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.95,80,,26.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.77,65,,21.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.08,100,,,Fee Schedule,100% of Custom Fee Schedule,37.07,90,,29.66,percent of total billed charges,90% of total billed charges for outpatient setting,0.08,37.07,
ATROPINE SULFATE INJ 1MG/ML1ML,3300636,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ATROPINE SULFATE OPTH SOL 1% 15ML,3300633,CDM,259,RC,,,Outpatient,,,9.1,9.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,7.72,84.88,,6.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.55,50,,3.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.83,75,,5.46,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,80,,5.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.92,65,,4.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,35,,2.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.19,90,,6.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.17,8.19,
ATTACHEMENT 11.35MM DISTAL / D-201-10704,800241,CDM,272,RC,,,Outpatient,,,140.1,140.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,118.92,84.88,,95.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.05,50,,56.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.08,75,,84.06,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.08,80,,89.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.07,65,,72.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.04,35,,39.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.09,90,,100.87,percent of total billed charges,90% of total billed charges for outpatient setting,17.99,126.09,
ATTACHEMENT 13.4MM DISTAL / D-201-12704,69169034,CDM,272,RC,,,Outpatient,,,140.1,140.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,118.92,84.88,,95.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.05,50,,56.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.08,75,,84.06,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.08,80,,89.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.07,65,,72.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.04,35,,39.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.09,90,,100.87,percent of total billed charges,90% of total billed charges for outpatient setting,17.99,126.09,
ATTAPULGITE K-PEK LIQ 750/15 240ML,3300639,CDM,259,RC,,,Outpatient,,,8.77,8.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,84.88,,5.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.39,50,,3.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.58,75,,5.26,percent of total billed charges,75% of total billed charges for outpatient setting,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,80,,5.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.7,65,,4.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,35,,2.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.89,90,,6.31,percent of total billed charges,90% of total billed charges for outpatient setting,1.13,7.89,
AUGMENT 10MM SZ 3 TRTHLN / 5541-A-302,71000842,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 10MM SZ 3 TRTHLN / 5544-A-300,71000841,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 10MM SZ 4 TRTHLN / 5541-A-401,71000868,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 10MM SZ 4 TRTHLN / 5544-A-400,71000464,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 10MM SZ 5 TRTHLN / 5544-A-500,71000831,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 10MM SZ 7 TRTHLN / 5544-A-700,71000579,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 2 TRTHLN / 5540-A-201,71000518,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 2 TRTHLN / 5543-A-200,71000515,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 3 TRTHLN / 5540-A-301,71000922,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 3 TRTHLN / 5543-A-300,71000951,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 4 TRTHLN / 5540-A-402,71000373,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 5 TRTHLN / 5540-A-501,71000649,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 5 TRTHLN / 5543-A-500,71000651,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 6 TRTHLN / 5540-A-601,71000878,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 6 TRTHLN / 5543-A-600,71000879,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 7 TRTHLN / 5540-A-702,71000528,CDM,278,RC,C1734,HCPCS,Outpatient,,,2191.24,2191.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1859.92,84.88,,1487.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.43,75,,1314.74,percent of total billed charges,75% of total billed charges for outpatient setting,1095.62,50,,876.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.99,80,,1402.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,281.36,12.84,,225.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2300.8,105,,1840.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,60,,1051.79,percent of total billed charges,60% of total billed charges for outpatient setting,281.36,2300.8,
AUGMENT 5MM SZ 7 TRTHLN / 5543-A-700,71000484,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENT 5MM SZ 8 TRTHLN / 5543-A-400,71000372,CDM,278,RC,C1734,HCPCS,Outpatient,,,2302.6,2302.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total Billed charges for outpatient setting,1954.45,84.88,,1563.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.95,75,,1381.56,percent of total billed charges,75% of total billed charges for outpatient setting,1151.3,50,,921.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.08,80,,1473.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,295.65,12.84,,236.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2417.73,105,,1934.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.56,60,,1105.25,percent of total billed charges,60% of total billed charges for outpatient setting,295.65,2417.73,
AUGMENTIN SUSP 125MG/5ML75ML,3300594,CDM,259,RC,,,Outpatient,,,62.61,62.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.83,70,,35.06,percent of total billed charges,70% of total billed charges for outpatient setting,53.14,84.88,,42.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.31,50,,25.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.96,75,,37.57,percent of total billed charges,75% of total billed charges for outpatient setting,43.83,70,,35.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.04,12.84,,6.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,80,,40.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.04,12.84,,6.43,percent of total billed charges,12.84% of total billed charges,8.04,12.84,,6.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.7,65,,32.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.91,35,,17.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.35,90,,45.08,percent of total billed charges,90% of total billed charges for outpatient setting,8.04,56.35,
AUGMENTN SUSP 250MG/5ML75ML,3300595,CDM,259,RC,,,Outpatient,,,108.58,108.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.01,70,,60.81,percent of total billed charges,70% of total billed charges for outpatient setting,92.16,84.88,,73.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.29,50,,43.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.44,75,,65.15,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,70,,60.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,12.84,,11.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.86,80,,69.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,12.84,,11.15,percent of total billed charges,12.84% of total billed charges,13.94,12.84,,11.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.58,65,,56.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38,35,,30.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.72,90,,78.18,percent of total billed charges,90% of total billed charges for outpatient setting,13.94,97.72,
AVALIDE 150-12.5MG TAB,3303070,CDM,259,RC,,,Outpatient,,,58.07,58.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.65,70,,32.52,percent of total billed charges,70% of total billed charges for outpatient setting,49.29,84.88,,39.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.04,50,,23.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.55,75,,34.84,percent of total billed charges,75% of total billed charges for outpatient setting,40.65,70,,32.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,12.84,,5.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.46,80,,37.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,12.84,,5.97,percent of total billed charges,12.84% of total billed charges,7.46,12.84,,5.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.75,65,,30.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,35,,16.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.26,90,,41.81,percent of total billed charges,90% of total billed charges for outpatient setting,7.46,52.26,
AVALIDE 300-12.5MG TAB,3303103,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AVANDAMET 4/1000 TAB,3303082,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
AVANDAMET 4/500: TAB,3303006,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
AVAPRO (IRBESARTAN) 150MG: TAB,3302948,CDM,259,RC,,,Outpatient,,,48,48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,70,,26.88,percent of total billed charges,70% of total billed charges for outpatient setting,40.74,84.88,,32.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,24,50,,19.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,75,,28.8,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,70,,26.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,12.84,,4.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,80,,30.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,12.84,,4.93,percent of total billed charges,12.84% of total billed charges,6.16,12.84,,4.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,65,,24.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,35,,13.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.2,90,,34.56,percent of total billed charges,90% of total billed charges for outpatient setting,6.16,43.2,
AVAPRO (IRBESARTAN)300MG TAB,3302801,CDM,259,RC,,,Outpatient,,,57.7,57.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.39,70,,32.31,percent of total billed charges,70% of total billed charges for outpatient setting,48.98,84.88,,39.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.85,50,,23.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.28,75,,34.62,percent of total billed charges,75% of total billed charges for outpatient setting,40.39,70,,32.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.16,80,,36.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.51,65,,30.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.2,35,,16.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.93,90,,41.54,percent of total billed charges,90% of total billed charges for outpatient setting,7.41,51.93,
AVITENE 1 GM(MICROFIB COLLAGEN HEMOSTAT),3302644,CDM,259,RC,,,Outpatient,,,922.61,922.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.83,70,,516.66,percent of total billed charges,70% of total billed charges for outpatient setting,783.11,84.88,,626.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,461.31,50,,369.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,691.96,75,,553.57,percent of total billed charges,75% of total billed charges for outpatient setting,645.83,70,,516.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.46,12.84,,94.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.09,80,,590.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.46,12.84,,94.77,percent of total billed charges,12.84% of total billed charges,118.46,12.84,,94.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,599.7,65,,479.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.91,35,,258.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,830.35,90,,664.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.46,830.35,
AVITENE SHEET 70X35X1MM,3302771,CDM,259,RC,,,Outpatient,,,599.89,599.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.92,70,,335.94,percent of total billed charges,70% of total billed charges for outpatient setting,509.19,84.88,,407.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.95,50,,239.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,449.92,75,,359.94,percent of total billed charges,75% of total billed charges for outpatient setting,419.92,70,,335.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.03,12.84,,61.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.91,80,,383.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.03,12.84,,61.62,percent of total billed charges,12.84% of total billed charges,77.03,12.84,,61.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,389.93,65,,311.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.96,35,,167.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,539.9,90,,431.92,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,539.9,
AWL  3.8MM TAPERED /72202621,69169111,CDM,272,RC,,,Outpatient,,,263.89,263.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.72,70,,147.78,percent of total billed charges,70% of total billed charges for outpatient setting,223.99,84.88,,179.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.95,50,,105.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.92,75,,158.34,percent of total billed charges,75% of total billed charges for outpatient setting,184.72,70,,147.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,12.84,,27.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.11,80,,168.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,12.84,,27.1,percent of total billed charges,12.84% of total billed charges,33.88,12.84,,27.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.53,65,,137.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.36,35,,73.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,237.5,90,,190,percent of total billed charges,90% of total billed charges for outpatient setting,33.88,237.5,
AXIS DERMIS 6X12 / 93-9612,69169360,CDM,278,RC,C1762,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
AXOGUARD 3X10MM NERVE CONTR / AGX310,69169598,CDM,278,RC,C9353,HCPCS,Outpatient,,,2520,2520,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,60,,1209.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2138.98,84.88,,1711.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,75,,1512,percent of total billed charges,75% of total billed charges for outpatient setting,1260,50,,1008,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.57,12.84,,258.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2016,80,,1612.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.57,12.84,,258.86,percent of total billed charges,12.84% of total billed charges,323.57,12.84,,258.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2646,105,,2116.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,60,,1209.6,percent of total billed charges,60% of total billed charges for outpatient setting,323.57,2646,
AZACTAM INJ: 1GM,3302538,CDM,250,RC,,,Outpatient,,,50.95,50.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,43.25,84.88,,34.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.48,50,,20.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.21,75,,30.57,percent of total billed charges,75% of total billed charges for outpatient setting,35.67,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.76,80,,32.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.12,65,,26.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,35,,14.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.86,90,,36.69,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.86,
AZATHIOPRINE IMURAN TAB  50 MG,3300640,CDM,259,RC,J7501,HCPCS,Outpatient,,,3.22,3.22,,378.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.25,70,,1.8,percent of total billed charges,70% of total billed charges for outpatient setting,2.73,84.88,,2.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,270,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.42,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,70,,1.8,percent of total billed charges,70% of total billed charges for outpatient setting,402.54,170,,,Fee Schedule,170% of Medicare OPPS rate,509.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,0.41,12.84,,0.328,percent of total billed charges,12.84% of total billed charges,414.38,175,,,Fee Schedule,175% of Medicare OPPS rate,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.58,80,,2.06,percent of total billed charges,80% of total billed charges for outpatient setting,331.5,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,295.98,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,0.41,12.84,,0.33,percent of total billed charges,12.84% of total billed charges,0.41,12.84,,0.33,percent of total billed charges,12.84% of total billed charges,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.09,65,,1.67,percent of total billed charges,65% of total billed charges for outpatient setting,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,236.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,258.5,100,,,Fee Schedule,100% of Custom Fee Schedule,2.9,90,,2.32,percent of total billed charges,90% of total billed charges for outpatient setting,0.41,509.09,
AZITHROMYCIN (genZITHROMAX) 500MG INJ,3300642,CDM,636,RC,J0456,HCPCS,Outpatient,,,25.8,25.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,21.9,84.88,,17.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.35,75,,15.48,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,80,,16.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.77,65,,13.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,100,,,Fee Schedule,100% of Custom Fee Schedule,23.22,90,,18.58,percent of total billed charges,90% of total billed charges for outpatient setting,2.73,23.22,
AZITHROMYCIN 250MG TABS (ZPAK-6TABS),3302536,CDM,259,RC,,,Outpatient,,,103.02,103.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.11,70,,57.69,percent of total billed charges,70% of total billed charges for outpatient setting,87.44,84.88,,69.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.51,50,,41.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.27,75,,61.82,percent of total billed charges,75% of total billed charges for outpatient setting,72.11,70,,57.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,12.84,,10.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.42,80,,65.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,13.23,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.96,65,,53.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.06,35,,28.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.72,90,,74.18,percent of total billed charges,90% of total billed charges for outpatient setting,13.23,92.72,
AZITHROMYCIN ZITHROMAX LIQ 200MG/5ML 22,3300641,CDM,259,RC,,,Outpatient,,,89.76,89.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.83,70,,50.26,percent of total billed charges,70% of total billed charges for outpatient setting,76.19,84.88,,60.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.88,50,,35.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,75,,53.86,percent of total billed charges,75% of total billed charges for outpatient setting,62.83,70,,50.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,12.84,,9.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.81,80,,57.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,11.53,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.34,65,,46.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,35,,25.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.78,90,,64.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,80.78,
AZITHROMYCIN ZITHROMAX TAB 250 MG,3300643,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
AZTREONAM AZACTAM  INJ 1 GM,3300644,CDM,250,RC,,,Outpatient,,,152.92,152.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.04,70,,85.63,percent of total billed charges,70% of total billed charges for outpatient setting,129.8,84.88,,103.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.46,50,,61.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.69,75,,91.75,percent of total billed charges,75% of total billed charges for outpatient setting,107.04,70,,85.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,12.84,,15.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.34,80,,97.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,12.84,,15.7,percent of total billed charges,12.84% of total billed charges,19.63,12.84,,15.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.4,65,,79.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.52,35,,42.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.63,90,,110.1,percent of total billed charges,90% of total billed charges for outpatient setting,19.63,137.63,
AZULFIDINE 500MG TAB,3302912,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
B CELLS; TOTAL COUNT,201662,CDM,310,RC,86355,HCPCS,Outpatient,,,169.79,152.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,144.12,84.88,,115.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.34,75,,101.87,percent of total billed charges,75% of total billed charges for outpatient setting,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.83,80,,108.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,55.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of Custom Fee Schedule,152.81,90,,122.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,152.81,
BABESIA SPECIES BY PCR,201443,CDM,302,RC,87798,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
BACITR/NEOMYC/POLY(TRIPLE ABX) OINT 28G,3301638,CDM,259,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
BACITRACIN (POLYSPORIN) 10GM POWD :,3300651,CDM,259,RC,,,Outpatient,,,25.96,25.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.17,70,,14.54,percent of total billed charges,70% of total billed charges for outpatient setting,22.03,84.88,,17.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.98,50,,10.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,75,,15.58,percent of total billed charges,75% of total billed charges for outpatient setting,18.17,70,,14.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.77,80,,16.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.87,65,,13.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,35,,7.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.36,90,,18.69,percent of total billed charges,90% of total billed charges for outpatient setting,3.33,23.36,
BACITRACIN OINT 30GM,3300646,CDM,259,RC,,,Outpatient,,,5.92,5.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.96,50,,2.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.44,75,,3.55,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.33,90,,4.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.33,
BACITRACIN OINT 500U/GM 30GM,3300645,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
"BACITRACIN STERILE INJ 50,000 UNITS",3300647,CDM,250,RC,J3490,HCPCS,Outpatient,,,170.52,170.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.36,70,,95.49,percent of total billed charges,70% of total billed charges for outpatient setting,144.74,84.88,,115.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.89,75,,102.31,percent of total billed charges,75% of total billed charges for outpatient setting,119.36,70,,95.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.89,12.84,,17.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.42,80,,109.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.89,12.84,,17.51,percent of total billed charges,12.84% of total billed charges,21.89,12.84,,17.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.84,65,,88.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.68,35,,47.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.47,90,,122.78,percent of total billed charges,90% of total billed charges for outpatient setting,21.89,153.47,
BACITRACIN ZINC OINT 500U/GM :30GM,3300648,CDM,259,RC,,,Outpatient,,,5.92,5.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.96,50,,2.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.44,75,,3.55,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.33,90,,4.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.33,
BACITRACIN/NEOMY/POLYMB  0.9GM PACKET,3300649,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BACK TABLE COVER HVY DUTY / 8186,6150642,CDM,272,RC,,,Outpatient,,,36.54,36.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.58,70,,20.46,percent of total billed charges,70% of total billed charges for outpatient setting,31.02,84.88,,24.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.27,50,,14.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.41,75,,21.93,percent of total billed charges,75% of total billed charges for outpatient setting,25.58,70,,20.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,12.84,,3.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.23,80,,23.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,12.84,,3.75,percent of total billed charges,12.84% of total billed charges,4.69,12.84,,3.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.75,65,,19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.79,35,,10.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.89,90,,26.31,percent of total billed charges,90% of total billed charges for outpatient setting,4.69,32.89,
BACLOFEN (LIORESAL) TAB : 10 MG,3300652,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BACLOFEN (LIORESAL) TAB :10 MG,3300653,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BACLOFEN (LIORESAL) TAB 10 MG,3300654,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BACTO SHIELD 2 GAL/1322-08,6152614,CDM,272,RC,,,Outpatient,,,128.92,128.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,70,,72.19,percent of total billed charges,70% of total billed charges for outpatient setting,109.43,84.88,,87.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.46,50,,51.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.69,75,,77.35,percent of total billed charges,75% of total billed charges for outpatient setting,90.24,70,,72.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.55,12.84,,13.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,80,,82.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.55,12.84,,13.24,percent of total billed charges,12.84% of total billed charges,16.55,12.84,,13.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.8,65,,67.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,35,,36.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.03,90,,92.82,percent of total billed charges,90% of total billed charges for outpatient setting,16.55,116.03,
BACTRIM: REGULAR STRENGTH TAB,3303005,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BAG 100ML SALINE 0.9 / 2B1307,70000695,CDM,258,RC,,,Outpatient,,,15.9,15.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.13,70,,8.9,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,84.88,,10.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.95,50,,6.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,75,,9.54,percent of total billed charges,75% of total billed charges for outpatient setting,11.13,70,,8.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,80,,10.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.34,65,,8.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.31,90,,11.45,percent of total billed charges,90% of total billed charges for outpatient setting,2.04,14.31,
BAG 1L BREATHING / 321625,6152571,CDM,272,RC,,,Outpatient,,,12.96,12.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,11,84.88,,8.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.48,50,,5.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.72,75,,7.78,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,80,,8.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.42,65,,6.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,35,,3.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.66,90,,9.33,percent of total billed charges,90% of total billed charges for outpatient setting,1.66,11.66,
BAG 2L BREATHING / BB2000LF,6152011,CDM,270,RC,,,Outpatient,,,14.13,14.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,11.99,84.88,,9.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.07,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.6,75,,8.48,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,80,,9.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.18,65,,7.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,35,,3.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.72,90,,10.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.72,
BAG 3L BREATHING / BB3000LF,71000128,CDM,272,RC,,,Outpatient,,,11.97,11.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,10.16,84.88,,8.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.99,50,,4.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.98,75,,7.18,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,70,,6.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,80,,7.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.78,65,,6.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.19,35,,3.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.77,90,,8.62,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.77,
BAG BILE 9 OZ.  (0015860)DC1586,69161065,CDM,272,RC,,,Outpatient,,,42.04,42.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.43,70,,23.54,percent of total billed charges,70% of total billed charges for outpatient setting,35.68,84.88,,28.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.02,50,,16.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.53,75,,25.22,percent of total billed charges,75% of total billed charges for outpatient setting,29.43,70,,23.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.63,80,,26.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.33,65,,21.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,35,,11.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.84,90,,30.27,percent of total billed charges,90% of total billed charges for outpatient setting,5.4,37.84,
BAG DECANTOR / 40040,6150747,CDM,272,RC,,,Outpatient,,,16.55,16.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.05,84.88,,11.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.41,75,,9.93,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,80,,10.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,35,,4.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
BAG INFUSOR DISP PRESSURE 500CC,69159054,CDM,270,RC,,,Outpatient,,,52.11,52.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.48,70,,29.18,percent of total billed charges,70% of total billed charges for outpatient setting,44.23,84.88,,35.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.06,50,,20.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.08,75,,31.26,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,70,,29.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.69,12.84,,5.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.69,80,,33.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.69,12.84,,5.35,percent of total billed charges,12.84% of total billed charges,6.69,12.84,,5.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.87,65,,27.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,35,,14.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.9,90,,37.52,percent of total billed charges,90% of total billed charges for outpatient setting,6.69,46.9,
BAG INFUSOR DISP PRSSRE 1000CC / ET4010,6150848,CDM,270,RC,,,Outpatient,,,80.85,80.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.6,70,,45.28,percent of total billed charges,70% of total billed charges for outpatient setting,68.63,84.88,,54.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.43,50,,32.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.64,75,,48.51,percent of total billed charges,75% of total billed charges for outpatient setting,56.6,70,,45.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,12.84,,8.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,80,,51.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,12.84,,8.3,percent of total billed charges,12.84% of total billed charges,10.38,12.84,,8.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.55,65,,42.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.3,35,,22.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.77,90,,58.22,percent of total billed charges,90% of total billed charges for outpatient setting,10.38,72.77,
BAG LARGE ICE W/ TIE / 4003,5050011,CDM,270,RC,,,Outpatient,,,8.02,8.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,70,,4.49,percent of total billed charges,70% of total billed charges for outpatient setting,6.81,84.88,,5.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.01,50,,3.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.02,75,,4.82,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,70,,4.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,80,,5.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.21,65,,4.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,35,,2.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.22,90,,5.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,7.22,
BAG PRESSURE 3000CC / 4030,6152063,CDM,270,RC,,,Outpatient,,,113.18,113.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.23,70,,63.38,percent of total billed charges,70% of total billed charges for outpatient setting,96.07,84.88,,76.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.59,50,,45.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.89,75,,67.91,percent of total billed charges,75% of total billed charges for outpatient setting,79.23,70,,63.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,12.84,,11.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.54,80,,72.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,12.84,,11.62,percent of total billed charges,12.84% of total billed charges,14.53,12.84,,11.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.57,65,,58.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.61,35,,31.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.86,90,,81.49,percent of total billed charges,90% of total billed charges for outpatient setting,14.53,101.86,
BAG SMALL ICE W/ TIE / 4001,745005,CDM,271,RC,,,Outpatient,,,7.67,7.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.37,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,84.88,,5.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,75,,4.6,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,35,,2.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.9,90,,5.52,percent of total billed charges,90% of total billed charges for outpatient setting,0.98,6.9,
BALLINGER 6FRX37CM GREEN ELECT / 245,6153100,CDM,272,RC,,,Outpatient,,,389.17,389.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.42,70,,217.94,percent of total billed charges,70% of total billed charges for outpatient setting,330.33,84.88,,264.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.59,50,,155.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.88,75,,233.5,percent of total billed charges,75% of total billed charges for outpatient setting,272.42,70,,217.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.97,12.84,,39.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.34,80,,249.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.97,12.84,,39.98,percent of total billed charges,12.84% of total billed charges,49.97,12.84,,39.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252.96,65,,202.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.21,35,,108.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.25,90,,280.2,percent of total billed charges,90% of total billed charges for outpatient setting,49.97,350.25,
BALLOON SCORING ANGIOSCULPT 4.X40MM,69160610,CDM,272,RC,C1725,HCPCS,Outpatient,,,3879.32,3879.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2715.52,70,,2172.42,percent of total billed charges,70% of total billed charges for outpatient setting,3292.77,84.88,,2634.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2909.49,75,,2327.59,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.1,12.84,,398.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3103.46,80,,2482.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.1,12.84,,398.48,percent of total billed charges,12.84% of total billed charges,498.1,12.84,,398.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2521.56,65,,2017.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1357.76,35,,1086.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3491.39,90,,2793.11,percent of total billed charges,90% of total billed charges for outpatient setting,498.1,3491.39,
BALLOON SCORING ANGIOSCULPT/2076-5020,69160593,CDM,272,RC,C1725,HCPCS,Outpatient,,,3801.35,3801.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660.95,70,,2128.76,percent of total billed charges,70% of total billed charges for outpatient setting,3226.59,84.88,,2581.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2851.01,75,,2280.81,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.09,12.84,,390.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3041.08,80,,2432.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.09,12.84,,390.47,percent of total billed charges,12.84% of total billed charges,488.09,12.84,,390.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2470.88,65,,1976.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1330.47,35,,1064.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3421.22,90,,2736.98,percent of total billed charges,90% of total billed charges for outpatient setting,488.09,3421.22,
BALLOON SINUPLASTY GUIDE FRONTAL / RSF70,69161515,CDM,272,RC,,,Outpatient,,,1425.85,1425.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.1,70,,798.48,percent of total billed charges,70% of total billed charges for outpatient setting,1210.26,84.88,,968.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,712.93,50,,570.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1069.39,75,,855.51,percent of total billed charges,75% of total billed charges for outpatient setting,998.1,70,,798.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.08,12.84,,146.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1140.68,80,,912.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.08,12.84,,146.46,percent of total billed charges,12.84% of total billed charges,183.08,12.84,,146.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,926.8,65,,741.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.05,35,,399.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1283.27,90,,1026.62,percent of total billed charges,90% of total billed charges for outpatient setting,183.08,1283.27,
BALLOON SINUPLASTY SYS RELIEVA / 5X16,69161514,CDM,272,RC,,,Outpatient,,,3350,3350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2345,70,,1876,percent of total billed charges,70% of total billed charges for outpatient setting,2843.48,84.88,,2274.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1675,50,,1340,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2512.5,75,,2010,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.14,12.84,,344.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2680,80,,2144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.14,12.84,,344.11,percent of total billed charges,12.84% of total billed charges,430.14,12.84,,344.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2177.5,65,,1742,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.5,35,,938,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3015,90,,2412,percent of total billed charges,90% of total billed charges for outpatient setting,430.14,3015,
BALSAM BABY (BALMEX) OINT : 60GM,3300655,CDM,259,RC,,,Outpatient,,,7.28,7.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,70,,4.08,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,84.88,,4.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.64,50,,2.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.46,75,,4.37,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,70,,4.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,12.84,,0.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,80,,4.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.93,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.73,65,,3.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,35,,2.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.55,90,,5.24,percent of total billed charges,90% of total billed charges for outpatient setting,0.93,6.55,
BALSAM PERU/ZINC OXIDE (FLANDERS) 4OZ,3303036,CDM,259,RC,,,Outpatient,,,25.2,25.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,70,,14.11,percent of total billed charges,70% of total billed charges for outpatient setting,21.39,84.88,,17.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.6,50,,10.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,75,,15.12,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,70,,14.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,80,,16.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.38,65,,13.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,35,,7.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.68,90,,18.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.24,22.68,
BANANA SMOOTHIE REDI-CAT 2 BARIUM,69160569,CDM,270,RC,,,Outpatient,,,25.84,25.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,21.93,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,50,,10.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.38,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.67,80,,16.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.8,65,,13.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,35,,7.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.26,90,,18.61,percent of total billed charges,90% of total billed charges for outpatient setting,3.32,23.26,
BAND LEG CATH HOLD N PLACE / 316,70000447,CDM,272,RC,,,Outpatient,,,34.32,34.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.02,70,,19.22,percent of total billed charges,70% of total billed charges for outpatient setting,29.13,84.88,,23.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.16,50,,13.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.74,75,,20.59,percent of total billed charges,75% of total billed charges for outpatient setting,24.02,70,,19.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.46,80,,21.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.31,65,,17.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.01,35,,9.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.89,90,,24.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.41,30.89,
BANDAGE 2IN TAN COHESIVE / CAH25LFS,71000238,CDM,272,RC,,,Outpatient,,,13.05,13.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,11.08,84.88,,8.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.53,50,,5.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.79,75,,7.83,percent of total billed charges,75% of total billed charges for outpatient setting,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,80,,8.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.48,65,,6.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,35,,3.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.75,90,,9.4,percent of total billed charges,90% of total billed charges for outpatient setting,1.68,11.75,
BARDPORT 9.6FR./0602270,6152758,CDM,278,RC,C1788,HCPCS,Outpatient,,,2247.12,2247.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1348.27,60,,1078.62,percent of total billed charges,60% of total Billed charges for outpatient setting,1907.36,84.88,,1525.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.34,75,,1348.27,percent of total billed charges,75% of total billed charges for outpatient setting,1123.56,50,,898.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.53,12.84,,230.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.7,80,,1438.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.53,12.84,,230.82,percent of total billed charges,12.84% of total billed charges,288.53,12.84,,230.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2359.48,105,,1887.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.49,35,,629.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1348.27,60,,1078.62,percent of total billed charges,60% of total billed charges for outpatient setting,288.53,2359.48,
BARIUM ENEMA,2400645,CDM,320,RC,74270,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
BARIUM ENEMA W/AIR,2400650,CDM,320,RC,74280,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
BARIUM HONEY VARIBAR THIN SUSP / 900004,70000427,CDM,270,RC,,,Outpatient,,,254.2,254.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.94,70,,142.35,percent of total billed charges,70% of total billed charges for outpatient setting,215.76,84.88,,172.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.1,50,,101.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.65,75,,152.52,percent of total billed charges,75% of total billed charges for outpatient setting,177.94,70,,142.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,12.84,,26.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.36,80,,162.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,12.84,,26.11,percent of total billed charges,12.84% of total billed charges,32.64,12.84,,26.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.23,65,,132.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.97,35,,71.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.78,90,,183.02,percent of total billed charges,90% of total billed charges for outpatient setting,32.64,228.78,
BARIUM ORANGE VANILLA / 705694,7439090,CDM,272,RC,,,Outpatient,,,17.91,17.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,15.2,84.88,,12.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,50,,7.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.43,75,,10.74,percent of total billed charges,75% of total billed charges for outpatient setting,12.54,70,,10.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.33,80,,11.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,2.3,12.84,,1.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.64,65,,9.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,35,,5.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.12,90,,12.9,percent of total billed charges,90% of total billed charges for outpatient setting,2.3,16.12,
BARIUM REDI CAT BERRY SMOOTH / 705696,69159077,CDM,270,RC,,,Outpatient,,,25.84,25.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,21.93,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,50,,10.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.38,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.67,80,,16.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.8,65,,13.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,35,,7.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.26,90,,18.61,percent of total billed charges,90% of total billed charges for outpatient setting,3.32,23.26,
BARIUM SULFATE TABS / 778,70000283,CDM,271,RC,,,Outpatient,,,7.88,7.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,70,,4.42,percent of total billed charges,70% of total billed charges for outpatient setting,6.69,84.88,,5.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.94,50,,3.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.91,75,,4.73,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,70,,4.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,80,,5.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.12,65,,4.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,35,,2.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.09,90,,5.67,percent of total billed charges,90% of total billed charges for outpatient setting,1.01,7.09,
BARIUM VAIRBAR NECTAR SUSP / 705700,70000429,CDM,270,RC,,,Outpatient,,,92.52,92.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.76,70,,51.81,percent of total billed charges,70% of total billed charges for outpatient setting,78.53,84.88,,62.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.26,50,,37.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.39,75,,55.51,percent of total billed charges,75% of total billed charges for outpatient setting,64.76,70,,51.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.88,12.84,,9.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.02,80,,59.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.88,12.84,,9.5,percent of total billed charges,12.84% of total billed charges,11.88,12.84,,9.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.14,65,,48.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.38,35,,25.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.27,90,,66.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.88,83.27,
BARIUM VANILLA REDI CAT / 705698,69160570,CDM,270,RC,,,Outpatient,,,25.84,25.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,21.93,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,50,,10.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.38,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.09,70,,14.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.67,80,,16.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.8,65,,13.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,35,,7.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.26,90,,18.61,percent of total billed charges,90% of total billed charges for outpatient setting,3.32,23.26,
BARIUM VARIBAR HONEY SUSP / 900005,70000426,CDM,270,RC,,,Outpatient,,,225.35,225.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.75,70,,126.2,percent of total billed charges,70% of total billed charges for outpatient setting,191.28,84.88,,153.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.68,50,,90.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.01,75,,135.21,percent of total billed charges,75% of total billed charges for outpatient setting,157.75,70,,126.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,12.84,,23.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.28,80,,144.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,12.84,,23.14,percent of total billed charges,12.84% of total billed charges,28.93,12.84,,23.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.48,65,,117.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.87,35,,63.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.82,90,,162.26,percent of total billed charges,90% of total billed charges for outpatient setting,28.93,202.82,
BARRICAID 10MM ANNULAR CL DV/BAR-A8-10MM,69169587,CDM,278,RC,C1713,HCPCS,Outpatient,,,9000,9000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400,60,,4320,percent of total billed charges,60% of total Billed charges for outpatient setting,7639.2,84.88,,6111.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6750,75,,5400,percent of total billed charges,75% of total billed charges for outpatient setting,4500,50,,3600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7200,80,,5760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9450,105,,7560,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3150,35,,2520,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5400,60,,4320,percent of total billed charges,60% of total billed charges for outpatient setting,1155.6,9450,
BARRICAID 8MM ANNULAR CL DEV/ BAR-A8-8MM,69169586,CDM,278,RC,C1713,HCPCS,Outpatient,,,9000,9000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400,60,,4320,percent of total billed charges,60% of total Billed charges for outpatient setting,7639.2,84.88,,6111.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6750,75,,5400,percent of total billed charges,75% of total billed charges for outpatient setting,4500,50,,3600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7200,80,,5760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9450,105,,7560,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3150,35,,2520,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5400,60,,4320,percent of total billed charges,60% of total billed charges for outpatient setting,1155.6,9450,
BARRON RADIAL VACUUM TREPHINES 7.0,6150537,CDM,272,RC,,,Outpatient,,,389.6,389.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.72,70,,218.18,percent of total billed charges,70% of total billed charges for outpatient setting,330.69,84.88,,264.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.8,50,,155.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.2,75,,233.76,percent of total billed charges,75% of total billed charges for outpatient setting,272.72,70,,218.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.02,12.84,,40.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.68,80,,249.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.02,12.84,,40.02,percent of total billed charges,12.84% of total billed charges,50.02,12.84,,40.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.24,65,,202.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.36,35,,109.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.64,90,,280.51,percent of total billed charges,90% of total billed charges for outpatient setting,50.02,350.64,
BARTONELLA ANTIBODY PROFILE,220114,CDM,300,RC,86611,HCPCS,Outpatient,,,45.81,41.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,84.88,,31.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.36,75,,27.49,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,80,,29.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,100,,,Fee Schedule,100% of Custom Fee Schedule,41.23,90,,32.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,41.23,
"BARTONELLA HENSELEA DNA, TISSUE, PCR",200278,CDM,310,RC,87801,HCPCS,Outpatient,,,315.9,284.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.13,70,,176.9,percent of total billed charges,70% of total billed charges for outpatient setting,268.14,84.88,,214.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,120.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,236.93,75,,189.54,percent of total billed charges,75% of total billed charges for outpatient setting,221.13,70,,176.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.72,80,,202.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.11,100,,,Fee Schedule,100% of Custom Fee Schedule,284.31,90,,227.45,percent of total billed charges,90% of total billed charges for outpatient setting,53.11,284.31,
BASE GLENOID 4MM LARGE  113956,69162389,CDM,278,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
BASEPLATE LARGE AUGMENTED / 110032430,2450466,CDM,278,RC,C1776,HCPCS,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
BASEPLATE MED AUGMENTED / 110032420,2461018,CDM,278,RC,C1776,HCPCS,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
BASEPLATE SM AUGMENTED / 110032410,2419553,CDM,278,RC,C1776,HCPCS,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
BASEPLATE SZ 2 TIBIA TRIATH / 5520-B-200,71000394,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASEPLATE SZ 2 TRTHLN / 5521-B-200,71000483,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 3 TIB REV LT / 71424003,71000695,CDM,278,RC,C1713,HCPCS,Outpatient,,,4721.96,4721.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2833.18,60,,2266.54,percent of total billed charges,60% of total Billed charges for outpatient setting,4008,84.88,,3206.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3541.47,75,,2833.18,percent of total billed charges,75% of total billed charges for outpatient setting,2360.98,50,,1888.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3777.57,80,,3022.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4958.06,105,,3966.45,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.69,35,,1322.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2833.18,60,,2266.54,percent of total billed charges,60% of total billed charges for outpatient setting,606.3,4958.06,
BASEPLATE SZ 3 TIBIA TRIATH / 5520-B-300,71000123,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASEPLATE SZ 3 TRTHLN / 5521-B-300,71000486,CDM,278,RC,C1713,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 4 TIBIA TRIATH / 5520-B-400,71000125,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASEPLATE SZ 4 TRTHLN / 5521-B-400,71000462,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 5 TIB REV LT / 71424005,69161873,CDM,278,RC,C1713,HCPCS,Outpatient,,,4721.96,4721.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2833.18,60,,2266.54,percent of total billed charges,60% of total Billed charges for outpatient setting,4008,84.88,,3206.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3541.47,75,,2833.18,percent of total billed charges,75% of total billed charges for outpatient setting,2360.98,50,,1888.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3777.57,80,,3022.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4958.06,105,,3966.45,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.69,35,,1322.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2833.18,60,,2266.54,percent of total billed charges,60% of total billed charges for outpatient setting,606.3,4958.06,
BASEPLATE SZ 5 TIBIA TRIATH / 5520-B-500,71000616,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASEPLATE SZ 5 TRTHLN / 5521-B-500,71000369,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 6 TIBIA TRIATH / 5520-B-600,69169765,CDM,278,RC,C1776,HCPCS,Outpatient,,,3087,3087,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1852.2,60,,1481.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2620.25,84.88,,2096.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,75,,1852.2,percent of total billed charges,75% of total billed charges for outpatient setting,1543.5,50,,1234.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2469.6,80,,1975.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3241.35,105,,2593.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.45,35,,864.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1852.2,60,,1481.76,percent of total billed charges,60% of total billed charges for outpatient setting,396.37,3241.35,
BASEPLATE SZ 6 TRTHLN / 5521-B-600,71000641,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 7 TIBIA TRIATH / 5520-B-700,71000480,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASEPLATE SZ 7 TIBIA TRIATH / 5521-B-700,69169800,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
BASEPLATE SZ 8 TIBIA TRIATH / 5520-B-800,71000392,CDM,278,RC,C1776,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
BASIC METABOLIC PANEL W/ CALCIUM TOTAL,200010,CDM,300,RC,80048,HCPCS,Outpatient,,,38.07,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,32.31,84.88,,25.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.55,75,,22.84,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,80,,24.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,100,,,Fee Schedule,100% of Custom Fee Schedule,34.26,90,,27.41,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,34.26,
BATTERY EVR AA : 4 PK,3300656,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BAYONET BOVIE / 050600,69161710,CDM,272,RC,,,Outpatient,,,320,320,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,70,,179.2,percent of total billed charges,70% of total billed charges for outpatient setting,271.62,84.88,,217.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,160,50,,128,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240,75,,192,percent of total billed charges,75% of total billed charges for outpatient setting,224,70,,179.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.09,12.84,,32.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256,80,,204.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.09,12.84,,32.87,percent of total billed charges,12.84% of total billed charges,41.09,12.84,,32.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208,65,,166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,35,,89.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,90,,230.4,percent of total billed charges,90% of total billed charges for outpatient setting,41.09,288,
BB ABO TYPE,1000170,CDM,302,RC,86900,HCPCS,Outpatient,,,446.25,401.63,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,378.78,84.88,,303.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,334.69,75,,267.75,percent of total billed charges,75% of total billed charges for outpatient setting,312.38,70,,249.9,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,357,80,,285.6,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,401.63,90,,321.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,401.63,
BB ADSORPTION PER ADSORPTION,1001310,CDM,302,RC,86978,HCPCS,Outpatient,,,136.13,122.52,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.29,70,,76.23,percent of total billed charges,70% of total billed charges for outpatient setting,115.55,84.88,,92.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.1,75,,81.68,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,70,,76.23,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.9,80,,87.12,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,122.52,90,,98.02,percent of total billed charges,90% of total billed charges for outpatient setting,10.6,122.52,
BB AG SCREEN REAGENT,1000180,CDM,302,RC,86902,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,4.97,1044.92,
BB AG TYPING,1000185,CDM,302,RC,86904,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.88,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.23,121.4,
BB AHG CROSSMATCH,1000200,CDM,302,RC,86922,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,37.56,535.12,
BB ANTIBODY COLD,1000160,CDM,302,RC,86870,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,37.56,1044.92,
BB ANTIBODY IDENTIFICATION,1001300,CDM,302,RC,86975,HCPCS,Outpatient,,,1077.15,969.44,,389.12,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,754.01,70,,603.21,percent of total billed charges,70% of total billed charges for outpatient setting,914.28,84.88,,731.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,807.86,75,,646.29,percent of total billed charges,75% of total billed charges for outpatient setting,754.01,70,,603.21,percent of total billed charges,70% of total billed charges for outpatient setting,413.44,170,,,Fee Schedule,170% of Medicare OPPS rate,522.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,425.6,175,,,Fee Schedule,175% of Medicare OPPS rate,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,861.72,80,,689.38,percent of total billed charges,80% of total billed charges for outpatient setting,340.48,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,304,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,243.2,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,969.44,90,,775.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.76,969.44,
BB ANTIBODY SCREEN,1000155,CDM,302,RC,86850,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,178.52,
BB ANTIHUMAN GLOB TEST EA TITER,1000165,CDM,302,RC,86886,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,535.12,
BB AUTO SCREEN EA,1000210,CDM,302,RC,86940,HCPCS,Outpatient,,,39.47,35.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.63,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,33.5,84.88,,26.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.6,75,,23.68,percent of total billed charges,75% of total billed charges for outpatient setting,27.63,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,80,,25.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.55,100,,,Fee Schedule,100% of Custom Fee Schedule,35.52,90,,28.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.77,35.52,
BB CHEMICAL MODIFICATION,1001315,CDM,302,RC,86970,HCPCS,Outpatient,,,136.13,122.52,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.29,70,,76.23,percent of total billed charges,70% of total billed charges for outpatient setting,115.55,84.88,,92.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.1,75,,81.68,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,70,,76.23,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.9,80,,87.12,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,122.52,90,,98.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.76,122.52,
BB COLD AB SCRN,1000215,CDM,302,RC,86941,HCPCS,Outpatient,,,54.5,49.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,46.26,84.88,,37.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.88,75,,32.7,percent of total billed charges,75% of total billed charges for outpatient setting,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.6,80,,34.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.96,100,,,Fee Schedule,100% of Custom Fee Schedule,49.05,90,,39.24,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,49.05,
BB CRYOPRECIPITATE STORAGE AND PROCESSIN,1000231,CDM,390,RC,P9012,HCPCS,Outpatient,,,159.7,159.7,,130.44,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,111.79,70,,89.43,percent of total billed charges,70% of total billed charges for outpatient setting,135.55,84.88,,108.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,119.78,75,,95.82,percent of total billed charges,75% of total billed charges for outpatient setting,111.79,70,,89.43,percent of total billed charges,70% of total billed charges for outpatient setting,138.6,170,,,Fee Schedule,170% of Medicare OPPS rate,175.28,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,20.51,12.84,,16.408,percent of total billed charges,12.84% of total billed charges,142.66,175,,,Fee Schedule,175% of Medicare OPPS rate,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,127.76,80,,102.21,percent of total billed charges,80% of total billed charges for outpatient setting,114.14,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,101.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,20.51,12.84,,16.41,percent of total billed charges,12.84% of total billed charges,20.51,12.84,,16.41,percent of total billed charges,12.84% of total billed charges,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,103.81,65,,83.05,percent of total billed charges,65% of total billed charges for outpatient setting,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.9,35,,44.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.73,90,,114.98,percent of total billed charges,90% of total billed charges for outpatient setting,20.51,175.28,
BB ELUTION PREP,1001320,CDM,302,RC,86860,HCPCS,Outpatient,,,599.72,539.75,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,419.8,70,,335.84,percent of total billed charges,70% of total billed charges for outpatient setting,509.04,84.88,,407.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,449.79,75,,359.83,percent of total billed charges,75% of total billed charges for outpatient setting,419.8,70,,335.84,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,479.78,80,,383.82,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,71.92,100,,,Fee Schedule,100% of Custom Fee Schedule,539.75,90,,431.8,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,539.75,
BB FFP STORAGE AND PROCESSING,1000240,CDM,390,RC,P9017,HCPCS,Outpatient,,,165.32,165.32,,135.04,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,115.72,70,,92.58,percent of total billed charges,70% of total billed charges for outpatient setting,140.32,84.88,,112.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,123.99,75,,99.19,percent of total billed charges,75% of total billed charges for outpatient setting,115.72,70,,92.58,percent of total billed charges,70% of total billed charges for outpatient setting,143.47,170,,,Fee Schedule,170% of Medicare OPPS rate,181.46,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,21.23,12.84,,16.984,percent of total billed charges,12.84% of total billed charges,147.69,175,,,Fee Schedule,175% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,132.26,80,,105.81,percent of total billed charges,80% of total billed charges for outpatient setting,118.16,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,105.5,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,21.23,12.84,,16.98,percent of total billed charges,12.84% of total billed charges,21.23,12.84,,16.98,percent of total billed charges,12.84% of total billed charges,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.46,65,,85.97,percent of total billed charges,65% of total billed charges for outpatient setting,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,57.86,35,,46.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,148.79,90,,119.03,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,181.46,
BB INC CROSSMATCH,1000195,CDM,302,RC,86921,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.42,535.12,
BB IRRADIATION CHARGE,1000220,CDM,302,RC,86945,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,47.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,47.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,14.42,121.4,
BB IS CROSSMATCH,1000190,CDM,302,RC,86920,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,37.56,535.12,
BB PHER PLT LEUKRED/IRRAD STOR/ PROCESS,1000086,CDM,390,RC,P9037,HCPCS,Outpatient,,,1234.66,1234.66,,1008.51,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,864.26,70,,691.41,percent of total billed charges,70% of total billed charges for outpatient setting,1047.98,84.88,,838.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,868.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,926,75,,740.8,percent of total billed charges,75% of total billed charges for outpatient setting,864.26,70,,691.41,percent of total billed charges,70% of total billed charges for outpatient setting,1071.54,170,,,Fee Schedule,170% of Medicare OPPS rate,1355.18,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,158.53,12.84,,126.824,percent of total billed charges,12.84% of total billed charges,1103.06,175,,,Fee Schedule,175% of Medicare OPPS rate,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,987.73,80,,790.18,percent of total billed charges,80% of total billed charges for outpatient setting,882.44,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,787.9,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,158.53,12.84,,126.82,percent of total billed charges,12.84% of total billed charges,158.53,12.84,,126.82,percent of total billed charges,12.84% of total billed charges,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,802.53,65,,642.02,percent of total billed charges,65% of total billed charges for outpatient setting,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,630.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,796.63,100,,,Fee Schedule,100% of Custom Fee Schedule,1111.19,90,,888.95,percent of total billed charges,90% of total billed charges for outpatient setting,158.53,1355.18,
BB PLAMSA CRYO,1000245,CDM,390,RC,P9017,HCPCS,Outpatient,,,165.32,165.32,,135.04,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,115.72,70,,92.58,percent of total billed charges,70% of total billed charges for outpatient setting,140.32,84.88,,112.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,123.99,75,,99.19,percent of total billed charges,75% of total billed charges for outpatient setting,115.72,70,,92.58,percent of total billed charges,70% of total billed charges for outpatient setting,143.47,170,,,Fee Schedule,170% of Medicare OPPS rate,181.46,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,21.23,12.84,,16.984,percent of total billed charges,12.84% of total billed charges,147.69,175,,,Fee Schedule,175% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,132.26,80,,105.81,percent of total billed charges,80% of total billed charges for outpatient setting,118.16,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,105.5,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,21.23,12.84,,16.98,percent of total billed charges,12.84% of total billed charges,21.23,12.84,,16.98,percent of total billed charges,12.84% of total billed charges,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.46,65,,85.97,percent of total billed charges,65% of total billed charges for outpatient setting,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,57.86,35,,46.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,148.79,90,,119.03,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,181.46,
BB PLASMA POOLED MULT/DONOR SOLV DETR,1000050,CDM,383,RC,P9023,HCPCS,Outpatient,,,178.3,178.3,,145.61,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,124.81,70,,99.85,percent of total billed charges,70% of total billed charges for outpatient setting,151.34,84.88,,121.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.73,75,,106.98,percent of total billed charges,75% of total billed charges for outpatient setting,124.81,70,,99.85,percent of total billed charges,70% of total billed charges for outpatient setting,154.71,170,,,Fee Schedule,170% of Medicare OPPS rate,195.67,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,22.89,12.84,,18.312,percent of total billed charges,12.84% of total billed charges,159.26,175,,,Fee Schedule,175% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,142.64,80,,114.11,percent of total billed charges,80% of total billed charges for outpatient setting,127.41,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,113.76,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,115.9,65,,92.72,percent of total billed charges,65% of total billed charges for outpatient setting,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,62.41,35,,49.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.47,90,,128.38,percent of total billed charges,90% of total billed charges for outpatient setting,22.89,195.67,
BB PLASMA POOLED SOL DET,1000265,CDM,390,RC,P9023,HCPCS,Outpatient,,,178.3,178.3,,145.61,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,124.81,70,,99.85,percent of total billed charges,70% of total billed charges for outpatient setting,151.34,84.88,,121.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.73,75,,106.98,percent of total billed charges,75% of total billed charges for outpatient setting,124.81,70,,99.85,percent of total billed charges,70% of total billed charges for outpatient setting,154.71,170,,,Fee Schedule,170% of Medicare OPPS rate,195.67,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,22.89,12.84,,18.312,percent of total billed charges,12.84% of total billed charges,159.26,175,,,Fee Schedule,175% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,142.64,80,,114.11,percent of total billed charges,80% of total billed charges for outpatient setting,127.41,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,113.76,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,115.9,65,,92.72,percent of total billed charges,65% of total billed charges for outpatient setting,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.01,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,62.41,35,,49.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.47,90,,128.38,percent of total billed charges,90% of total billed charges for outpatient setting,22.89,195.67,
BB PLATELET PHERESIS STOR AND PROCESSIN,1000081,CDM,390,RC,P9036,HCPCS,Outpatient,,,1209.78,1209.78,,988.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,846.85,70,,677.48,percent of total billed charges,70% of total billed charges for outpatient setting,1026.86,84.88,,821.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,771.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,907.34,75,,725.87,percent of total billed charges,75% of total billed charges for outpatient setting,846.85,70,,677.48,percent of total billed charges,70% of total billed charges for outpatient setting,1049.93,170,,,Fee Schedule,170% of Medicare OPPS rate,1327.86,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,155.34,12.84,,124.272,percent of total billed charges,12.84% of total billed charges,1080.81,175,,,Fee Schedule,175% of Medicare OPPS rate,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,967.82,80,,774.26,percent of total billed charges,80% of total billed charges for outpatient setting,864.65,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,772.01,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,155.34,12.84,,124.27,percent of total billed charges,12.84% of total billed charges,155.34,12.84,,124.27,percent of total billed charges,12.84% of total billed charges,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,786.36,65,,629.09,percent of total billed charges,65% of total billed charges for outpatient setting,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,423.42,35,,338.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1088.8,90,,871.04,percent of total billed charges,90% of total billed charges for outpatient setting,155.34,1327.86,
BB PLATELETS,1000030,CDM,384,RC,P9019,HCPCS,Outpatient,,,215.53,215.53,,116.46,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.87,70,,120.7,percent of total billed charges,70% of total billed charges for outpatient setting,182.94,84.88,,146.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,161.65,75,,129.32,percent of total billed charges,75% of total billed charges for outpatient setting,150.87,70,,120.7,percent of total billed charges,70% of total billed charges for outpatient setting,123.74,170,,,Fee Schedule,170% of Medicare OPPS rate,156.49,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,27.67,12.84,,22.136,percent of total billed charges,12.84% of total billed charges,127.38,175,,,Fee Schedule,175% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.42,80,,137.94,percent of total billed charges,80% of total billed charges for outpatient setting,101.9,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.98,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,27.67,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,27.67,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.09,65,,112.07,percent of total billed charges,65% of total billed charges for outpatient setting,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,75.44,35,,60.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.98,90,,155.18,percent of total billed charges,90% of total billed charges for outpatient setting,27.67,193.98,
"BB PLATELETS,  PTP PROCESSING / STORAGE",1000250,CDM,390,RC,P9019,HCPCS,Outpatient,,,215.53,215.53,,116.46,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.87,70,,120.7,percent of total billed charges,70% of total billed charges for outpatient setting,182.94,84.88,,146.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,161.65,75,,129.32,percent of total billed charges,75% of total billed charges for outpatient setting,150.87,70,,120.7,percent of total billed charges,70% of total billed charges for outpatient setting,123.74,170,,,Fee Schedule,170% of Medicare OPPS rate,156.49,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,27.67,12.84,,22.136,percent of total billed charges,12.84% of total billed charges,127.38,175,,,Fee Schedule,175% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.42,80,,137.94,percent of total billed charges,80% of total billed charges for outpatient setting,101.9,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.98,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,27.67,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,27.67,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.09,65,,112.07,percent of total billed charges,65% of total billed charges for outpatient setting,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,75.44,35,,60.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.98,90,,155.18,percent of total billed charges,90% of total billed charges for outpatient setting,27.67,193.98,
BB PLTPHER STORAGE AND PROCESSING,1000071,CDM,390,RC,P9034,HCPCS,Outpatient,,,647.98,647.98,,529.28,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,453.59,70,,362.87,percent of total billed charges,70% of total billed charges for outpatient setting,550.01,84.88,,440.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,585.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,485.99,75,,388.79,percent of total billed charges,75% of total billed charges for outpatient setting,453.59,70,,362.87,percent of total billed charges,70% of total billed charges for outpatient setting,562.36,170,,,Fee Schedule,170% of Medicare OPPS rate,711.22,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,578.9,175,,,Fee Schedule,175% of Medicare OPPS rate,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,518.38,80,,414.7,percent of total billed charges,80% of total billed charges for outpatient setting,463.12,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,413.5,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,421.19,65,,336.95,percent of total billed charges,65% of total billed charges for outpatient setting,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,330.8,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,478.47,100,,,Fee Schedule,100% of Custom Fee Schedule,583.18,90,,466.54,percent of total billed charges,90% of total billed charges for outpatient setting,83.2,711.22,
BB PLTS IRR,1000270,CDM,390,RC,P9032,HCPCS,Outpatient,,,283.38,283.38,,231.48,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,198.37,70,,158.7,percent of total billed charges,70% of total billed charges for outpatient setting,240.53,84.88,,192.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,212.54,75,,170.03,percent of total billed charges,75% of total billed charges for outpatient setting,198.37,70,,158.7,percent of total billed charges,70% of total billed charges for outpatient setting,245.95,170,,,Fee Schedule,170% of Medicare OPPS rate,311.06,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,36.39,12.84,,29.112,percent of total billed charges,12.84% of total billed charges,253.19,175,,,Fee Schedule,175% of Medicare OPPS rate,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.7,80,,181.36,percent of total billed charges,80% of total billed charges for outpatient setting,202.55,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,180.85,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,36.39,12.84,,29.11,percent of total billed charges,12.84% of total billed charges,36.39,12.84,,29.11,percent of total billed charges,12.84% of total billed charges,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,184.2,65,,147.36,percent of total billed charges,65% of total billed charges for outpatient setting,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.18,35,,79.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,255.04,90,,204.03,percent of total billed charges,90% of total billed charges for outpatient setting,36.39,311.06,
BB PRBC (WASHED) STORAGE & PROCESSING EA,1000260,CDM,390,RC,P9022,HCPCS,Outpatient,,,759.72,759.72,,620.54,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,531.8,70,,425.44,percent of total billed charges,70% of total billed charges for outpatient setting,644.85,84.88,,515.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,534.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,569.79,75,,455.83,percent of total billed charges,75% of total billed charges for outpatient setting,531.8,70,,425.44,percent of total billed charges,70% of total billed charges for outpatient setting,659.34,170,,,Fee Schedule,170% of Medicare OPPS rate,833.87,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,97.55,12.84,,78.04,percent of total billed charges,12.84% of total billed charges,678.73,175,,,Fee Schedule,175% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,607.78,80,,486.22,percent of total billed charges,80% of total billed charges for outpatient setting,542.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,484.81,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,97.55,12.84,,78.04,percent of total billed charges,12.84% of total billed charges,97.55,12.84,,78.04,percent of total billed charges,12.84% of total billed charges,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,493.82,65,,395.06,percent of total billed charges,65% of total billed charges for outpatient setting,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,265.9,35,,212.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,683.75,90,,547,percent of total billed charges,90% of total billed charges for outpatient setting,97.55,833.87,
BB PRBC LR STORAGE AND PROCESSING,1000236,CDM,390,RC,P9016,HCPCS,Outpatient,,,377.02,377.02,,307.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,263.91,70,,211.13,percent of total billed charges,70% of total billed charges for outpatient setting,320.01,84.88,,256.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,255.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,282.77,75,,226.22,percent of total billed charges,75% of total billed charges for outpatient setting,263.91,70,,211.13,percent of total billed charges,70% of total billed charges for outpatient setting,327.06,170,,,Fee Schedule,170% of Medicare OPPS rate,413.63,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,48.41,12.84,,38.728,percent of total billed charges,12.84% of total billed charges,336.68,175,,,Fee Schedule,175% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,301.62,80,,241.3,percent of total billed charges,80% of total billed charges for outpatient setting,269.33,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,240.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,48.41,12.84,,38.73,percent of total billed charges,12.84% of total billed charges,48.41,12.84,,38.73,percent of total billed charges,12.84% of total billed charges,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,245.06,65,,196.05,percent of total billed charges,65% of total billed charges for outpatient setting,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.87,100,,,Fee Schedule,100% of Custom Fee Schedule,339.32,90,,271.46,percent of total billed charges,90% of total billed charges for outpatient setting,48.41,413.63,
BB PRBC STORAGE AND PROCESSING EA UNIT,1000255,CDM,390,RC,P9021,HCPCS,Outpatient,,,275.26,275.26,,224.84,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.68,70,,154.14,percent of total billed charges,70% of total billed charges for outpatient setting,233.64,84.88,,186.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,198.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.45,75,,165.16,percent of total billed charges,75% of total billed charges for outpatient setting,192.68,70,,154.14,percent of total billed charges,70% of total billed charges for outpatient setting,238.9,170,,,Fee Schedule,170% of Medicare OPPS rate,302.13,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,35.34,12.84,,28.272,percent of total billed charges,12.84% of total billed charges,245.92,175,,,Fee Schedule,175% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,220.21,80,,176.17,percent of total billed charges,80% of total billed charges for outpatient setting,196.74,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,175.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,35.34,12.84,,28.27,percent of total billed charges,12.84% of total billed charges,35.34,12.84,,28.27,percent of total billed charges,12.84% of total billed charges,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,178.92,65,,143.14,percent of total billed charges,65% of total billed charges for outpatient setting,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,180.21,100,,,Fee Schedule,100% of Custom Fee Schedule,247.73,90,,198.18,percent of total billed charges,90% of total billed charges for outpatient setting,35.34,302.13,
"BB PRBC, IRR, STORAGE AND PROCESSING",1000091,CDM,390,RC,P9038,HCPCS,Outpatient,,,338.62,338.62,,276.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.03,70,,189.62,percent of total billed charges,70% of total billed charges for outpatient setting,287.42,84.88,,229.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,297.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.97,75,,203.18,percent of total billed charges,75% of total billed charges for outpatient setting,237.03,70,,189.62,percent of total billed charges,70% of total billed charges for outpatient setting,293.87,170,,,Fee Schedule,170% of Medicare OPPS rate,371.67,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,43.48,12.84,,34.784,percent of total billed charges,12.84% of total billed charges,302.52,175,,,Fee Schedule,175% of Medicare OPPS rate,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,270.9,80,,216.72,percent of total billed charges,80% of total billed charges for outpatient setting,242.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,216.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,43.48,12.84,,34.78,percent of total billed charges,12.84% of total billed charges,43.48,12.84,,34.78,percent of total billed charges,12.84% of total billed charges,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,220.1,65,,176.08,percent of total billed charges,65% of total billed charges for outpatient setting,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,118.52,35,,94.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,304.76,90,,243.81,percent of total billed charges,90% of total billed charges for outpatient setting,43.48,371.67,
BB RH TYPE,1000175,CDM,302,RC,86901,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,121.4,
BB SPLITTING OF PRODUCT,1000300,CDM,390,RC,86985,HCPCS,Outpatient,,,594.58,594.58,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,76.34,12.84,,61.072,percent of total billed charges,12.84% of total billed charges,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,386.48,65,,309.18,percent of total billed charges,65% of total billed charges for outpatient setting,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,71.92,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,71.92,535.12,
BB THAWING FEE,1000275,CDM,300,RC,86927,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.19,170,,,Fee Schedule,170% of Medicare OPPS rate,287.33,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,11.05,535.12,
BB UNIT POOLING,1000295,CDM,390,RC,86965,HCPCS,Outpatient,,,594.58,594.58,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,76.34,12.84,,61.072,percent of total billed charges,12.84% of total billed charges,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,386.48,65,,309.18,percent of total billed charges,65% of total billed charges for outpatient setting,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,71.92,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,71.92,535.12,
BB-TAK THREADED   / AR-13226T,69162345,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
BEARING 10MM TIB VNGRD / VE183420,71000390,CDM,278,RC,C1713,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
BEARING 28MM 50MM SZ H/ 110031015,69169883,CDM,278,RC,C1713,HCPCS,Outpatient,,,4025,4025,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2415,60,,1932,percent of total billed charges,60% of total Billed charges for outpatient setting,3416.42,84.88,,2733.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3018.75,75,,2415,percent of total billed charges,75% of total billed charges for outpatient setting,2012.5,50,,1610,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.81,12.84,,413.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3220,80,,2576,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.81,12.84,,413.45,percent of total billed charges,12.84% of total billed charges,516.81,12.84,,413.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4226.25,105,,3381,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1408.75,35,,1127,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2415,60,,1932,percent of total billed charges,60% of total billed charges for outpatient setting,516.81,4226.25,
BEARING 28X40MM VIVACIT E / 110031010,71000222,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
BEARING 28X42MM VIVACIT E / 110031011,71000217,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
BEARING 28X44MM LONGEVITY / 110031000,71000335,CDM,278,RC,C1713,HCPCS,Outpatient,,,2537.5,2537.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.5,60,,1218,percent of total billed charges,60% of total Billed charges for outpatient setting,2153.83,84.88,,1723.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1903.13,75,,1522.5,percent of total billed charges,75% of total billed charges for outpatient setting,1268.75,50,,1015,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.82,12.84,,260.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2030,80,,1624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.82,12.84,,260.66,percent of total billed charges,12.84% of total billed charges,325.82,12.84,,260.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2664.38,105,,2131.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.13,35,,710.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1522.5,60,,1218,percent of total billed charges,60% of total billed charges for outpatient setting,325.82,2664.38,
BEARING 28X44MM VIVACIT E / 110031000,71000601,CDM,278,RC,C1713,HCPCS,Outpatient,,,2537.5,2537.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.5,60,,1218,percent of total billed charges,60% of total Billed charges for outpatient setting,2153.83,84.88,,1723.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1903.13,75,,1522.5,percent of total billed charges,75% of total billed charges for outpatient setting,1268.75,50,,1015,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.82,12.84,,260.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2030,80,,1624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.82,12.84,,260.66,percent of total billed charges,12.84% of total billed charges,325.82,12.84,,260.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2664.38,105,,2131.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.13,35,,710.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1522.5,60,,1218,percent of total billed charges,60% of total billed charges for outpatient setting,325.82,2664.38,
BEARING 28X44MM VIVACIT E / 110031012,71000215,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
BEARING 28X46MM VIVACIT E / 110031013,71000151,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
BEARING 36MM +3MM SHOULDER /110031425,69169630,CDM,278,RC,C1776,HCPCS,Outpatient,,,3264,3264,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1958.4,60,,1566.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2770.48,84.88,,2216.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2448,75,,1958.4,percent of total billed charges,75% of total billed charges for outpatient setting,1632,50,,1305.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.1,12.84,,335.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2611.2,80,,2088.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.1,12.84,,335.28,percent of total billed charges,12.84% of total billed charges,419.1,12.84,,335.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3427.2,105,,2741.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.4,35,,913.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1958.4,60,,1566.72,percent of total billed charges,60% of total billed charges for outpatient setting,419.1,3427.2,
BEARING 36MM HUMERAL / 110031420,7079683,CDM,278,RC,C1776,HCPCS,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,60,,624,percent of total billed charges,60% of total Billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1300,65,,1040,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,780,60,,624,percent of total billed charges,60% of total billed charges for outpatient setting,166.92,1300,
BEARING 4 RT TIBIAL ATTUNE / 1520-20-407,71000408,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING 4 RT TIBIAL ATTUNE / 1520-20-410,71000453,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING 4 RT TIBIAL ATTUNE / 1520-20-412,71000845,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING 4 TIBIAL ATTUNE / 1506-40-004,71000259,CDM,278,RC,C1713,HCPCS,Outpatient,,,5900,5900,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3540,60,,2832,percent of total billed charges,60% of total Billed charges for outpatient setting,5007.92,84.88,,4006.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4425,75,,3540,percent of total billed charges,75% of total billed charges for outpatient setting,2950,50,,2360,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.56,12.84,,606.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4720,80,,3776,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.56,12.84,,606.05,percent of total billed charges,12.84% of total billed charges,757.56,12.84,,606.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6195,105,,4956,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2065,35,,1652,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3540,60,,2832,percent of total billed charges,60% of total billed charges for outpatient setting,757.56,6195,
BEARING 40MM HUMERAL / 110031421,7079682,CDM,278,RC,C1713,HCPCS,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,60,,1092,percent of total billed charges,60% of total Billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2388.75,105,,1911,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1365,60,,1092,percent of total billed charges,60% of total billed charges for outpatient setting,292.11,2388.75,
BEARING 5 RT TIBIAL ATTUNE / 1520-20-506,71000257,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING 50MM H LINER / 110024466,69169882,CDM,278,RC,C1713,HCPCS,Outpatient,,,6097,6097,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3658.2,60,,2926.56,percent of total billed charges,60% of total Billed charges for outpatient setting,5175.13,84.88,,4140.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4572.75,75,,3658.2,percent of total billed charges,75% of total billed charges for outpatient setting,3048.5,50,,2438.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.85,12.84,,626.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4877.6,80,,3902.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.85,12.84,,626.28,percent of total billed charges,12.84% of total billed charges,782.85,12.84,,626.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6401.85,105,,5121.48,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2133.95,35,,1707.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3658.2,60,,2926.56,percent of total billed charges,60% of total billed charges for outpatient setting,782.85,6401.85,
BEARING 6 RT TIBIAL ATTUNE / 1520-20-606,71000278,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING 6 RT TIBIAL ATTUNE / 1520-20-610,71000455,CDM,278,RC,C1776,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING E1 44-36 STD HMRL / EP-115393,70000255,CDM,278,RC,,,Outpatient,,,2835,2835,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,60,,1360.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2406.35,84.88,,1925.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1417.5,50,,1134,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2126.25,75,,1701,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,50,,1134,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2268,80,,1814.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2976.75,105,,2381.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.25,35,,793.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,60,,1360.8,percent of total billed charges,60% of total billed charges for outpatient setting,364.01,2976.75,
BEARING SZ 3 ATTUNE TIB / 1506-70-003,71000439,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
BEARING SZ 4 ATTUNE TIB / 1506-70-004,71000457,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
BEARING SZ 5 ATTUNE TIB / 1506-70-005,71000406,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
BEARING SZ 6 ATTUNE TIB / 1506-70-006,71000212,CDM,278,RC,C1776,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
BEARING SZ 6 TIB AOX / 1518-20-608,71000233,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING SZ 6 TIB AOX LT / 1518-20-605,71000458,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING SZ 7 ATTUNE TIB / 1506-70-007,71000797,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
BEARING SZ 7 TIB AOX LT / 1518-20-705,71000796,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BEARING SZ 8 TIB ATTUNE RT / 1520-20-805,71000676,CDM,278,RC,C1713,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
BECAPLERMIN (REGRANEX) GEL: 15 GM,3300657,CDM,259,RC,,,Outpatient,,,1235.05,1235.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.54,70,,691.63,percent of total billed charges,70% of total billed charges for outpatient setting,1048.31,84.88,,838.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,617.53,50,,494.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,926.29,75,,741.03,percent of total billed charges,75% of total billed charges for outpatient setting,864.54,70,,691.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.58,12.84,,126.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,988.04,80,,790.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.58,12.84,,126.86,percent of total billed charges,12.84% of total billed charges,158.58,12.84,,126.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,802.78,65,,642.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.27,35,,345.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1111.55,90,,889.24,percent of total billed charges,90% of total billed charges for outpatient setting,158.58,1111.55,
BECLOMETHASE(BECLOVENT)6.7GM INH:,3300658,CDM,259,RC,,,Outpatient,,,73.24,73.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.27,70,,41.02,percent of total billed charges,70% of total billed charges for outpatient setting,62.17,84.88,,49.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.62,50,,29.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.93,75,,43.94,percent of total billed charges,75% of total billed charges for outpatient setting,51.27,70,,41.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,12.84,,7.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.59,80,,46.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,12.84,,7.52,percent of total billed charges,12.84% of total billed charges,9.4,12.84,,7.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.61,65,,38.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,35,,20.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.92,90,,52.74,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,65.92,
BECLOMETHASONE (VANCERIL) INH : 42MCG,3300659,CDM,259,RC,,,Outpatient,,,127.51,127.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.26,70,,71.41,percent of total billed charges,70% of total billed charges for outpatient setting,108.23,84.88,,86.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.76,50,,51.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,75,,76.5,percent of total billed charges,75% of total billed charges for outpatient setting,89.26,70,,71.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.37,12.84,,13.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.01,80,,81.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.37,12.84,,13.1,percent of total billed charges,12.84% of total billed charges,16.37,12.84,,13.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.88,65,,66.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.63,35,,35.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.76,90,,91.81,percent of total billed charges,90% of total billed charges for outpatient setting,16.37,114.76,
BECLOMETHSNE (BECONASE AQ)42MCG NSL25GM,3300660,CDM,259,RC,,,Outpatient,,,136.34,136.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,70,,76.35,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.17,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,70,,76.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.07,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.62,65,,70.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.71,90,,98.17,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.71,
BEDPAN STACKABLE GOLD / DYND80216H,5050012,CDM,270,RC,,,Outpatient,,,11.88,11.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.91,75,,7.13,percent of total billed charges,75% of total billed charges for outpatient setting,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,35,,3.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.69,90,,8.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.53,10.69,
BEDSIDE GLUCOSE MONITOR,200171,CDM,300,RC,82948,HCPCS,Outpatient,,,22.68,20.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,19.25,84.88,,15.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.01,75,,13.61,percent of total billed charges,75% of total billed charges for outpatient setting,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,80,,14.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,100% of Custom Fee Schedule,20.41,90,,16.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.07,20.41,
BEDSIDE PROC > 30 MIN,6000120,CDM,360,RC,,,Outpatient,,,636.37,636.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,540.15,84.88,,432.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.19,50,,254.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.28,75,,381.82,percent of total billed charges,75% of total billed charges for outpatient setting,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.1,80,,407.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.73,35,,178.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.73,90,,458.18,percent of total billed charges,90% of total billed charges for outpatient setting,81.71,572.73,
BEDSIDE PROC CATEGORY < 30 MIN,6000115,CDM,360,RC,,,Outpatient,,,1022.61,1022.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.83,70,,572.66,percent of total billed charges,70% of total billed charges for outpatient setting,867.99,84.88,,694.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,511.31,50,,409.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,766.96,75,,613.57,percent of total billed charges,75% of total billed charges for outpatient setting,715.83,70,,572.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.3,12.84,,105.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.09,80,,654.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.3,12.84,,105.04,percent of total billed charges,12.84% of total billed charges,131.3,12.84,,105.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.91,35,,286.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,920.35,90,,736.28,percent of total billed charges,90% of total billed charges for outpatient setting,131.3,920.35,
BEDSIDE PROC COMPLICATED,6000125,CDM,360,RC,,,Outpatient,,,954.54,954.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.18,70,,534.54,percent of total billed charges,70% of total billed charges for outpatient setting,810.21,84.88,,648.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,477.27,50,,381.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.91,75,,572.73,percent of total billed charges,75% of total billed charges for outpatient setting,668.18,70,,534.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.56,12.84,,98.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.63,80,,610.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.56,12.84,,98.05,percent of total billed charges,12.84% of total billed charges,122.56,12.84,,98.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.09,35,,267.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,859.09,90,,687.27,percent of total billed charges,90% of total billed charges for outpatient setting,122.56,859.09,
BELIMUMAB(BENLYSTA) 10MG/UNIT INJ120MG,3305382,CDM,636,RC,J0490,HCPCS,Outpatient,,,1780.12,1780.12,,79.15,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1246.08,70,,996.86,percent of total billed charges,70% of total billed charges for outpatient setting,1510.97,84.88,,1208.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1335.09,75,,1068.07,percent of total billed charges,75% of total billed charges for outpatient setting,1246.08,70,,996.86,percent of total billed charges,70% of total billed charges for outpatient setting,84.09,170,,,Fee Schedule,170% of Medicare OPPS rate,106.36,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,228.57,12.84,,182.856,percent of total billed charges,12.84% of total billed charges,86.57,175,,,Fee Schedule,175% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1424.1,80,,1139.28,percent of total billed charges,80% of total billed charges for outpatient setting,69.25,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,61.83,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,228.57,12.84,,182.86,percent of total billed charges,12.84% of total billed charges,228.57,12.84,,182.86,percent of total billed charges,12.84% of total billed charges,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1157.08,65,,925.66,percent of total billed charges,65% of total billed charges for outpatient setting,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,46.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1602.11,90,,1281.69,percent of total billed charges,90% of total billed charges for outpatient setting,46.16,1602.11,
BELIMUMAB(BENLYSTA) 120MG (WASTAGE),3305385,CDM,636,RC,J0490,HCPCS,Outpatient,,,1780.12,1780.12,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246.08,70,,996.86,percent of total billed charges,70% of total billed charges for outpatient setting,1510.97,84.88,,1208.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,890.06,50,,712.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1335.09,75,,1068.07,percent of total billed charges,75% of total billed charges for outpatient setting,1246.08,70,,996.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.57,12.84,,182.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1424.1,80,,1139.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.57,12.84,,182.86,percent of total billed charges,12.84% of total billed charges,228.57,12.84,,182.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1157.08,65,,925.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.04,35,,498.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1602.11,90,,1281.69,percent of total billed charges,90% of total billed charges for outpatient setting,228.57,1602.11,
BELIMUMAB(BENLYSTA)10MG/UNIT 400MG INJ,3305383,CDM,636,RC,J0490,HCPCS,Outpatient,,,5933.62,5933.62,,79.15,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4153.53,70,,3322.82,percent of total billed charges,70% of total billed charges for outpatient setting,5036.46,84.88,,4029.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4450.22,75,,3560.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,84.09,170,,,Fee Schedule,170% of Medicare OPPS rate,106.36,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,761.88,12.84,,609.504,percent of total billed charges,12.84% of total billed charges,86.57,175,,,Fee Schedule,175% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4746.9,80,,3797.52,percent of total billed charges,80% of total billed charges for outpatient setting,69.25,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,61.83,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,761.88,12.84,,609.5,percent of total billed charges,12.84% of total billed charges,761.88,12.84,,609.5,percent of total billed charges,12.84% of total billed charges,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3856.85,65,,3085.48,percent of total billed charges,65% of total billed charges for outpatient setting,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,46.16,100,,,Fee Schedule,100% of Custom Fee Schedule,5340.26,90,,4272.21,percent of total billed charges,90% of total billed charges for outpatient setting,46.16,5340.26,
BELLADONNA ALK./PHENOBARB. EL DONNATAL,3303042,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BELLADONNA ALKALOIDS-OPIUM 30 MG:SUPP,3305111,CDM,259,RC,,,Outpatient,,,69.15,69.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.41,70,,38.73,percent of total billed charges,70% of total billed charges for outpatient setting,58.69,84.88,,46.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.58,50,,27.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.86,75,,41.49,percent of total billed charges,75% of total billed charges for outpatient setting,48.41,70,,38.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,12.84,,7.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.32,80,,44.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,12.84,,7.1,percent of total billed charges,12.84% of total billed charges,8.88,12.84,,7.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.95,65,,35.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.2,35,,19.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.24,90,,49.79,percent of total billed charges,90% of total billed charges for outpatient setting,8.88,62.24,
BELLADONNA -OPIUM 16.2MG/60 MG SUPP,3302739,CDM,259,RC,,,Outpatient,,,137.03,137.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.92,70,,76.74,percent of total billed charges,70% of total billed charges for outpatient setting,116.31,84.88,,93.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.52,50,,54.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.77,75,,82.22,percent of total billed charges,75% of total billed charges for outpatient setting,95.92,70,,76.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.59,12.84,,14.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.62,80,,87.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.59,12.84,,14.07,percent of total billed charges,12.84% of total billed charges,17.59,12.84,,14.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.07,65,,71.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.96,35,,38.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.33,90,,98.66,percent of total billed charges,90% of total billed charges for outpatient setting,17.59,123.33,
BENAZEPRIL (LOTENSIN) TAB 20MG,3300662,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BENAZEPRIL(genLOTENSIN) 40 MG TAB,3302878,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
BENICAR 20MG TAB,3302897,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BENICAR HCT 20/12.5 TAB,3303087,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BENTYL TAB 20 MG,3303086,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BENZALKONIUM CL(ZEPHIRAN)1/750:236 ML,3302793,CDM,259,RC,,,Outpatient,,,66.56,66.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.59,70,,37.27,percent of total billed charges,70% of total billed charges for outpatient setting,56.5,84.88,,45.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.28,50,,26.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.92,75,,39.94,percent of total billed charges,75% of total billed charges for outpatient setting,46.59,70,,37.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.25,80,,42.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.26,65,,34.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,35,,18.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.9,90,,47.92,percent of total billed charges,90% of total billed charges for outpatient setting,8.55,59.9,
BENZOCAINE (CETACAINE) SPRAY 56ML,3300666,CDM,259,RC,,,Outpatient,,,145.19,145.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.63,70,,81.3,percent of total billed charges,70% of total billed charges for outpatient setting,123.24,84.88,,98.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.6,50,,58.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.89,75,,87.11,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,70,,81.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.64,12.84,,14.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.15,80,,92.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.64,12.84,,14.91,percent of total billed charges,12.84% of total billed charges,18.64,12.84,,14.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.37,65,,75.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.82,35,,40.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.67,90,,104.54,percent of total billed charges,90% of total billed charges for outpatient setting,18.64,130.67,
BENZOCAINE (HURRICAINE) KIT:,3300665,CDM,259,RC,,,Outpatient,,,77.64,77.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.35,70,,43.48,percent of total billed charges,70% of total billed charges for outpatient setting,65.9,84.88,,52.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.82,50,,31.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.23,75,,46.58,percent of total billed charges,75% of total billed charges for outpatient setting,54.35,70,,43.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.11,80,,49.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.47,65,,40.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,35,,21.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.88,90,,55.9,percent of total billed charges,90% of total billed charges for outpatient setting,9.97,69.88,
BENZOCAINE (HURRICAINE) SPRAY 57 GMS,3300664,CDM,259,RC,,,Outpatient,,,145.9,145.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.13,70,,81.7,percent of total billed charges,70% of total billed charges for outpatient setting,123.84,84.88,,99.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.95,50,,58.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.43,75,,87.54,percent of total billed charges,75% of total billed charges for outpatient setting,102.13,70,,81.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,12.84,,14.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.72,80,,93.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,12.84,,14.98,percent of total billed charges,12.84% of total billed charges,18.73,12.84,,14.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.84,65,,75.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.07,35,,40.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.31,90,,105.05,percent of total billed charges,90% of total billed charges for outpatient setting,18.73,131.31,
BENZOCAINE (ORAJEL MAX ST) GEL,3300663,CDM,259,RC,,,Outpatient,,,14.83,14.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,12.59,84.88,,10.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.42,50,,5.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.12,75,,8.9,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.86,80,,9.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.64,65,,7.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,35,,4.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.35,90,,10.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.9,13.35,
BENZOIN COMPOUND SOL :,3300667,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BENZOIN POPPER / C1544,7650085,CDM,272,RC,,,Outpatient,,,3.99,3.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.79,70,,2.23,percent of total billed charges,70% of total billed charges for outpatient setting,3.39,84.88,,2.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,2,50,,1.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.99,75,,2.39,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,70,,2.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,80,,2.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.59,65,,2.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,35,,1.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.59,90,,2.87,percent of total billed charges,90% of total billed charges for outpatient setting,0.51,3.59,
BENZTROPINE (COGENTIN) INJ 1MG/ML :2ML,3300669,CDM,250,RC,,,Outpatient,,,23.29,23.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,70,,13.04,percent of total billed charges,70% of total billed charges for outpatient setting,19.77,84.88,,15.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.65,50,,9.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.47,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,70,,13.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.63,80,,14.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.14,65,,12.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,35,,6.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.96,90,,16.77,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,20.96,
BENZTROPINE (COGENTIN) TAB : 1 MG,3300668,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BERKELEY CANNISTERS & LIDS / 003987-901,69160434,CDM,271,RC,,,Outpatient,,,65.23,65.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.66,70,,36.53,percent of total billed charges,70% of total billed charges for outpatient setting,55.37,84.88,,44.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.62,50,,26.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.92,75,,39.14,percent of total billed charges,75% of total billed charges for outpatient setting,45.66,70,,36.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,12.84,,6.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,80,,41.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,12.84,,6.7,percent of total billed charges,12.84% of total billed charges,8.38,12.84,,6.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.4,65,,33.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.83,35,,18.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.71,90,,46.97,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,58.71,
BERKELEY COLLECTION SYSTEM / 003984-901,6150750,CDM,271,RC,,,Outpatient,,,77.76,77.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.43,70,,43.54,percent of total billed charges,70% of total billed charges for outpatient setting,66,84.88,,52.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.88,50,,31.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.32,75,,46.66,percent of total billed charges,75% of total billed charges for outpatient setting,54.43,70,,43.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,12.84,,7.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,80,,49.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.98,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.54,65,,40.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.22,35,,21.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,90% of total billed charges for outpatient setting,9.98,69.98,
BERKELEY COLLECTION TRAPS  003853-902,69161525,CDM,271,RC,,,Outpatient,,,66.29,66.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.4,70,,37.12,percent of total billed charges,70% of total billed charges for outpatient setting,56.27,84.88,,45.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.15,50,,26.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.72,75,,39.78,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,70,,37.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.03,80,,42.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.09,65,,34.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.2,35,,18.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.66,90,,47.73,percent of total billed charges,90% of total billed charges for outpatient setting,8.51,59.66,
BETA STREP GROUP B,200880,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
BETA-2 GLYCOPROTEIN I AB,200657,CDM,302,RC,86146,HCPCS,Outpatient,,,114.53,103.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.17,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,97.21,84.88,,77.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.9,75,,68.72,percent of total billed charges,75% of total billed charges for outpatient setting,80.17,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.62,80,,73.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,100% of Custom Fee Schedule,103.08,90,,82.46,percent of total billed charges,90% of total billed charges for outpatient setting,16.15,103.08,
BETA-2 MICROGLOBULIN,200439,CDM,301,RC,82232,HCPCS,Outpatient,,,72.81,65.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,70,,40.78,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,84.88,,49.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.61,75,,43.69,percent of total billed charges,75% of total billed charges for outpatient setting,50.97,70,,40.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,80,,46.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.68,100,,,Fee Schedule,100% of Custom Fee Schedule,65.53,90,,52.42,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,65.53,
BETADINE 5% OPTH SOLN 30 ML,3302778,CDM,259,RC,,,Outpatient,,,48.13,48.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.69,70,,26.95,percent of total billed charges,70% of total billed charges for outpatient setting,40.85,84.88,,32.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.07,50,,19.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.1,75,,28.88,percent of total billed charges,75% of total billed charges for outpatient setting,33.69,70,,26.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.18,12.84,,4.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.5,80,,30.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.18,12.84,,4.94,percent of total billed charges,12.84% of total billed charges,6.18,12.84,,4.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.28,65,,25.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,35,,13.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.32,90,,34.66,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,43.32,
BETADINE 5% PREP SOLN STERILE / 00650411,6150511,CDM,272,RC,,,Outpatient,,,76.72,76.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.7,70,,42.96,percent of total billed charges,70% of total billed charges for outpatient setting,65.12,84.88,,52.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.36,50,,30.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.54,75,,46.03,percent of total billed charges,75% of total billed charges for outpatient setting,53.7,70,,42.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,12.84,,7.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.38,80,,49.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,12.84,,7.88,percent of total billed charges,12.84% of total billed charges,9.85,12.84,,7.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.87,65,,39.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.85,35,,21.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.05,90,,55.24,percent of total billed charges,90% of total billed charges for outpatient setting,9.85,69.05,
BETADINE DOUCHE 6OZ,3301245,CDM,259,RC,,,Outpatient,,,24.19,24.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,20.53,84.88,,16.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.1,50,,9.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.14,75,,14.51,percent of total billed charges,75% of total billed charges for outpatient setting,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,80,,15.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.72,65,,12.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,35,,6.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.77,90,,17.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,21.77,
BETADINE SOLUTION 16OZ,2450007,CDM,272,RC,,,Outpatient,,,45.4,45.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.78,70,,25.42,percent of total billed charges,70% of total billed charges for outpatient setting,38.54,84.88,,30.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.7,50,,18.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.05,75,,27.24,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,70,,25.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,80,,29.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.51,65,,23.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.89,35,,12.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.86,90,,32.69,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.86,
BETADINE SWAB STICK PK 3 / MDS093902,69159791,CDM,272,RC,,,Outpatient,,,1.17,1.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.82,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,84.88,,0.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.59,50,,0.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.88,75,,0.7,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,80,,0.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.76,65,,0.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.41,35,,0.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.05,90,,0.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,1.05,
BETAMETH (genCELESTONE) 6MG/1ML 5ml MDV,3302603,CDM,250,RC,,,Outpatient,,,46.51,46.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.56,70,,26.05,percent of total billed charges,70% of total billed charges for outpatient setting,39.48,84.88,,31.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.26,50,,18.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,75,,27.9,percent of total billed charges,75% of total billed charges for outpatient setting,32.56,70,,26.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.21,80,,29.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.23,65,,24.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.28,35,,13.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.86,90,,33.49,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,41.86,
BETAMETH AF (DIPROLENE) 0.05% CRM 50GM,3300670,CDM,259,RC,,,Outpatient,,,236.84,236.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.79,70,,132.63,percent of total billed charges,70% of total billed charges for outpatient setting,201.03,84.88,,160.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.42,50,,94.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.63,75,,142.1,percent of total billed charges,75% of total billed charges for outpatient setting,165.79,70,,132.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.41,12.84,,24.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.47,80,,151.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.41,12.84,,24.33,percent of total billed charges,12.84% of total billed charges,30.41,12.84,,24.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.95,65,,123.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.89,35,,66.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,213.16,90,,170.53,percent of total billed charges,90% of total billed charges for outpatient setting,30.41,213.16,
BETAMETHASONE (DIPROLENE) 0.05% GEL :15G,3300672,CDM,259,RC,,,Outpatient,,,103.79,103.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.65,70,,58.12,percent of total billed charges,70% of total billed charges for outpatient setting,88.1,84.88,,70.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.9,50,,41.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.84,75,,62.27,percent of total billed charges,75% of total billed charges for outpatient setting,72.65,70,,58.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,12.84,,10.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,80,,66.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,13.33,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.46,65,,53.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.33,35,,29.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.41,90,,74.73,percent of total billed charges,90% of total billed charges for outpatient setting,13.33,93.41,
BETAMETHASONE (DIPROLENE) LOT 0.05%:20ML,3300671,CDM,259,RC,,,Outpatient,,,14.16,14.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,12.02,84.88,,9.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.08,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.62,75,,8.5,percent of total billed charges,75% of total billed charges for outpatient setting,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.33,80,,9.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.2,65,,7.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,35,,3.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.74,90,,10.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.74,
BETAMETHASONE VALERATE CRM 45 GM,3300673,CDM,259,RC,,,Outpatient,,,24.63,24.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.24,70,,13.79,percent of total billed charges,70% of total billed charges for outpatient setting,20.91,84.88,,16.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.32,50,,9.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.47,75,,14.78,percent of total billed charges,75% of total billed charges for outpatient setting,17.24,70,,13.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.16,12.84,,2.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.7,80,,15.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.16,12.84,,2.53,percent of total billed charges,12.84% of total billed charges,3.16,12.84,,2.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.01,65,,12.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,35,,6.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.17,90,,17.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.16,22.17,
BETAMETHASONE VALERATE CRM: 45 GM,3300674,CDM,259,RC,,,Outpatient,,,21.64,21.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.15,70,,12.12,percent of total billed charges,70% of total billed charges for outpatient setting,18.37,84.88,,14.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.82,50,,8.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.23,75,,12.98,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,70,,12.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,12.84,,2.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,80,,13.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.78,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.07,65,,11.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.57,35,,6.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.48,90,,15.58,percent of total billed charges,90% of total billed charges for outpatient setting,2.78,19.48,
BETAVENT (GUAIFEN/CRBETAPENT: SYRUP,3303208,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
BETAXOLOL (BETOPT) OPTH SOL 0.25% :2.5ML,3300675,CDM,259,RC,,,Outpatient,,,43.82,43.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,37.19,84.88,,29.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.91,50,,17.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.87,75,,26.3,percent of total billed charges,75% of total billed charges for outpatient setting,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,80,,28.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.48,65,,22.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,35,,12.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,90,,31.55,percent of total billed charges,90% of total billed charges for outpatient setting,5.63,39.44,
"BETAXOLOL HCL TAB 10MG {10MG, TABLET, 10",3303186,CDM,259,RC,,,Outpatient,,,12.68,12.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,10.76,84.88,,8.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.34,50,,5.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.51,75,,7.61,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.14,80,,8.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.24,65,,6.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,35,,3.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.41,90,,9.13,percent of total billed charges,90% of total billed charges for outpatient setting,1.63,11.41,
BETHANECHOL (URECHOLINE) INJ 5MG :1ML,3300677,CDM,250,RC,,,Outpatient,,,16.68,16.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,70,,9.34,percent of total billed charges,70% of total billed charges for outpatient setting,14.16,84.88,,11.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.34,50,,6.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.51,75,,10.01,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,70,,9.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,80,,10.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.84,65,,8.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,35,,4.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.01,90,,12.01,percent of total billed charges,90% of total billed charges for outpatient setting,2.14,15.01,
BETHANECHOL (URECHOLINE) TAB : 10 MG,3303288,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BETHANECHOL (URECHOLINE) TAB 10 MG,3309374,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BETHANECHOL (URECHOLINE) TAB 25 MG,3300676,CDM,259,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
BEXTRA: 10 MG TAB,3302926,CDM,259,RC,,,Outpatient,,,13.69,13.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,11.62,84.88,,9.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.85,50,,5.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.27,75,,8.22,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.95,80,,8.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.9,65,,7.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,35,,3.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.32,90,,9.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.32,
BEXTRA: 20 MG,3302981,CDM,259,RC,,,Outpatient,,,12.74,12.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.92,70,,7.14,percent of total billed charges,70% of total billed charges for outpatient setting,10.81,84.88,,8.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.37,50,,5.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,75,,7.65,percent of total billed charges,75% of total billed charges for outpatient setting,8.92,70,,7.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,80,,8.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.28,65,,6.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,35,,3.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.47,90,,9.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.64,11.47,
BEZLOTOXUMAB (ZINPLAVA)25MG/ML 10MG/UNIT,3313347,CDM,636,RC,J0565,HCPCS,Outpatient,,,139.65,139.65,,63.84,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.76,70,,78.21,percent of total billed charges,70% of total billed charges for outpatient setting,118.53,84.88,,94.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,104.74,75,,83.79,percent of total billed charges,75% of total billed charges for outpatient setting,97.76,70,,78.21,percent of total billed charges,70% of total billed charges for outpatient setting,67.83,170,,,Fee Schedule,170% of Medicare OPPS rate,85.78,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,17.93,12.84,,14.344,percent of total billed charges,12.84% of total billed charges,69.81,175,,,Fee Schedule,175% of Medicare OPPS rate,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,111.72,80,,89.38,percent of total billed charges,80% of total billed charges for outpatient setting,55.86,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,49.87,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,17.93,12.84,,14.34,percent of total billed charges,12.84% of total billed charges,17.93,12.84,,14.34,percent of total billed charges,12.84% of total billed charges,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,90.77,65,,72.62,percent of total billed charges,65% of total billed charges for outpatient setting,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,39.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.24,100,,,Fee Schedule,100% of Custom Fee Schedule,125.69,90,,100.55,percent of total billed charges,90% of total billed charges for outpatient setting,17.93,125.69,
BIAXIN 500MG TAB (CLARITHROMYCIN),3302643,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BIAXIN SUSP 250MG/5ML 500 MG,3302641,CDM,259,RC,,,Outpatient,,,216.64,216.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.65,70,,121.32,percent of total billed charges,70% of total billed charges for outpatient setting,183.88,84.88,,147.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.32,50,,86.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.48,75,,129.98,percent of total billed charges,75% of total billed charges for outpatient setting,151.65,70,,121.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,12.84,,22.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.31,80,,138.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,12.84,,22.26,percent of total billed charges,12.84% of total billed charges,27.82,12.84,,22.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.82,65,,112.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.82,35,,60.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.98,90,,155.98,percent of total billed charges,90% of total billed charges for outpatient setting,27.82,194.98,
BIAXIN TAB 250MG,3302642,CDM,259,RC,,,Outpatient,,,13.24,13.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,70,,7.42,percent of total billed charges,70% of total billed charges for outpatient setting,11.24,84.88,,8.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.62,50,,5.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.93,75,,7.94,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,70,,7.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.59,80,,8.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.61,65,,6.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,35,,3.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.92,90,,9.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.7,11.92,
BICALUTAMIDE (CASODEX)  ORAL TABLET 50MG,3307963,CDM,250,RC,,,Outpatient,,,12.93,12.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.05,70,,7.24,percent of total billed charges,70% of total billed charges for outpatient setting,10.97,84.88,,8.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.47,50,,5.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.7,75,,7.76,percent of total billed charges,75% of total billed charges for outpatient setting,9.05,70,,7.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,80,,8.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.4,65,,6.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,35,,3.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.64,90,,9.31,percent of total billed charges,90% of total billed charges for outpatient setting,1.66,11.64,
BICALUTAMIDE (CASODEX) TAB: 50 MG,3300678,CDM,259,RC,,,Outpatient,,,34.99,34.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.49,70,,19.59,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,84.88,,23.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.5,50,,14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.24,75,,20.99,percent of total billed charges,75% of total billed charges for outpatient setting,24.49,70,,19.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.99,80,,22.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.74,65,,18.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,35,,9.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.49,90,,25.19,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.49,
BIO SUTURETAK DISP. KIT/ AR-1934DS-2,69162762,CDM,272,RC,C1713,HCPCS,Outpatient,,,692.16,692.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,70,,387.61,percent of total billed charges,70% of total billed charges for outpatient setting,587.51,84.88,,470.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,75,,415.3,percent of total billed charges,75% of total billed charges for outpatient setting,484.51,70,,387.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.87,12.84,,71.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.73,80,,442.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.87,12.84,,71.1,percent of total billed charges,12.84% of total billed charges,88.87,12.84,,71.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,449.9,65,,359.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.26,35,,193.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,622.94,90,,498.35,percent of total billed charges,90% of total billed charges for outpatient setting,88.87,622.94,
BIOCLUSIVE DRESS 2 X3,5150092,CDM,272,RC,,,Outpatient,,,4.17,4.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,70,,2.34,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,84.88,,2.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.09,50,,1.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.13,75,,2.5,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,70,,2.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,80,,2.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.71,65,,2.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,35,,1.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.75,90,,3,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.75,
BIOCLUSIVE DRESSING 4 X5,5150093,CDM,272,RC,,,Outpatient,,,19.74,19.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,70,,11.06,percent of total billed charges,70% of total billed charges for outpatient setting,16.76,84.88,,13.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.87,50,,7.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.81,75,,11.85,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,70,,11.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.79,80,,12.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.83,65,,10.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.91,35,,5.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.77,90,,14.22,percent of total billed charges,90% of total billed charges for outpatient setting,2.53,17.77,
BIOCUE MINI PLTLET CONCNTR KIT 800-0610A,69162308,CDM,272,RC,,,Outpatient,,,2394,2394,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1675.8,70,,1340.64,percent of total billed charges,70% of total billed charges for outpatient setting,2032.03,84.88,,1625.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,1197,50,,957.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1795.5,75,,1436.4,percent of total billed charges,75% of total billed charges for outpatient setting,1675.8,70,,1340.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.39,12.84,,245.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.2,80,,1532.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.39,12.84,,245.91,percent of total billed charges,12.84% of total billed charges,307.39,12.84,,245.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1556.1,65,,1244.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.9,35,,670.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2154.6,90,,1723.68,percent of total billed charges,90% of total billed charges for outpatient setting,307.39,2154.6,
BIOCUE PLTLET CONCNTR KIT 800-0611A,69162471,CDM,272,RC,,,Outpatient,,,2394,2394,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1675.8,70,,1340.64,percent of total billed charges,70% of total billed charges for outpatient setting,2032.03,84.88,,1625.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,1197,50,,957.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1795.5,75,,1436.4,percent of total billed charges,75% of total billed charges for outpatient setting,1675.8,70,,1340.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.39,12.84,,245.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.2,80,,1532.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.39,12.84,,245.91,percent of total billed charges,12.84% of total billed charges,307.39,12.84,,245.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1556.1,65,,1244.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.9,35,,670.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2154.6,90,,1723.68,percent of total billed charges,90% of total billed charges for outpatient setting,307.39,2154.6,
BIOPSY PROSTATE 1-20 SPECIMENS,900060,CDM,314,RC,G0416,HCPCS,Outpatient,,,903.01,812.71,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,632.11,70,,505.69,percent of total billed charges,70% of total billed charges for outpatient setting,766.47,84.88,,613.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,677.26,75,,541.81,percent of total billed charges,75% of total billed charges for outpatient setting,632.11,70,,505.69,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,115.95,12.84,,92.76,percent of total billed charges,12.84% of total billed charges,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,722.41,80,,577.93,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,115.95,12.84,,92.76,percent of total billed charges,12.84% of total billed charges,115.95,12.84,,92.76,percent of total billed charges,12.84% of total billed charges,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.73,100,,,Fee Schedule,100% of Custom Fee Schedule,812.71,90,,650.17,percent of total billed charges,90% of total billed charges for outpatient setting,115.95,812.71,
BIOPSY VALVE / MB-358,6151196,CDM,270,RC,,,Outpatient,,,19.35,19.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,16.42,84.88,,13.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.68,50,,7.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.51,75,,11.61,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,80,,12.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.58,65,,10.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,35,,5.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.42,90,,13.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.48,17.42,
BIOTIN  VITAMIN B7,220254,CDM,300,RC,84591,HCPCS,Outpatient,,,76.77,69.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.74,70,,42.99,percent of total billed charges,70% of total billed charges for outpatient setting,65.16,84.88,,52.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.58,75,,46.06,percent of total billed charges,75% of total billed charges for outpatient setting,53.74,70,,42.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.42,80,,49.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,100,,,Fee Schedule,100% of Custom Fee Schedule,69.09,90,,55.27,percent of total billed charges,90% of total billed charges for outpatient setting,16.13,69.09,
BIOTINIDASE,200621,CDM,300,RC,82261,HCPCS,Outpatient,,,75.92,68.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.14,70,,42.51,percent of total billed charges,70% of total billed charges for outpatient setting,64.44,84.88,,51.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.94,75,,45.55,percent of total billed charges,75% of total billed charges for outpatient setting,53.14,70,,42.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.74,80,,48.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.98,100,,,Fee Schedule,100% of Custom Fee Schedule,68.33,90,,54.66,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,68.33,
BIPLR PLASMA NDL RT ANG 12/30 / WA22740S,69169855,CDM,272,RC,,,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.46,70,,1079.57,percent of total billed charges,70% of total billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,1349.46,70,,1079.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1253.07,65,,1002.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.02,90,,1388.02,percent of total billed charges,90% of total billed charges for outpatient setting,247.53,1735.02,
BIPOLAR CORD / DYNJ01207,6150571,CDM,272,RC,,,Outpatient,,,13.59,13.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,84.88,,9.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.8,50,,5.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.19,75,,8.15,percent of total billed charges,75% of total billed charges for outpatient setting,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.87,80,,8.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.83,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,35,,3.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.23,90,,9.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.23,
BIPOLAR OVAL BUTTON / WA22766S,69169505,CDM,272,RC,,,Outpatient,,,2023,2023,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1416.1,70,,1132.88,percent of total billed charges,70% of total billed charges for outpatient setting,1717.12,84.88,,1373.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1011.5,50,,809.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1517.25,75,,1213.8,percent of total billed charges,75% of total billed charges for outpatient setting,1416.1,70,,1132.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.75,12.84,,207.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.4,80,,1294.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.75,12.84,,207.8,percent of total billed charges,12.84% of total billed charges,259.75,12.84,,207.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1314.95,65,,1051.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.05,35,,566.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1820.7,90,,1456.56,percent of total billed charges,90% of total billed charges for outpatient setting,259.75,1820.7,
BIPOLAR PENCIL 18G CURVED / E7918C,6152204,CDM,270,RC,,,Outpatient,,,67.68,67.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.38,70,,37.9,percent of total billed charges,70% of total billed charges for outpatient setting,57.45,84.88,,45.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.84,50,,27.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.76,75,,40.61,percent of total billed charges,75% of total billed charges for outpatient setting,47.38,70,,37.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,12.84,,6.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.14,80,,43.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,12.84,,6.95,percent of total billed charges,12.84% of total billed charges,8.69,12.84,,6.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.99,65,,35.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.69,35,,18.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.91,90,,48.73,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,60.91,
BIPOLAR PENCIL 23G TAPERED  /E7923,6152203,CDM,270,RC,,,Outpatient,,,143.43,143.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.4,70,,80.32,percent of total billed charges,70% of total billed charges for outpatient setting,121.74,84.88,,97.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.72,50,,57.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.57,75,,86.06,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,70,,80.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.42,12.84,,14.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.74,80,,91.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.42,12.84,,14.74,percent of total billed charges,12.84% of total billed charges,18.42,12.84,,14.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.23,65,,74.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.2,35,,40.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.09,90,,103.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.42,129.09,
BIPOLAR PLASMA LOOP LG 12/16  / WA22703S,69169498,CDM,272,RC,,,Outpatient,,,1606.5,1606.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.55,70,,899.64,percent of total billed charges,70% of total billed charges for outpatient setting,1363.6,84.88,,1090.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,803.25,50,,642.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1204.88,75,,963.9,percent of total billed charges,75% of total billed charges for outpatient setting,1124.55,70,,899.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.27,12.84,,165.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.2,80,,1028.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.27,12.84,,165.02,percent of total billed charges,12.84% of total billed charges,206.27,12.84,,165.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1044.23,65,,835.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.28,35,,449.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1445.85,90,,1156.68,percent of total billed charges,90% of total billed charges for outpatient setting,206.27,1445.85,
BIPOLAR PLASMA LOOP LONG  / WA22737S,69169600,CDM,272,RC,,,Outpatient,,,1894.54,1894.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.18,70,,1060.94,percent of total billed charges,70% of total billed charges for outpatient setting,1608.09,84.88,,1286.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,947.27,50,,757.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1420.91,75,,1136.73,percent of total billed charges,75% of total billed charges for outpatient setting,1326.18,70,,1060.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.26,12.84,,194.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1515.63,80,,1212.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.26,12.84,,194.61,percent of total billed charges,12.84% of total billed charges,243.26,12.84,,194.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1231.45,65,,985.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.09,35,,530.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1705.09,90,,1364.07,percent of total billed charges,90% of total billed charges for outpatient setting,243.26,1705.09,
BIPOLAR PLASMA LOOP MED  / WA22702S,69169497,CDM,272,RC,,,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.46,70,,1079.57,percent of total billed charges,70% of total billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,1349.46,70,,1079.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1253.07,65,,1002.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.02,90,,1388.02,percent of total billed charges,90% of total billed charges for outpatient setting,247.53,1735.02,
BISACODYL (BISAC-EVAC) SUPP: 10 MG,3300682,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BISACODYL (DULCOLAX) TAB : 5 MG,3300680,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BISACODYL (genericDULCOLAX) SUPP 10 MG,3300681,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BISACODYL (genericDULCOLAX) TAB 5 MG UD,3300679,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BISMUTH (PINK BISMUTH) CHEW,3300684,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BISMUTH (PINK BISMUTH) LIQ 265/15 118ML,3300683,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BISMUTH SUB (BISMATROL) LIQ 262/15:240ML,3300685,CDM,259,RC,,,Outpatient,,,6.74,6.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.72,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.37,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,80,,4.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.38,65,,3.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.07,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.07,
BISMUTH SUBGALLATE: POWDER  1 OZ,3302874,CDM,259,RC,,,Outpatient,,,13.74,13.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.62,70,,7.7,percent of total billed charges,70% of total billed charges for outpatient setting,11.66,84.88,,9.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.87,50,,5.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.31,75,,8.25,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,70,,7.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.99,80,,8.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.93,65,,7.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,35,,3.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.37,90,,9.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.37,
BISOPROLOL/HCTZ (genZIAC) 2.5/6.25MG TAB,3300686,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BISOPROLOL/HCTZ TAB 10/6.25MG,3303065,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BIT 1.5MM DRILL HEX / AR-8737-37,71000808,CDM,272,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,891.24,84.88,,712.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,525,50,,420,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.5,75,,630,percent of total billed charges,75% of total billed charges for outpatient setting,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,80,,672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,682.5,65,,546,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,35,,294,percent of total billed charges,35% of total Billed charges for Outpatient Setting,945,90,,756,percent of total billed charges,90% of total billed charges for outpatient setting,134.82,945,
BIT 1.7MM DRILL / AR-8916-14,70000537,CDM,272,RC,,,Outpatient,,,331.8,331.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.26,70,,185.81,percent of total billed charges,70% of total billed charges for outpatient setting,281.63,84.88,,225.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,165.9,50,,132.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.85,75,,199.08,percent of total billed charges,75% of total billed charges for outpatient setting,232.26,70,,185.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,12.84,,34.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.44,80,,212.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,12.84,,34.08,percent of total billed charges,12.84% of total billed charges,42.6,12.84,,34.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,215.67,65,,172.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.13,35,,92.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.62,90,,238.9,percent of total billed charges,90% of total billed charges for outpatient setting,42.6,298.62,
BIT 1.8X110MM DRILL / 310.509,69162210,CDM,272,RC,,,Outpatient,,,765.12,765.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.58,70,,428.46,percent of total billed charges,70% of total billed charges for outpatient setting,649.43,84.88,,519.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,382.56,50,,306.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,573.84,75,,459.07,percent of total billed charges,75% of total billed charges for outpatient setting,535.58,70,,428.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.24,12.84,,78.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.1,80,,489.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.24,12.84,,78.59,percent of total billed charges,12.84% of total billed charges,98.24,12.84,,78.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.33,65,,397.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.79,35,,214.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,688.61,90,,550.89,percent of total billed charges,90% of total billed charges for outpatient setting,98.24,688.61,
BIT 1.9X2.50MM DRILL YELLOW / IS1112,1438971,CDM,272,RC,,,Outpatient,,,1056,1056,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,70,,591.36,percent of total billed charges,70% of total billed charges for outpatient setting,896.33,84.88,,717.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,528,50,,422.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,792,75,,633.6,percent of total billed charges,75% of total billed charges for outpatient setting,739.2,70,,591.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.59,12.84,,108.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.8,80,,675.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.59,12.84,,108.47,percent of total billed charges,12.84% of total billed charges,135.59,12.84,,108.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,686.4,65,,549.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.6,35,,295.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,950.4,90,,760.32,percent of total billed charges,90% of total billed charges for outpatient setting,135.59,950.4,
BIT 2.0 DRILL STRYKER / 708891,71000220,CDM,272,RC,,,Outpatient,,,661.76,661.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,70,,370.58,percent of total billed charges,70% of total billed charges for outpatient setting,561.7,84.88,,449.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,330.88,50,,264.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.32,75,,397.06,percent of total billed charges,75% of total billed charges for outpatient setting,463.23,70,,370.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.97,12.84,,67.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.41,80,,423.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.97,12.84,,67.98,percent of total billed charges,12.84% of total billed charges,84.97,12.84,,67.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,430.14,65,,344.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.62,35,,185.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,595.58,90,,476.46,percent of total billed charges,90% of total billed charges for outpatient setting,84.97,595.58,
BIT 2.0MM 110X30MM DRILL / 03.133.100,7170479,CDM,272,RC,,,Outpatient,,,707.36,707.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.15,70,,396.12,percent of total billed charges,70% of total billed charges for outpatient setting,600.41,84.88,,480.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,353.68,50,,282.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,530.52,75,,424.42,percent of total billed charges,75% of total billed charges for outpatient setting,495.15,70,,396.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.83,12.84,,72.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.89,80,,452.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.83,12.84,,72.66,percent of total billed charges,12.84% of total billed charges,90.83,12.84,,72.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459.78,65,,367.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.58,35,,198.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,636.62,90,,509.3,percent of total billed charges,90% of total billed charges for outpatient setting,90.83,636.62,
BIT 2.0MM 140X60MM DRILL / 03.133.101,69169694,CDM,272,RC,,,Outpatient,,,624.24,624.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.97,70,,349.58,percent of total billed charges,70% of total billed charges for outpatient setting,529.85,84.88,,423.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,312.12,50,,249.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,468.18,75,,374.54,percent of total billed charges,75% of total billed charges for outpatient setting,436.97,70,,349.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,12.84,,64.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.39,80,,399.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,12.84,,64.12,percent of total billed charges,12.84% of total billed charges,80.15,12.84,,64.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,405.76,65,,324.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.48,35,,174.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,561.82,90,,449.46,percent of total billed charges,90% of total billed charges for outpatient setting,80.15,561.82,
BIT 2.0MM CANNULATED DRILL / 03.333.101,7171127,CDM,272,RC,,,Outpatient,,,1883.7,1883.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1318.59,70,,1054.87,percent of total billed charges,70% of total billed charges for outpatient setting,1598.88,84.88,,1279.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,941.85,50,,753.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1412.78,75,,1130.22,percent of total billed charges,75% of total billed charges for outpatient setting,1318.59,70,,1054.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.87,12.84,,193.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1506.96,80,,1205.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.87,12.84,,193.5,percent of total billed charges,12.84% of total billed charges,241.87,12.84,,193.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1224.41,65,,979.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.3,35,,527.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1695.33,90,,1356.26,percent of total billed charges,90% of total billed charges for outpatient setting,241.87,1695.33,
BIT 2.0MM DRILL / 323.062,69160867,CDM,270,RC,,,Outpatient,,,765.12,765.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.58,70,,428.46,percent of total billed charges,70% of total billed charges for outpatient setting,649.43,84.88,,519.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,382.56,50,,306.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,573.84,75,,459.07,percent of total billed charges,75% of total billed charges for outpatient setting,535.58,70,,428.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.24,12.84,,78.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.1,80,,489.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.24,12.84,,78.59,percent of total billed charges,12.84% of total billed charges,98.24,12.84,,78.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.33,65,,397.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.79,35,,214.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,688.61,90,,550.89,percent of total billed charges,90% of total billed charges for outpatient setting,98.24,688.61,
BIT 2.0MM DRILL CALBRTD / AR-8737-34,69169661,CDM,272,RC,,,Outpatient,,,819,819,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,695.17,84.88,,556.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,409.5,50,,327.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.25,75,,491.4,percent of total billed charges,75% of total billed charges for outpatient setting,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,80,,524.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,532.35,65,,425.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,35,,229.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,737.1,90,,589.68,percent of total billed charges,90% of total billed charges for outpatient setting,105.16,737.1,
BIT 2.0MM DRILL CALBRTD / AR-8943-16,69162483,CDM,272,RC,,,Outpatient,,,399,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.3,70,,223.44,percent of total billed charges,70% of total billed charges for outpatient setting,338.67,84.88,,270.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,199.5,50,,159.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.25,75,,239.4,percent of total billed charges,75% of total billed charges for outpatient setting,279.3,70,,223.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.23,12.84,,40.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.2,80,,255.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.23,12.84,,40.98,percent of total billed charges,12.84% of total billed charges,51.23,12.84,,40.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.35,65,,207.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,35,,111.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,359.1,90,,287.28,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,359.1,
BIT 2.1X3MM DRILL GREEN / IS1113,1459969,CDM,272,RC,,,Outpatient,,,1056,1056,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,70,,591.36,percent of total billed charges,70% of total billed charges for outpatient setting,896.33,84.88,,717.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,528,50,,422.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,792,75,,633.6,percent of total billed charges,75% of total billed charges for outpatient setting,739.2,70,,591.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.59,12.84,,108.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.8,80,,675.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.59,12.84,,108.47,percent of total billed charges,12.84% of total billed charges,135.59,12.84,,108.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,686.4,65,,549.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.6,35,,295.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,950.4,90,,760.32,percent of total billed charges,90% of total billed charges for outpatient setting,135.59,950.4,
BIT 2.3X2MM DRILL QUICK COUP / 80-0318,790166,CDM,272,RC,,,Outpatient,,,468,468,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,70,,262.08,percent of total billed charges,70% of total billed charges for outpatient setting,397.24,84.88,,317.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,234,50,,187.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351,75,,280.8,percent of total billed charges,75% of total billed charges for outpatient setting,327.6,70,,262.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,80,,299.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,304.2,65,,243.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,35,,131.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,421.2,90,,336.96,percent of total billed charges,90% of total billed charges for outpatient setting,60.09,421.2,
BIT 2.5MM 35X45MM DRILL / 03.133.102,69169633,CDM,272,RC,,,Outpatient,,,635.32,635.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.72,70,,355.78,percent of total billed charges,70% of total billed charges for outpatient setting,539.26,84.88,,431.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,317.66,50,,254.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,476.49,75,,381.19,percent of total billed charges,75% of total billed charges for outpatient setting,444.72,70,,355.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.58,12.84,,65.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.26,80,,406.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.58,12.84,,65.26,percent of total billed charges,12.84% of total billed charges,81.58,12.84,,65.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,412.96,65,,330.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.36,35,,177.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,571.79,90,,457.43,percent of total billed charges,90% of total billed charges for outpatient setting,81.58,571.79,
BIT 2.5MM 80MM DRILL / 03.133.103,7170473,CDM,272,RC,,,Outpatient,,,751,751,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.7,70,,420.56,percent of total billed charges,70% of total billed charges for outpatient setting,637.45,84.88,,509.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,375.5,50,,300.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,563.25,75,,450.6,percent of total billed charges,75% of total billed charges for outpatient setting,525.7,70,,420.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.43,12.84,,77.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.8,80,,480.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.43,12.84,,77.14,percent of total billed charges,12.84% of total billed charges,96.43,12.84,,77.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,488.15,65,,390.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.85,35,,210.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,675.9,90,,540.72,percent of total billed charges,90% of total billed charges for outpatient setting,96.43,675.9,
BIT 2.5MM DRILL / AR-8943-30,69162328,CDM,272,RC,,,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.5,50,,142.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
BIT 2.5MM DRILL AO CALBRT / 703586,85852,CDM,272,RC,,,Outpatient,,,579.12,579.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.38,70,,324.3,percent of total billed charges,70% of total billed charges for outpatient setting,491.56,84.88,,393.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,289.56,50,,231.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.34,75,,347.47,percent of total billed charges,75% of total billed charges for outpatient setting,405.38,70,,324.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.36,12.84,,59.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.3,80,,370.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.36,12.84,,59.49,percent of total billed charges,12.84% of total billed charges,74.36,12.84,,59.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,376.43,65,,301.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.69,35,,162.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,521.21,90,,416.97,percent of total billed charges,90% of total billed charges for outpatient setting,74.36,521.21,
BIT 2.5MM DRILL AXSOS / 705025S,1862941,CDM,272,RC,,,Outpatient,,,946.88,946.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.82,70,,530.26,percent of total billed charges,70% of total billed charges for outpatient setting,803.71,84.88,,642.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,473.44,50,,378.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,710.16,75,,568.13,percent of total billed charges,75% of total billed charges for outpatient setting,662.82,70,,530.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.58,12.84,,97.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.5,80,,606,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.58,12.84,,97.26,percent of total billed charges,12.84% of total billed charges,121.58,12.84,,97.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,615.47,65,,492.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.41,35,,265.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,852.19,90,,681.75,percent of total billed charges,90% of total billed charges for outpatient setting,121.58,852.19,
BIT 2.5MM DRILL CALIBRATED / AR-8916-06,70000536,CDM,272,RC,,,Outpatient,,,285.6,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.92,70,,159.94,percent of total billed charges,70% of total billed charges for outpatient setting,242.42,84.88,,193.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,142.8,50,,114.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,75,,171.36,percent of total billed charges,75% of total billed charges for outpatient setting,199.92,70,,159.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.67,12.84,,29.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.48,80,,182.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.67,12.84,,29.34,percent of total billed charges,12.84% of total billed charges,36.67,12.84,,29.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,185.64,65,,148.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.96,35,,79.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,257.04,90,,205.63,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,257.04,
BIT 2.5MM DRILL CALIBRATED / AR-8943-42,69162329,CDM,272,RC,,,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.5,50,,142.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
BIT 2.5MM DRILL CLBRTED / AR-8943-14,71000541,CDM,272,RC,,,Outpatient,,,2480.62,2480.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.43,70,,1389.14,percent of total billed charges,70% of total billed charges for outpatient setting,2105.55,84.88,,1684.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,1240.31,50,,992.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1860.47,75,,1488.38,percent of total billed charges,75% of total billed charges for outpatient setting,1736.43,70,,1389.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.51,12.84,,254.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,80,,1587.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.51,12.84,,254.81,percent of total billed charges,12.84% of total billed charges,318.51,12.84,,254.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1612.4,65,,1289.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.22,35,,694.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2232.56,90,,1786.05,percent of total billed charges,90% of total billed charges for outpatient setting,318.51,2232.56,
BIT 2.5MM GOLD DRILL / 310.23,191204,CDM,270,RC,,,Outpatient,,,420.48,420.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.34,70,,235.47,percent of total billed charges,70% of total billed charges for outpatient setting,356.9,84.88,,285.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,210.24,50,,168.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.36,75,,252.29,percent of total billed charges,75% of total billed charges for outpatient setting,294.34,70,,235.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.99,12.84,,43.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.38,80,,269.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.99,12.84,,43.19,percent of total billed charges,12.84% of total billed charges,53.99,12.84,,43.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,273.31,65,,218.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.17,35,,117.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378.43,90,,302.74,percent of total billed charges,90% of total billed charges for outpatient setting,53.99,378.43,
BIT 2.5X216MM DRILL STRYKER / 705025,70000625,CDM,272,RC,,,Outpatient,,,755.2,755.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.64,70,,422.91,percent of total billed charges,70% of total billed charges for outpatient setting,641.01,84.88,,512.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,377.6,50,,302.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,566.4,75,,453.12,percent of total billed charges,75% of total billed charges for outpatient setting,528.64,70,,422.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.97,12.84,,77.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.16,80,,483.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.97,12.84,,77.58,percent of total billed charges,12.84% of total billed charges,96.97,12.84,,77.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490.88,65,,392.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.32,35,,211.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,679.68,90,,543.74,percent of total billed charges,90% of total billed charges for outpatient setting,96.97,679.68,
BIT 2.6MM DRILL / 703886,69162586,CDM,272,RC,,,Outpatient,,,1139.2,1139.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.44,70,,637.95,percent of total billed charges,70% of total billed charges for outpatient setting,966.95,84.88,,773.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,569.6,50,,455.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,854.4,75,,683.52,percent of total billed charges,75% of total billed charges for outpatient setting,797.44,70,,637.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.27,12.84,,117.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.36,80,,729.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.27,12.84,,117.02,percent of total billed charges,12.84% of total billed charges,146.27,12.84,,117.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,740.48,65,,592.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.72,35,,318.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1025.28,90,,820.22,percent of total billed charges,90% of total billed charges for outpatient setting,146.27,1025.28,
BIT 2.6MM DRILL CANN / AR-8943-02,69162766,CDM,272,RC,,,Outpatient,,,735,735,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,623.87,84.88,,499.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,367.5,50,,294,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.25,75,,441,percent of total billed charges,75% of total billed charges for outpatient setting,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,80,,470.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,477.75,65,,382.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.25,35,,205.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,661.5,90,,529.2,percent of total billed charges,90% of total billed charges for outpatient setting,94.37,661.5,
BIT 2.6MM DRILL CHARLOTTE / 43512600,881867,CDM,272,RC,,,Outpatient,,,648,648,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.6,70,,362.88,percent of total billed charges,70% of total billed charges for outpatient setting,550.02,84.88,,440.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,324,50,,259.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486,75,,388.8,percent of total billed charges,75% of total billed charges for outpatient setting,453.6,70,,362.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.4,80,,414.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,83.2,12.84,,66.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.2,65,,336.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.8,35,,181.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,583.2,90,,466.56,percent of total billed charges,90% of total billed charges for outpatient setting,83.2,583.2,
BIT 2.6X135MM DRILL AO SCALED / 703691,70000344,CDM,272,RC,,,Outpatient,,,467.2,467.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.04,70,,261.63,percent of total billed charges,70% of total billed charges for outpatient setting,396.56,84.88,,317.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,233.6,50,,186.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350.4,75,,280.32,percent of total billed charges,75% of total billed charges for outpatient setting,327.04,70,,261.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.99,12.84,,47.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.76,80,,299.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.99,12.84,,47.99,percent of total billed charges,12.84% of total billed charges,59.99,12.84,,47.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,303.68,65,,242.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.52,35,,130.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,420.48,90,,336.38,percent of total billed charges,90% of total billed charges for outpatient setting,59.99,420.48,
BIT 2.7MM DRILL / AR-8827D-01,71000509,CDM,272,RC,,,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.5,50,,142.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
BIT 2.7MM DRILL CANLTED / 702449,69161564,CDM,272,RC,,,Outpatient,,,1232,1232,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,862.4,70,,689.92,percent of total billed charges,70% of total billed charges for outpatient setting,1045.72,84.88,,836.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,616,50,,492.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,924,75,,739.2,percent of total billed charges,75% of total billed charges for outpatient setting,862.4,70,,689.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.19,12.84,,126.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.6,80,,788.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.19,12.84,,126.55,percent of total billed charges,12.84% of total billed charges,158.19,12.84,,126.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800.8,65,,640.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.2,35,,344.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1108.8,90,,887.04,percent of total billed charges,90% of total billed charges for outpatient setting,158.19,1108.8,
BIT 2.7MM DRILL SCREW / 405889,69161569,CDM,272,RC,,,Outpatient,,,556,556,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.2,70,,311.36,percent of total billed charges,70% of total billed charges for outpatient setting,471.93,84.88,,377.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,278,50,,222.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417,75,,333.6,percent of total billed charges,75% of total billed charges for outpatient setting,389.2,70,,311.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.39,12.84,,57.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.8,80,,355.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.39,12.84,,57.11,percent of total billed charges,12.84% of total billed charges,71.39,12.84,,57.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,361.4,65,,289.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.6,35,,155.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,500.4,90,,400.32,percent of total billed charges,90% of total billed charges for outpatient setting,71.39,500.4,
BIT 2.7X100MM DRILL / 310.26,69169245,CDM,270,RC,,,Outpatient,,,331.68,331.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,70,,185.74,percent of total billed charges,70% of total billed charges for outpatient setting,281.53,84.88,,225.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,165.84,50,,132.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.76,75,,199.01,percent of total billed charges,75% of total billed charges for outpatient setting,232.18,70,,185.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.59,12.84,,34.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.34,80,,212.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.59,12.84,,34.07,percent of total billed charges,12.84% of total billed charges,42.59,12.84,,34.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,215.59,65,,172.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.09,35,,92.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.51,90,,238.81,percent of total billed charges,90% of total billed charges for outpatient setting,42.59,298.51,
BIT 2.8MM DRILL CLBRT / 324.214,759939,CDM,272,RC,,,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.1,70,,388.08,percent of total billed charges,70% of total billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,485.1,70,,388.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,450.45,65,,360.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,623.7,90,,498.96,percent of total billed charges,90% of total billed charges for outpatient setting,88.98,623.7,
BIT 2.8X3.5MM DRILL QUICK RLS / 80-0387,879463,CDM,272,RC,,,Outpatient,,,508,508,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.6,70,,284.48,percent of total billed charges,70% of total billed charges for outpatient setting,431.19,84.88,,344.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,254,50,,203.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,381,75,,304.8,percent of total billed charges,75% of total billed charges for outpatient setting,355.6,70,,284.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.23,12.84,,52.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.4,80,,325.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.23,12.84,,52.18,percent of total billed charges,12.84% of total billed charges,65.23,12.84,,52.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,330.2,65,,264.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.8,35,,142.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,457.2,90,,365.76,percent of total billed charges,90% of total billed charges for outpatient setting,65.23,457.2,
BIT 2.9MM DRILL JUGGERKNOT / 110005306,1342304,CDM,272,RC,,,Outpatient,,,327.24,327.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.07,70,,183.26,percent of total billed charges,70% of total billed charges for outpatient setting,277.76,84.88,,222.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,163.62,50,,130.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.43,75,,196.34,percent of total billed charges,75% of total billed charges for outpatient setting,229.07,70,,183.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,12.84,,33.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.79,80,,209.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,12.84,,33.62,percent of total billed charges,12.84% of total billed charges,42.02,12.84,,33.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,212.71,65,,170.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.53,35,,91.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,294.52,90,,235.62,percent of total billed charges,90% of total billed charges for outpatient setting,42.02,294.52,
BIT 3.10X216MM DRILL LOCKING / 705031,69169335,CDM,272,RC,,,Outpatient,,,744,744,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.8,70,,416.64,percent of total billed charges,70% of total billed charges for outpatient setting,631.51,84.88,,505.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,372,50,,297.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558,75,,446.4,percent of total billed charges,75% of total billed charges for outpatient setting,520.8,70,,416.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.53,12.84,,76.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.2,80,,476.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.53,12.84,,76.42,percent of total billed charges,12.84% of total billed charges,95.53,12.84,,76.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.6,65,,386.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.4,35,,208.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.6,90,,535.68,percent of total billed charges,90% of total billed charges for outpatient setting,95.53,669.6,
BIT 3.1MM DRILL SHORT / 705031S,1884314,CDM,272,RC,,,Outpatient,,,839.52,839.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.66,70,,470.13,percent of total billed charges,70% of total billed charges for outpatient setting,712.58,84.88,,570.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,419.76,50,,335.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,629.64,75,,503.71,percent of total billed charges,75% of total billed charges for outpatient setting,587.66,70,,470.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.79,12.84,,86.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.62,80,,537.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.79,12.84,,86.23,percent of total billed charges,12.84% of total billed charges,107.79,12.84,,86.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,545.69,65,,436.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.83,35,,235.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,755.57,90,,604.46,percent of total billed charges,90% of total billed charges for outpatient setting,107.79,755.57,
BIT 3.1X285MM DRILL AO / 703585,703585,CDM,272,RC,,,Outpatient,,,579.12,579.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.38,70,,324.3,percent of total billed charges,70% of total billed charges for outpatient setting,491.56,84.88,,393.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,289.56,50,,231.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.34,75,,347.47,percent of total billed charges,75% of total billed charges for outpatient setting,405.38,70,,324.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.36,12.84,,59.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.3,80,,370.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.36,12.84,,59.49,percent of total billed charges,12.84% of total billed charges,74.36,12.84,,59.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,376.43,65,,301.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.69,35,,162.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,521.21,90,,416.97,percent of total billed charges,90% of total billed charges for outpatient setting,74.36,521.21,
BIT 3.20X315MM DRILL AO / 703542,859702,CDM,272,RC,,,Outpatient,,,604.8,604.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.36,70,,338.69,percent of total billed charges,70% of total billed charges for outpatient setting,513.35,84.88,,410.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.4,50,,241.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453.6,75,,362.88,percent of total billed charges,75% of total billed charges for outpatient setting,423.36,70,,338.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.66,12.84,,62.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.84,80,,387.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.66,12.84,,62.13,percent of total billed charges,12.84% of total billed charges,77.66,12.84,,62.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.12,65,,314.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.68,35,,169.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,544.32,90,,435.46,percent of total billed charges,90% of total billed charges for outpatient setting,77.66,544.32,
BIT 3.2MM DRILL FOR SCREWS / 405883,69161580,CDM,272,RC,,,Outpatient,,,432,432,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.4,70,,241.92,percent of total billed charges,70% of total billed charges for outpatient setting,366.68,84.88,,293.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,216,50,,172.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324,75,,259.2,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,70,,241.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.47,12.84,,44.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.6,80,,276.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.47,12.84,,44.38,percent of total billed charges,12.84% of total billed charges,55.47,12.84,,44.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,280.8,65,,224.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,35,,120.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.8,90,,311.04,percent of total billed charges,90% of total billed charges for outpatient setting,55.47,388.8,
BIT 3.2X30MM DRILL ACET / 31-323230,71000039,CDM,272,RC,,,Outpatient,,,272,272,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.4,70,,152.32,percent of total billed charges,70% of total billed charges for outpatient setting,230.87,84.88,,184.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,136,50,,108.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204,75,,163.2,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,70,,152.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,12.84,,27.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,80,,174.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,12.84,,27.94,percent of total billed charges,12.84% of total billed charges,34.92,12.84,,27.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,176.8,65,,141.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.2,35,,76.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,244.8,90,,195.84,percent of total billed charges,90% of total billed charges for outpatient setting,34.92,244.8,
BIT 3.50X150MM DRILL / 03.133.109,69169813,CDM,272,RC,,,Outpatient,,,370.32,370.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.22,70,,207.38,percent of total billed charges,70% of total billed charges for outpatient setting,314.33,84.88,,251.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,185.16,50,,148.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.74,75,,222.19,percent of total billed charges,75% of total billed charges for outpatient setting,259.22,70,,207.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.55,12.84,,38.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.26,80,,237.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.55,12.84,,38.04,percent of total billed charges,12.84% of total billed charges,47.55,12.84,,38.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240.71,65,,192.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.61,35,,103.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,333.29,90,,266.63,percent of total billed charges,90% of total billed charges for outpatient setting,47.55,333.29,
BIT 3.8X3MM DRILL PRCSN / 5820-107-530,687931,CDM,272,RC,,,Outpatient,,,401.28,401.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,340.61,84.88,,272.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.64,50,,160.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.96,75,,240.77,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.02,80,,256.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.83,65,,208.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.45,35,,112.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.15,90,,288.92,percent of total billed charges,90% of total billed charges for outpatient setting,51.52,361.15,
BIT 3X170MM DRILL CANNULATED / 705357,70000675,CDM,278,RC,,,Outpatient,,,816,816,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.6,60,,391.68,percent of total billed charges,60% of total Billed charges for outpatient setting,692.62,84.88,,554.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,408,50,,326.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,612,75,,489.6,percent of total billed charges,75% of total billed charges for outpatient setting,408,50,,326.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.77,12.84,,83.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.8,80,,522.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.77,12.84,,83.82,percent of total billed charges,12.84% of total billed charges,104.77,12.84,,83.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,816,65,,652.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,35,,228.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,489.6,60,,391.68,percent of total billed charges,60% of total billed charges for outpatient setting,104.77,816,
BIT 4.30X216MM DRILL AO / 705043,1740407,CDM,272,RC,,,Outpatient,,,818.4,818.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.88,70,,458.3,percent of total billed charges,70% of total billed charges for outpatient setting,694.66,84.88,,555.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,409.2,50,,327.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.8,75,,491.04,percent of total billed charges,75% of total billed charges for outpatient setting,572.88,70,,458.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.08,12.84,,84.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.72,80,,523.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.08,12.84,,84.06,percent of total billed charges,12.84% of total billed charges,105.08,12.84,,84.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,531.96,65,,425.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.44,35,,229.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,736.56,90,,589.25,percent of total billed charges,90% of total billed charges for outpatient setting,105.08,736.56,
BIT 4.30X315MM DRILL AO / 703541,859701,CDM,272,RC,,,Outpatient,,,627.2,627.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.04,70,,351.23,percent of total billed charges,70% of total billed charges for outpatient setting,532.37,84.88,,425.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,313.6,50,,250.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,470.4,75,,376.32,percent of total billed charges,75% of total billed charges for outpatient setting,439.04,70,,351.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.53,12.84,,64.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.76,80,,401.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.53,12.84,,64.42,percent of total billed charges,12.84% of total billed charges,80.53,12.84,,64.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,407.68,65,,326.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.52,35,,175.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,564.48,90,,451.58,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,564.48,
BIT DRILL 2.7MM CANNULATED / 310.67,69160134,CDM,272,RC,,,Outpatient,,,1779,1779,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.3,70,,996.24,percent of total billed charges,70% of total billed charges for outpatient setting,1510.02,84.88,,1208.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,889.5,50,,711.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.25,75,,1067.4,percent of total billed charges,75% of total billed charges for outpatient setting,1245.3,70,,996.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.42,12.84,,182.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1423.2,80,,1138.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.42,12.84,,182.74,percent of total billed charges,12.84% of total billed charges,228.42,12.84,,182.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1156.35,65,,925.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.65,35,,498.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1601.1,90,,1280.88,percent of total billed charges,90% of total billed charges for outpatient setting,228.42,1601.1,
BIT DRILL 2.7MM CMP LT / AR-8737-35,70000534,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
BIT DRILL 2.8MM / 310.288,6152079,CDM,272,RC,,,Outpatient,,,384.15,384.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.91,70,,215.13,percent of total billed charges,70% of total billed charges for outpatient setting,326.07,84.88,,260.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,192.08,50,,153.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.11,75,,230.49,percent of total billed charges,75% of total billed charges for outpatient setting,268.91,70,,215.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.32,12.84,,39.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.32,80,,245.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.32,12.84,,39.46,percent of total billed charges,12.84% of total billed charges,49.32,12.84,,39.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,249.7,65,,199.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,35,,107.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,345.74,90,,276.59,percent of total billed charges,90% of total billed charges for outpatient setting,49.32,345.74,
BIT DRILL 3.2MM 200MM / 03035,70000389,CDM,272,RC,,,Outpatient,,,657.55,657.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.29,70,,368.23,percent of total billed charges,70% of total billed charges for outpatient setting,558.13,84.88,,446.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,328.78,50,,263.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.16,75,,394.53,percent of total billed charges,75% of total billed charges for outpatient setting,460.29,70,,368.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.43,12.84,,67.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.04,80,,420.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.43,12.84,,67.54,percent of total billed charges,12.84% of total billed charges,84.43,12.84,,67.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,427.41,65,,341.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.14,35,,184.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,591.8,90,,473.44,percent of total billed charges,90% of total billed charges for outpatient setting,84.43,591.8,
BIT DRILL 4.8MM 180MM / 03025,70000387,CDM,272,RC,,,Outpatient,,,657.55,657.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.29,70,,368.23,percent of total billed charges,70% of total billed charges for outpatient setting,558.13,84.88,,446.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,328.78,50,,263.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.16,75,,394.53,percent of total billed charges,75% of total billed charges for outpatient setting,460.29,70,,368.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.43,12.84,,67.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.04,80,,420.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.43,12.84,,67.54,percent of total billed charges,12.84% of total billed charges,84.43,12.84,,67.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,427.41,65,,341.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.14,35,,184.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,591.8,90,,473.44,percent of total billed charges,90% of total billed charges for outpatient setting,84.43,591.8,
BIT DRILL SKY 12MM FLAT / 2868-20-012,70000482,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
BIT DRILL SKY 14MM FLAT / 2868-20-014,70000353,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
BLADDER INSTILLATION ANTICARCINOGENIC AG,6000025,CDM,361,RC,51720,HCPCS,Outpatient,,,456.75,456.75,,381.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,319.73,70,,255.78,percent of total billed charges,70% of total billed charges for outpatient setting,387.69,84.88,,310.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,319.23,50,,255.38,percent of total billed charges,50% of total Billed charges for outpatient setting,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.56,75,,274.05,percent of total billed charges,75% of total billed charges for outpatient setting,319.73,70,,255.78,percent of total billed charges,70% of total billed charges for outpatient setting,405.36,170,,,Fee Schedule,170% of Medicare OPPS rate,512.66,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,417.29,175,,,Fee Schedule,175% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,365.4,80,,292.32,percent of total billed charges,80% of total billed charges for outpatient setting,333.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,298.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,251.12,100,,,Fee Schedule,100% of Custom Fee Schedule,411.08,90,,328.86,percent of total billed charges,90% of total billed charges for outpatient setting,58.65,512.66,
BLADDER IRRIGATION SIMPLE/LAVAGE/INSTALL,5150212,CDM,360,RC,51700,HCPCS,Outpatient,,,448.08,448.08,,381.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,313.66,70,,250.93,percent of total billed charges,70% of total billed charges for outpatient setting,380.33,84.88,,304.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,319.23,50,,255.38,percent of total billed charges,50% of total Billed charges for outpatient setting,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,336.06,75,,268.85,percent of total billed charges,75% of total billed charges for outpatient setting,313.66,70,,250.93,percent of total billed charges,70% of total billed charges for outpatient setting,405.36,170,,,Fee Schedule,170% of Medicare OPPS rate,512.66,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,57.53,12.84,,46.024,percent of total billed charges,12.84% of total billed charges,417.29,175,,,Fee Schedule,175% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,358.46,80,,286.77,percent of total billed charges,80% of total billed charges for outpatient setting,333.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,298.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,57.53,12.84,,46.02,percent of total billed charges,12.84% of total billed charges,57.53,12.84,,46.02,percent of total billed charges,12.84% of total billed charges,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,251.12,100,,,Fee Schedule,100% of Custom Fee Schedule,403.27,90,,322.62,percent of total billed charges,90% of total billed charges for outpatient setting,57.53,512.66,
BLADDER SCAN,5100025,CDM,402,RC,51798,HCPCS,Outpatient,,,640.79,640.79,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,448.55,70,,358.84,percent of total billed charges,70% of total billed charges for outpatient setting,543.9,84.88,,435.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,480.59,75,,384.47,percent of total billed charges,75% of total billed charges for outpatient setting,448.55,70,,358.84,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,82.28,12.84,,65.824,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,512.63,80,,410.1,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,82.28,12.84,,65.82,percent of total billed charges,12.84% of total billed charges,82.28,12.84,,65.82,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.57,100,,,Fee Schedule,100% of Custom Fee Schedule,576.71,90,,461.37,percent of total billed charges,90% of total billed charges for outpatient setting,49.88,576.71,
BLADE 10MM TENDON STRIP / AR-2385-10,71000799,CDM,272,RC,,,Outpatient,,,735,735,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,623.87,84.88,,499.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,367.5,50,,294,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.25,75,,441,percent of total billed charges,75% of total billed charges for outpatient setting,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,80,,470.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,477.75,65,,382.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.25,35,,205.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,661.5,90,,529.2,percent of total billed charges,90% of total billed charges for outpatient setting,94.37,661.5,
BLADE 11.5X5.5MM PRCSN / 2296-003-410,418367,CDM,272,RC,,,Outpatient,,,127.86,127.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,108.53,84.88,,86.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.93,50,,51.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.9,75,,76.72,percent of total billed charges,75% of total billed charges for outpatient setting,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.29,80,,81.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.11,65,,66.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,35,,35.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,115.07,90,,92.06,percent of total billed charges,90% of total billed charges for outpatient setting,16.42,115.07,
BLADE 11X40MM SAW LAPIPLASTY / SM-4011,2208207,CDM,272,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,169.76,84.88,,135.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,100,50,,80,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,75,,120,percent of total billed charges,75% of total billed charges for outpatient setting,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,80,,128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130,65,,104,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,35,,56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,90,,144,percent of total billed charges,90% of total billed charges for outpatient setting,25.68,180,
BLADE 15C / 371716,6150122,CDM,272,RC,,,Outpatient,,,10.9,10.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,9.25,84.88,,7.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.45,50,,4.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.18,75,,6.54,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,80,,6.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.09,65,,5.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,35,,3.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.81,90,,7.85,percent of total billed charges,90% of total billed charges for outpatient setting,1.4,9.81,
BLADE 18X5.5MM PRCSN / 2296-003-412,418369,CDM,272,RC,,,Outpatient,,,127.86,127.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,108.53,84.88,,86.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.93,50,,51.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.9,75,,76.72,percent of total billed charges,75% of total billed charges for outpatient setting,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.29,80,,81.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.11,65,,66.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,35,,35.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,115.07,90,,92.06,percent of total billed charges,90% of total billed charges for outpatient setting,16.42,115.07,
BLADE 2MM 7CM SABRE / AR-9200SR,71000642,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
BLADE 3.4MM 13CM QUADCUT / 1883480EM,69161828,CDM,272,RC,,,Outpatient,,,1386.52,1386.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.56,70,,776.45,percent of total billed charges,70% of total billed charges for outpatient setting,1176.88,84.88,,941.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,693.26,50,,554.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1039.89,75,,831.91,percent of total billed charges,75% of total billed charges for outpatient setting,970.56,70,,776.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.03,12.84,,142.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1109.22,80,,887.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.03,12.84,,142.42,percent of total billed charges,12.84% of total billed charges,178.03,12.84,,142.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,901.24,65,,720.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.28,35,,388.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1247.87,90,,998.3,percent of total billed charges,90% of total billed charges for outpatient setting,178.03,1247.87,
BLADE 3.5MM TRICUT / 1883504,69161350,CDM,272,RC,,,Outpatient,,,778.36,778.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.85,70,,435.88,percent of total billed charges,70% of total billed charges for outpatient setting,660.67,84.88,,528.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,389.18,50,,311.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,583.77,75,,467.02,percent of total billed charges,75% of total billed charges for outpatient setting,544.85,70,,435.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.94,12.84,,79.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.69,80,,498.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.94,12.84,,79.95,percent of total billed charges,12.84% of total billed charges,99.94,12.84,,79.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.93,65,,404.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.43,35,,217.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,700.52,90,,560.42,percent of total billed charges,90% of total billed charges for outpatient setting,99.94,700.52,
BLADE 38MM MICRO SAGITAL / 2296-003-525,6153025,CDM,272,RC,,,Outpatient,,,125.04,125.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.53,70,,70.02,percent of total billed charges,70% of total billed charges for outpatient setting,106.13,84.88,,84.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.52,50,,50.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.78,75,,75.02,percent of total billed charges,75% of total billed charges for outpatient setting,87.53,70,,70.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,12.84,,12.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.03,80,,80.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,12.84,,12.85,percent of total billed charges,12.84% of total billed charges,16.06,12.84,,12.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.28,65,,65.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.76,35,,35.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.54,90,,90.03,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,112.54,
BLADE 38MM PRCSN MICRO / 2296-003-414,6153026,CDM,272,RC,,,Outpatient,,,127.86,127.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,108.53,84.88,,86.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.93,50,,51.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.9,75,,76.72,percent of total billed charges,75% of total billed charges for outpatient setting,89.5,70,,71.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.29,80,,81.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,16.42,12.84,,13.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.11,65,,66.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,35,,35.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,115.07,90,,92.06,percent of total billed charges,90% of total billed charges for outpatient setting,16.42,115.07,
BLADE 3MM 13CM QUADCUT M4 / 1883080HRE,1430103,CDM,272,RC,,,Outpatient,,,884.16,884.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.91,70,,495.13,percent of total billed charges,70% of total billed charges for outpatient setting,750.48,84.88,,600.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,442.08,50,,353.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,663.12,75,,530.5,percent of total billed charges,75% of total billed charges for outpatient setting,618.91,70,,495.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.53,12.84,,90.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.33,80,,565.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.53,12.84,,90.82,percent of total billed charges,12.84% of total billed charges,113.53,12.84,,90.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,574.7,65,,459.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.46,35,,247.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,795.74,90,,636.59,percent of total billed charges,90% of total billed charges for outpatient setting,113.53,795.74,
BLADE 3MM 7CM SABRE / AR-9300SR,71000450,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
BLADE 3MM STRAIGHT / SSB-223-0,69169228,CDM,272,RC,,,Outpatient,,,157.5,157.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,133.69,84.88,,106.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.75,50,,63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.13,75,,94.5,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,80,,100.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.38,65,,81.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,35,,44.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,90,,113.4,percent of total billed charges,90% of total billed charges for outpatient setting,20.22,141.75,
BLADE 45 DEGREE MYRINGOTOMY / 377120,69161637,CDM,272,RC,,,Outpatient,,,47.53,47.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.27,70,,26.62,percent of total billed charges,70% of total billed charges for outpatient setting,40.34,84.88,,32.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.77,50,,19.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.65,75,,28.52,percent of total billed charges,75% of total billed charges for outpatient setting,33.27,70,,26.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.1,12.84,,4.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,80,,30.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.1,12.84,,4.88,percent of total billed charges,12.84% of total billed charges,6.1,12.84,,4.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.89,65,,24.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.64,35,,13.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.78,90,,34.22,percent of total billed charges,90% of total billed charges for outpatient setting,6.1,42.78,
BLADE 4MM STRAIGHT / 1600581-001,69169227,CDM,272,RC,,,Outpatient,,,157.5,157.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,133.69,84.88,,106.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.75,50,,63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.13,75,,94.5,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,80,,100.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.38,65,,81.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,35,,44.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,90,,113.4,percent of total billed charges,90% of total billed charges for outpatient setting,20.22,141.75,
BLADE 70X12.5X0.8MM RECIP / 0277-096-276,378773,CDM,272,RC,,,Outpatient,,,143.94,143.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.76,70,,80.61,percent of total billed charges,70% of total billed charges for outpatient setting,122.18,84.88,,97.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.97,50,,57.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.96,75,,86.37,percent of total billed charges,75% of total billed charges for outpatient setting,100.76,70,,80.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.48,12.84,,14.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.15,80,,92.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.48,12.84,,14.78,percent of total billed charges,12.84% of total billed charges,18.48,12.84,,14.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.56,65,,74.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.38,35,,40.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.55,90,,103.64,percent of total billed charges,90% of total billed charges for outpatient setting,18.48,129.55,
BLADE 83.5X18.5MM SAGITAL / 6118-127-090,418411,CDM,272,RC,,,Outpatient,,,201.52,201.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.06,70,,112.85,percent of total billed charges,70% of total billed charges for outpatient setting,171.05,84.88,,136.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.76,50,,80.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.14,75,,120.91,percent of total billed charges,75% of total billed charges for outpatient setting,141.06,70,,112.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.22,80,,128.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130.99,65,,104.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.53,35,,56.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.37,90,,145.1,percent of total billed charges,90% of total billed charges for outpatient setting,25.88,181.37,
BLADE 9.5X25.5MM MICRO SGTL / 5023-138,71000418,CDM,272,RC,,,Outpatient,,,36.61,36.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,70,,20.5,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,84.88,,24.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.31,50,,14.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.46,75,,21.97,percent of total billed charges,75% of total billed charges for outpatient setting,25.63,70,,20.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.29,80,,23.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.8,65,,19.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.81,35,,10.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.95,90,,26.36,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,32.95,
BLADE 90X25MM OSC KNEE  / 6725-127-090,69169217,CDM,272,RC,,,Outpatient,,,1093.24,1093.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.27,70,,612.22,percent of total billed charges,70% of total billed charges for outpatient setting,927.94,84.88,,742.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,546.62,50,,437.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,819.93,75,,655.94,percent of total billed charges,75% of total billed charges for outpatient setting,765.27,70,,612.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.37,12.84,,112.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.59,80,,699.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.37,12.84,,112.3,percent of total billed charges,12.84% of total billed charges,140.37,12.84,,112.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,710.61,65,,568.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.63,35,,306.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,983.92,90,,787.14,percent of total billed charges,90% of total billed charges for outpatient setting,140.37,983.92,
BLADE 9MM MED SAGITTAL / 2296-3-511,6150556,CDM,270,RC,,,Outpatient,,,125.04,125.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.53,70,,70.02,percent of total billed charges,70% of total billed charges for outpatient setting,106.13,84.88,,84.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.52,50,,50.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.78,75,,75.02,percent of total billed charges,75% of total billed charges for outpatient setting,87.53,70,,70.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,12.84,,12.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.03,80,,80.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,12.84,,12.85,percent of total billed charges,12.84% of total billed charges,16.06,12.84,,12.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.28,65,,65.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.76,35,,35.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.54,90,,90.03,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,112.54,
BLADE BEAVER 2.0mm/50 DEG./BC374451,6153029,CDM,272,RC,,,Outpatient,,,110.88,110.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.62,70,,62.1,percent of total billed charges,70% of total billed charges for outpatient setting,94.11,84.88,,75.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.44,50,,44.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.16,75,,66.53,percent of total billed charges,75% of total billed charges for outpatient setting,77.62,70,,62.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,12.84,,11.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.7,80,,70.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,12.84,,11.39,percent of total billed charges,12.84% of total billed charges,14.24,12.84,,11.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.07,65,,57.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.81,35,,31.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.79,90,,79.83,percent of total billed charges,90% of total billed charges for outpatient setting,14.24,99.79,
BLADE BEAVER NARROW SFT45 DEG / 377121,69161087,CDM,272,RC,,,Outpatient,,,90.12,90.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.08,70,,50.46,percent of total billed charges,70% of total billed charges for outpatient setting,76.49,84.88,,61.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.06,50,,36.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.59,75,,54.07,percent of total billed charges,75% of total billed charges for outpatient setting,63.08,70,,50.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,12.84,,9.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.1,80,,57.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,12.84,,9.26,percent of total billed charges,12.84% of total billed charges,11.57,12.84,,9.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.58,65,,46.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.54,35,,25.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.11,90,,64.89,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,81.11,
BLADE CAST CUTTER / 940-23,6151086,CDM,270,RC,,,Outpatient,,,213.32,213.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.32,70,,119.46,percent of total billed charges,70% of total billed charges for outpatient setting,181.07,84.88,,144.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,106.66,50,,85.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.99,75,,127.99,percent of total billed charges,75% of total billed charges for outpatient setting,149.32,70,,119.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.39,12.84,,21.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.66,80,,136.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.39,12.84,,21.91,percent of total billed charges,12.84% of total billed charges,27.39,12.84,,21.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,138.66,65,,110.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.66,35,,59.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,191.99,90,,153.59,percent of total billed charges,90% of total billed charges for outpatient setting,27.39,191.99,
BLADE CRESCENT 2.3MM / MCU26,8370147,CDM,272,RC,,,Outpatient,,,60.56,60.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,51.4,84.88,,41.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.28,50,,24.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.42,75,,36.34,percent of total billed charges,75% of total billed charges for outpatient setting,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.45,80,,38.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.36,65,,31.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.2,35,,16.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.5,90,,43.6,percent of total billed charges,90% of total billed charges for outpatient setting,7.78,54.5,
BLADE DERMATOME / 8800-000-10,6152177,CDM,270,RC,,,Outpatient,,,238.61,238.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.03,70,,133.62,percent of total billed charges,70% of total billed charges for outpatient setting,202.53,84.88,,162.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.31,50,,95.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.96,75,,143.17,percent of total billed charges,75% of total billed charges for outpatient setting,167.03,70,,133.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.89,80,,152.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.1,65,,124.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.51,35,,66.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.75,90,,171.8,percent of total billed charges,90% of total billed charges for outpatient setting,30.64,214.75,
BLADE DIAMOND DISC /5120-130-250,6152220,CDM,272,RC,,,Outpatient,,,365.41,365.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.79,70,,204.63,percent of total billed charges,70% of total billed charges for outpatient setting,310.16,84.88,,248.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,182.71,50,,146.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.06,75,,219.25,percent of total billed charges,75% of total billed charges for outpatient setting,255.79,70,,204.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.92,12.84,,37.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.33,80,,233.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.92,12.84,,37.54,percent of total billed charges,12.84% of total billed charges,46.92,12.84,,37.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,237.52,65,,190.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.89,35,,102.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,328.87,90,,263.1,percent of total billed charges,90% of total billed charges for outpatient setting,46.92,328.87,
BLADE GRAFT KNIFE 10MM  AR-2285,69162417,CDM,272,RC,,,Outpatient,,,254.15,254.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.91,70,,142.33,percent of total billed charges,70% of total billed charges for outpatient setting,215.72,84.88,,172.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.08,50,,101.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.61,75,,152.49,percent of total billed charges,75% of total billed charges for outpatient setting,177.91,70,,142.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,12.84,,26.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.32,80,,162.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,12.84,,26.1,percent of total billed charges,12.84% of total billed charges,32.63,12.84,,26.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.2,65,,132.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.95,35,,71.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.74,90,,182.99,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,228.74,
BLADE GRAFT KNIFE 11MM / AR-2285-11,69162673,CDM,272,RC,,,Outpatient,,,254.15,254.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.91,70,,142.33,percent of total billed charges,70% of total billed charges for outpatient setting,215.72,84.88,,172.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.08,50,,101.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.61,75,,152.49,percent of total billed charges,75% of total billed charges for outpatient setting,177.91,70,,142.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,12.84,,26.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.32,80,,162.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,12.84,,26.1,percent of total billed charges,12.84% of total billed charges,32.63,12.84,,26.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.2,65,,132.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.95,35,,71.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.74,90,,182.99,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,228.74,
BLADE HOOK STRYKER / 3055-6,2312511,CDM,272,RC,,,Outpatient,,,502.4,502.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,426.44,84.88,,341.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.2,50,,200.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.8,75,,301.44,percent of total billed charges,75% of total billed charges for outpatient setting,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.92,80,,321.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,326.56,65,,261.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.84,35,,140.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.16,90,,361.73,percent of total billed charges,90% of total billed charges for outpatient setting,64.51,452.16,
BLADE LANCET / 130716,6150575,CDM,272,RC,,,Outpatient,,,44.1,44.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.87,70,,24.7,percent of total billed charges,70% of total billed charges for outpatient setting,37.43,84.88,,29.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.05,50,,17.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.08,75,,26.46,percent of total billed charges,75% of total billed charges for outpatient setting,30.87,70,,24.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,12.84,,4.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,80,,28.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,12.84,,4.53,percent of total billed charges,12.84% of total billed charges,5.66,12.84,,4.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.67,65,,22.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.44,35,,12.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.69,90,,31.75,percent of total billed charges,90% of total billed charges for outpatient setting,5.66,39.69,
BLADE MAC 3 OMNI HANDLE / 040-04-0130U,2354252,CDM,272,RC,,,Outpatient,,,66.15,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.08,50,,26.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43,65,,34.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.15,35,,18.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,8.49,59.54,
BLADE MAC 4 OMNI HANDLE / 040-04-013U,2354253,CDM,272,RC,,,Outpatient,,,66.15,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.08,50,,26.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43,65,,34.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.15,35,,18.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,8.49,59.54,
BLADE MIL 1 OMNI HANDLE / 040-04-013U,2354256,CDM,272,RC,,,Outpatient,,,66.15,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.08,50,,26.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43,65,,34.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.15,35,,18.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,8.49,59.54,
BLADE MIL 2 OMNI HANDLE / 040-04-0420U,2354257,CDM,272,RC,,,Outpatient,,,66.15,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.08,50,,26.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43,65,,34.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.15,35,,18.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,8.49,59.54,
BLADE MILLER 2 LRNGSCOPE DISP / 040-722U,1535857,CDM,272,RC,,,Outpatient,,,31.52,31.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.06,70,,17.65,percent of total billed charges,70% of total billed charges for outpatient setting,26.75,84.88,,21.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.76,50,,12.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.64,75,,18.91,percent of total billed charges,75% of total billed charges for outpatient setting,22.06,70,,17.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.22,80,,20.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.49,65,,16.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,35,,8.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.37,90,,22.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.05,28.37,
BLADE MILLER 3 HNDL COMBO / 040-723HU,1535446,CDM,272,RC,,,Outpatient,,,71.19,71.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,70,,39.86,percent of total billed charges,70% of total billed charges for outpatient setting,60.43,84.88,,48.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.6,50,,28.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.39,75,,42.71,percent of total billed charges,75% of total billed charges for outpatient setting,49.83,70,,39.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,12.84,,7.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.95,80,,45.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,12.84,,7.31,percent of total billed charges,12.84% of total billed charges,9.14,12.84,,7.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.27,65,,37.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.92,35,,19.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.07,90,,51.26,percent of total billed charges,90% of total billed charges for outpatient setting,9.14,64.07,
BLADE MILLER 3 LRNGSCOPE DISP / 040-723U,1535858,CDM,272,RC,,,Outpatient,,,31.52,31.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.06,70,,17.65,percent of total billed charges,70% of total billed charges for outpatient setting,26.75,84.88,,21.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.76,50,,12.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.64,75,,18.91,percent of total billed charges,75% of total billed charges for outpatient setting,22.06,70,,17.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.22,80,,20.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.49,65,,16.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,35,,8.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.37,90,,22.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.05,28.37,
BLADE MINI BEAVER / BEAVER6400,6151085,CDM,272,RC,,,Outpatient,,,15.59,15.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.91,70,,8.73,percent of total billed charges,70% of total billed charges for outpatient setting,13.23,84.88,,10.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.8,50,,6.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.69,75,,9.35,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,70,,8.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,80,,9.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.13,65,,8.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,35,,4.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.03,90,,11.22,percent of total billed charges,90% of total billed charges for outpatient setting,2,14.03,
BLADE OSC 25X1.27 PRECSN / 6725-127-105,69169267,CDM,272,RC,,,Outpatient,,,1089.36,1089.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.55,70,,610.04,percent of total billed charges,70% of total billed charges for outpatient setting,924.65,84.88,,739.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,544.68,50,,435.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,817.02,75,,653.62,percent of total billed charges,75% of total billed charges for outpatient setting,762.55,70,,610.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.87,12.84,,111.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,871.49,80,,697.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.87,12.84,,111.9,percent of total billed charges,12.84% of total billed charges,139.87,12.84,,111.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,708.08,65,,566.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.28,35,,305.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,980.42,90,,784.34,percent of total billed charges,90% of total billed charges for outpatient setting,139.87,980.42,
BLADE OSC 5.5MM/1102,6151046,CDM,272,RC,,,Outpatient,,,274.97,274.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.48,70,,153.98,percent of total billed charges,70% of total billed charges for outpatient setting,233.39,84.88,,186.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,137.49,50,,109.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.23,75,,164.98,percent of total billed charges,75% of total billed charges for outpatient setting,192.48,70,,153.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.31,12.84,,28.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.98,80,,175.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.31,12.84,,28.25,percent of total billed charges,12.84% of total billed charges,35.31,12.84,,28.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,178.73,65,,142.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,35,,76.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,247.47,90,,197.98,percent of total billed charges,90% of total billed charges for outpatient setting,35.31,247.47,
BLADE OSC. 5.5MM/2296-3-414,69159611,CDM,272,RC,,,Outpatient,,,513.23,513.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.26,70,,287.41,percent of total billed charges,70% of total billed charges for outpatient setting,435.63,84.88,,348.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.62,50,,205.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,384.92,75,,307.94,percent of total billed charges,75% of total billed charges for outpatient setting,359.26,70,,287.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.9,12.84,,52.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.58,80,,328.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.9,12.84,,52.72,percent of total billed charges,12.84% of total billed charges,65.9,12.84,,52.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,333.6,65,,266.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.63,35,,143.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,461.91,90,,369.53,percent of total billed charges,90% of total billed charges for outpatient setting,65.9,461.91,
BLADE OSTEOTOME 10MMX5IN / 2709-04-011,69169194,CDM,272,RC,,,Outpatient,,,888.56,888.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.99,70,,497.59,percent of total billed charges,70% of total billed charges for outpatient setting,754.21,84.88,,603.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,444.28,50,,355.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.42,75,,533.14,percent of total billed charges,75% of total billed charges for outpatient setting,621.99,70,,497.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.09,12.84,,91.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.85,80,,568.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.09,12.84,,91.27,percent of total billed charges,12.84% of total billed charges,114.09,12.84,,91.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,577.56,65,,462.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311,35,,248.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,799.7,90,,639.76,percent of total billed charges,90% of total billed charges for outpatient setting,114.09,799.7,
BLADE RECIP SHORT/TAPERED 5100-137-133,6151041,CDM,272,RC,,,Outpatient,,,286.32,286.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.42,70,,160.34,percent of total billed charges,70% of total billed charges for outpatient setting,243.03,84.88,,194.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,143.16,50,,114.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.74,75,,171.79,percent of total billed charges,75% of total billed charges for outpatient setting,200.42,70,,160.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.76,12.84,,29.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.06,80,,183.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.76,12.84,,29.41,percent of total billed charges,12.84% of total billed charges,36.76,12.84,,29.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,186.11,65,,148.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.21,35,,80.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,257.69,90,,206.15,percent of total billed charges,90% of total billed charges for outpatient setting,36.76,257.69,
BLADE SAGITTAL 25x9.4/ AR-300-043S,69162936,CDM,270,RC,,,Outpatient,,,135.19,135.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,114.75,84.88,,91.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.6,50,,54.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.39,75,,81.11,percent of total billed charges,75% of total billed charges for outpatient setting,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.15,80,,86.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.87,65,,70.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.32,35,,37.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.67,90,,97.34,percent of total billed charges,90% of total billed charges for outpatient setting,17.36,121.67,
BLADE SAW GIGLI / 2808-02,6152269,CDM,272,RC,,,Outpatient,,,165.67,165.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.97,70,,92.78,percent of total billed charges,70% of total billed charges for outpatient setting,140.62,84.88,,112.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.84,50,,66.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.25,75,,99.4,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,70,,92.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,12.84,,17.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.54,80,,106.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,12.84,,17.02,percent of total billed charges,12.84% of total billed charges,21.27,12.84,,17.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,107.69,65,,86.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.98,35,,46.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,149.1,90,,119.28,percent of total billed charges,90% of total billed charges for outpatient setting,21.27,149.1,
BLADE SAW VELYS / 451570000,71000425,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
BLADE T8 SCREWDRIVER AO / 703663,1627291,CDM,272,RC,,,Outpatient,,,1082.4,1082.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.68,70,,606.14,percent of total billed charges,70% of total billed charges for outpatient setting,918.74,84.88,,734.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,541.2,50,,432.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,811.8,75,,649.44,percent of total billed charges,75% of total billed charges for outpatient setting,757.68,70,,606.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.98,12.84,,111.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.92,80,,692.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.98,12.84,,111.18,percent of total billed charges,12.84% of total billed charges,138.98,12.84,,111.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,703.56,65,,562.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.84,35,,303.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,974.16,90,,779.33,percent of total billed charges,90% of total billed charges for outpatient setting,138.98,974.16,
BLADE TI SPIRAL 44MM / 462.644,70000407,CDM,270,RC,,,Outpatient,,,2173.65,2173.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1521.56,70,,1217.25,percent of total billed charges,70% of total billed charges for outpatient setting,1844.99,84.88,,1475.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1086.83,50,,869.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1630.24,75,,1304.19,percent of total billed charges,75% of total billed charges for outpatient setting,1521.56,70,,1217.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.1,12.84,,223.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1738.92,80,,1391.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.1,12.84,,223.28,percent of total billed charges,12.84% of total billed charges,279.1,12.84,,223.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1412.87,65,,1130.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.78,35,,608.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1956.29,90,,1565.03,percent of total billed charges,90% of total billed charges for outpatient setting,279.1,1956.29,
BLADE TRIANGLE ANGLED / 3054-6,2312507,CDM,272,RC,,,Outpatient,,,502.4,502.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,426.44,84.88,,341.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.2,50,,200.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.8,75,,301.44,percent of total billed charges,75% of total billed charges for outpatient setting,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.92,80,,321.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,326.56,65,,261.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.84,35,,140.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.16,90,,361.73,percent of total billed charges,90% of total billed charges for outpatient setting,64.51,452.16,
BLADE/HANDLE  MAC 2 / 004671002,69169638,CDM,271,RC,,,Outpatient,,,109.68,109.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,93.1,84.88,,74.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.84,50,,43.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.26,75,,65.81,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,80,,70.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.29,65,,57.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,35,,30.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.71,90,,78.97,percent of total billed charges,90% of total billed charges for outpatient setting,14.08,98.71,
BLADE/HANDLE  MAC 3 / 040-04-0130U,69169639,CDM,271,RC,,,Outpatient,,,113.04,113.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.13,70,,63.3,percent of total billed charges,70% of total billed charges for outpatient setting,95.95,84.88,,76.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.52,50,,45.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.78,75,,67.82,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,70,,63.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.43,80,,72.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.48,65,,58.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.56,35,,31.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.74,90,,81.39,percent of total billed charges,90% of total billed charges for outpatient setting,14.51,101.74,
BLADE/HANDLE  MILLER 1 / 040-06-0410U,69169635,CDM,271,RC,,,Outpatient,,,113.04,113.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.13,70,,63.3,percent of total billed charges,70% of total billed charges for outpatient setting,95.95,84.88,,76.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.52,50,,45.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.78,75,,67.82,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,70,,63.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.43,80,,72.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.48,65,,58.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.56,35,,31.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.74,90,,81.39,percent of total billed charges,90% of total billed charges for outpatient setting,14.51,101.74,
BLADE/HANDLE MAC 4 / 040-04-0140U,69169640,CDM,271,RC,,,Outpatient,,,109.68,109.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,93.1,84.88,,74.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.84,50,,43.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.26,75,,65.81,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,80,,70.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.29,65,,57.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,35,,30.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.71,90,,78.97,percent of total billed charges,90% of total billed charges for outpatient setting,14.08,98.71,
BLADE/HANDLE MILLER 2 / 040-04-0420U,1535445,CDM,272,RC,,,Outpatient,,,71.19,71.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,70,,39.86,percent of total billed charges,70% of total billed charges for outpatient setting,60.43,84.88,,48.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.6,50,,28.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.39,75,,42.71,percent of total billed charges,75% of total billed charges for outpatient setting,49.83,70,,39.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,12.84,,7.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.95,80,,45.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,12.84,,7.31,percent of total billed charges,12.84% of total billed charges,9.14,12.84,,7.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.27,65,,37.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.92,35,,19.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.07,90,,51.26,percent of total billed charges,90% of total billed charges for outpatient setting,9.14,64.07,
BLADES SAW OXF PART KNEE  506295,69169295,CDM,272,RC,,,Outpatient,,,1808.27,1808.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,1534.86,84.88,,1227.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,904.14,50,,723.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1356.2,75,,1084.96,percent of total billed charges,75% of total billed charges for outpatient setting,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.62,80,,1157.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1175.38,65,,940.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.89,35,,506.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.44,90,,1301.95,percent of total billed charges,90% of total billed charges for outpatient setting,232.18,1627.44,
BLADES SAW OXF PART KNEE PK3 506267,69162282,CDM,272,RC,,,Outpatient,,,1808.27,1808.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,1534.86,84.88,,1227.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,904.14,50,,723.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1356.2,75,,1084.96,percent of total billed charges,75% of total billed charges for outpatient setting,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.62,80,,1157.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1175.38,65,,940.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.89,35,,506.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.44,90,,1301.95,percent of total billed charges,90% of total billed charges for outpatient setting,232.18,1627.44,
BLANKET FULL BODY MODEL 300 / 40068,5050213,CDM,270,RC,,,Outpatient,,,37.46,37.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,31.8,84.88,,25.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.73,50,,14.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.1,75,,22.48,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,80,,23.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.35,65,,19.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,35,,10.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.71,90,,26.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,33.71,
BLANKET UPPER BODY / 62200,6150673,CDM,272,RC,,,Outpatient,,,41.51,41.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,70,,23.25,percent of total billed charges,70% of total billed charges for outpatient setting,35.23,84.88,,28.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.76,50,,16.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.13,75,,24.9,percent of total billed charges,75% of total billed charges for outpatient setting,29.06,70,,23.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,12.84,,4.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.21,80,,26.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,12.84,,4.26,percent of total billed charges,12.84% of total billed charges,5.33,12.84,,4.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.98,65,,21.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,35,,11.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.36,90,,29.89,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,37.36,
BLANKET WARMING LOWER / 52500,6150674,CDM,272,RC,,,Outpatient,,,36.26,36.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.38,70,,20.3,percent of total billed charges,70% of total billed charges for outpatient setting,30.78,84.88,,24.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.13,50,,14.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.2,75,,21.76,percent of total billed charges,75% of total billed charges for outpatient setting,25.38,70,,20.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,12.84,,3.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.01,80,,23.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,12.84,,3.73,percent of total billed charges,12.84% of total billed charges,4.66,12.84,,3.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.57,65,,18.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,35,,10.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,90% of total billed charges for outpatient setting,4.66,32.63,
BLASTOMYCES ANTIBODIES,220847,CDM,302,RC,86612,HCPCS,Outpatient,,,58.05,52.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,49.27,84.88,,39.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.54,75,,34.83,percent of total billed charges,75% of total billed charges for outpatient setting,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,80,,37.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.46,100,,,Fee Schedule,100% of Custom Fee Schedule,52.25,90,,41.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,52.25,
BLASTOMYCES ANTIGEN URINE,201431,CDM,301,RC,87449,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
"BLD COUNT, MAN DIF OTHER THAN SPUN",202101,CDM,305,RC,85014,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
BLOCK 45FR PED BITE / 100412,1465523,CDM,271,RC,,,Outpatient,,,7.56,7.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,70,,4.23,percent of total billed charges,70% of total billed charges for outpatient setting,6.42,84.88,,5.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.78,50,,3.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.67,75,,4.54,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,70,,4.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,12.84,,0.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.05,80,,4.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.97,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.91,65,,3.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,35,,2.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.8,90,,5.44,percent of total billed charges,90% of total billed charges for outpatient setting,0.97,6.8,
BLOCK 5MM LL PSN TIB / 42-5558-031-05,71000188,CDM,278,RC,C1776,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
BLOCK 5MM LM PSN TIB / 42-5558-033-05,71000187,CDM,278,RC,C1776,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
BLOCK 60FR ADULT BITE / MAJ-1632,1144270,CDM,272,RC,,,Outpatient,,,10.8,10.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,9.17,84.88,,7.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.4,50,,4.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.1,75,,6.48,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,70,,6.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,80,,6.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.02,65,,5.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,35,,3.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.72,90,,7.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.39,9.72,
BLOCK 60FR BITE ENDO / SBT-546,1739099,CDM,272,RC,,,Outpatient,,,4.95,4.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,70,,2.78,percent of total billed charges,70% of total billed charges for outpatient setting,4.2,84.88,,3.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.48,50,,1.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.71,75,,2.97,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,70,,2.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,80,,3.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.22,65,,2.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.46,90,,3.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.64,4.46,
BLOOD (WHOLE) FOR TRANSFUSION PER UNIT,1000005,CDM,382,RC,P9010,HCPCS,Outpatient,,,495.18,495.18,,245.07,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,346.63,70,,277.3,percent of total billed charges,70% of total billed charges for outpatient setting,420.31,84.88,,336.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,218.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,371.39,75,,297.11,percent of total billed charges,75% of total billed charges for outpatient setting,346.63,70,,277.3,percent of total billed charges,70% of total billed charges for outpatient setting,260.38,170,,,Fee Schedule,170% of Medicare OPPS rate,329.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,63.58,12.84,,50.864,percent of total billed charges,12.84% of total billed charges,268.04,175,,,Fee Schedule,175% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,396.14,80,,316.91,percent of total billed charges,80% of total billed charges for outpatient setting,214.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,191.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,63.58,12.84,,50.86,percent of total billed charges,12.84% of total billed charges,63.58,12.84,,50.86,percent of total billed charges,12.84% of total billed charges,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,321.87,65,,257.5,percent of total billed charges,65% of total billed charges for outpatient setting,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.31,35,,138.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,445.66,90,,356.53,percent of total billed charges,90% of total billed charges for outpatient setting,63.58,445.66,
BLOOD COUNT; MANUAL DIFFERENTIAL,201191,CDM,300,RC,85007,HCPCS,Outpatient,,,17.1,15.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,14.51,84.88,,11.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.83,75,,10.26,percent of total billed charges,75% of total billed charges for outpatient setting,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,80,,10.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,100% of Custom Fee Schedule,15.39,90,,12.31,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,15.39,
BLOOD SUGAR DIAG (PRECISION) TST STRIP:,3300687,CDM,272,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BLOOD WARMER SET W/EXT / 24250,69161264,CDM,272,RC,,,Outpatient,,,71.68,71.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.18,70,,40.14,percent of total billed charges,70% of total billed charges for outpatient setting,60.84,84.88,,48.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.84,50,,28.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.76,75,,43.01,percent of total billed charges,75% of total billed charges for outpatient setting,50.18,70,,40.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.34,80,,45.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.59,65,,37.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.09,35,,20.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.51,90,,51.61,percent of total billed charges,90% of total billed charges for outpatient setting,9.2,64.51,
BNP  PRO B-TYPE NATRIURETIC PEPTIDE,222014,CDM,301,RC,83880,HCPCS,Outpatient,,,176.67,159,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.67,70,,98.94,percent of total billed charges,70% of total billed charges for outpatient setting,149.96,84.88,,119.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,132.5,75,,106,percent of total billed charges,75% of total billed charges for outpatient setting,123.67,70,,98.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.34,80,,113.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,49.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of Custom Fee Schedule,159,90,,127.2,percent of total billed charges,90% of total billed charges for outpatient setting,39.26,159,
BOBBIN 2.7 VENT TUBE (double) 520-002,69161638,CDM,278,RC,,,Outpatient,,,130.74,130.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.44,60,,62.75,percent of total billed charges,60% of total Billed charges for outpatient setting,110.97,84.88,,88.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.37,50,,52.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.06,75,,78.45,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,50,,52.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,12.84,,13.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.59,80,,83.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,12.84,,13.43,percent of total billed charges,12.84% of total billed charges,16.79,12.84,,13.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130.74,65,,104.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.76,35,,36.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.44,60,,62.75,percent of total billed charges,60% of total billed charges for outpatient setting,16.79,130.74,
BODY FLUID AMYLASE,200724,CDM,300,RC,82150,HCPCS,Outpatient,,,29.16,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,24.75,84.88,,19.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.87,75,,17.5,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,80,,18.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of Custom Fee Schedule,26.24,90,,20.99,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,26.24,
BODY FLUID GLUCOSE,200722,CDM,300,RC,82945,HCPCS,Outpatient,,,17.69,15.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,84.88,,12.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.27,75,,10.62,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,80,,11.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of Custom Fee Schedule,15.92,90,,12.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,15.92,
BODY FLUID LDH,200723,CDM,300,RC,83615,HCPCS,Outpatient,,,27.18,24.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,70,,15.22,percent of total billed charges,70% of total billed charges for outpatient setting,23.07,84.88,,18.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.39,75,,16.31,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,70,,15.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.74,80,,17.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.44,100,,,Fee Schedule,100% of Custom Fee Schedule,24.46,90,,19.57,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,24.46,
BODY FLUID PROTEIN,200721,CDM,300,RC,84155,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
BOLT 24X75MM PRX RECLAIM / 1975-24-075,71000532,CDM,278,RC,C1713,HCPCS,Outpatient,,,10340.64,10340.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.38,60,,4963.5,percent of total billed charges,60% of total Billed charges for outpatient setting,8777.14,84.88,,7021.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7755.48,75,,6204.38,percent of total billed charges,75% of total billed charges for outpatient setting,5170.32,50,,4136.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1327.74,12.84,,1062.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8272.51,80,,6618.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1327.74,12.84,,1062.19,percent of total billed charges,12.84% of total billed charges,1327.74,12.84,,1062.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10857.67,105,,8686.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3619.22,35,,2895.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6204.38,60,,4963.5,percent of total billed charges,60% of total billed charges for outpatient setting,1327.74,10857.67,
BOLT APEX PIN 3 / 4933-1-022,70000774,CDM,278,RC,C1713,HCPCS,Outpatient,,,919.28,919.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.57,60,,441.26,percent of total billed charges,60% of total Billed charges for outpatient setting,780.28,84.88,,624.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,689.46,75,,551.57,percent of total billed charges,75% of total billed charges for outpatient setting,459.64,50,,367.71,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.04,12.84,,94.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.42,80,,588.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.04,12.84,,94.43,percent of total billed charges,12.84% of total billed charges,118.04,12.84,,94.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,919.28,65,,735.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.75,35,,257.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,551.57,60,,441.26,percent of total billed charges,60% of total billed charges for outpatient setting,118.04,919.28,
BOLT EXTRACTION / 309.039,415384,CDM,272,RC,,,Outpatient,,,507,507,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.9,70,,283.92,percent of total billed charges,70% of total billed charges for outpatient setting,430.34,84.88,,344.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,253.5,50,,202.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.25,75,,304.2,percent of total billed charges,75% of total billed charges for outpatient setting,354.9,70,,283.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.1,12.84,,52.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.6,80,,324.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.1,12.84,,52.08,percent of total billed charges,12.84% of total billed charges,65.1,12.84,,52.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,329.55,65,,263.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.45,35,,141.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,456.3,90,,365.04,percent of total billed charges,90% of total billed charges for outpatient setting,65.1,456.3,
BOLT TEMPORARY TENSION / A-2791.05,69169713,CDM,272,RC,,,Outpatient,,,797.16,797.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.01,70,,446.41,percent of total billed charges,70% of total billed charges for outpatient setting,676.63,84.88,,541.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,398.58,50,,318.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,597.87,75,,478.3,percent of total billed charges,75% of total billed charges for outpatient setting,558.01,70,,446.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.36,12.84,,81.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.73,80,,510.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.36,12.84,,81.89,percent of total billed charges,12.84% of total billed charges,102.36,12.84,,81.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,518.15,65,,414.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.01,35,,223.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,717.44,90,,573.95,percent of total billed charges,90% of total billed charges for outpatient setting,102.36,717.44,
BONE 5CC DEMINERALIZED FIBERS BL-1800-05,69169653,CDM,278,RC,C1713,HCPCS,Outpatient,,,2652,2652,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.2,60,,1272.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2251.02,84.88,,1800.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1989,75,,1591.2,percent of total billed charges,75% of total billed charges for outpatient setting,1326,50,,1060.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.52,12.84,,272.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2121.6,80,,1697.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.52,12.84,,272.42,percent of total billed charges,12.84% of total billed charges,340.52,12.84,,272.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2784.6,105,,2227.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,928.2,35,,742.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1591.2,60,,1272.96,percent of total billed charges,60% of total billed charges for outpatient setting,340.52,2784.6,
BONE AGE STUDIES,2400890,CDM,320,RC,77072,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
BONE AND/OR JOINT IMAGING MULTIPLE AREAS,3000385,CDM,341,RC,78305,HCPCS,Outpatient,,,1120.35,840.26,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,950.95,84.88,,760.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,840.26,75,,672.21,percent of total billed charges,75% of total billed charges for outpatient setting,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,896.28,80,,717.02,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.35,100,,,Fee Schedule,100% of Custom Fee Schedule,1008.32,90,,806.66,percent of total billed charges,90% of total billed charges for outpatient setting,143.85,1008.32,
BONE CANC CRUSHED 1-4MM 30CC /05A002LL,69162830,CDM,278,RC,C1713,HCPCS,Outpatient,,,1790.43,1790.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1074.26,60,,859.41,percent of total billed charges,60% of total Billed charges for outpatient setting,1519.72,84.88,,1215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1342.82,75,,1074.26,percent of total billed charges,75% of total billed charges for outpatient setting,895.22,50,,716.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.89,12.84,,183.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1432.34,80,,1145.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.89,12.84,,183.91,percent of total billed charges,12.84% of total billed charges,229.89,12.84,,183.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1790.43,65,,1432.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.65,35,,501.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1074.26,60,,859.41,percent of total billed charges,60% of total billed charges for outpatient setting,229.89,1790.43,
BONE CANCELLOUS CUBES 10CC  /0580,69162225,CDM,278,RC,,,Outpatient,,,856.55,856.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.93,60,,411.14,percent of total billed charges,60% of total Billed charges for outpatient setting,727.04,84.88,,581.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,428.28,50,,342.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,642.41,75,,513.93,percent of total billed charges,75% of total billed charges for outpatient setting,428.28,50,,342.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.98,12.84,,87.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.24,80,,548.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.98,12.84,,87.98,percent of total billed charges,12.84% of total billed charges,109.98,12.84,,87.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,856.55,65,,685.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.79,35,,239.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,513.93,60,,411.14,percent of total billed charges,60% of total billed charges for outpatient setting,109.98,856.55,
BONE CEMENT GENT SMARTSET/ 5150-35-500,69169645,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.6,663.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.16,60,,318.53,percent of total billed charges,60% of total Billed charges for outpatient setting,563.26,84.88,,450.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.7,75,,398.16,percent of total billed charges,75% of total billed charges for outpatient setting,331.8,50,,265.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.21,12.84,,68.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.88,80,,424.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.21,12.84,,68.17,percent of total billed charges,12.84% of total billed charges,85.21,12.84,,68.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.6,65,,530.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.26,35,,185.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.16,60,,318.53,percent of total billed charges,60% of total billed charges for outpatient setting,85.21,663.6,
BONE CEMENT REFOBACIN/ 110034355,69169367,CDM,278,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
BONE CEMENT VERSABOND AB 40G / 71271440,69162098,CDM,278,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
BONE CEMENT W/GEN PALACOS/00-1113-140-1,69162912,CDM,278,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
BONE CEMENT W/GENTAMYCIN,69161902,CDM,278,RC,C1713,HCPCS,Outpatient,,,817.61,817.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.57,60,,392.46,percent of total billed charges,60% of total Billed charges for outpatient setting,693.99,84.88,,555.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.21,75,,490.57,percent of total billed charges,75% of total billed charges for outpatient setting,408.81,50,,327.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,12.84,,83.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.09,80,,523.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,12.84,,83.98,percent of total billed charges,12.84% of total billed charges,104.98,12.84,,83.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,817.61,65,,654.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.16,35,,228.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,490.57,60,,392.46,percent of total billed charges,60% of total billed charges for outpatient setting,104.98,817.61,
BONE CEMENT W/GENTAMYCIN / 402283,69161603,CDM,278,RC,C1713,HCPCS,Outpatient,,,2062.47,2062.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1237.48,60,,989.98,percent of total billed charges,60% of total Billed charges for outpatient setting,1750.62,84.88,,1400.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1546.85,75,,1237.48,percent of total billed charges,75% of total billed charges for outpatient setting,1031.24,50,,824.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.82,12.84,,211.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1649.98,80,,1319.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.82,12.84,,211.86,percent of total billed charges,12.84% of total billed charges,264.82,12.84,,211.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2062.47,65,,1649.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.86,35,,577.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1237.48,60,,989.98,percent of total billed charges,60% of total billed charges for outpatient setting,264.82,2062.47,
BONE CEMENT W/GENTAMYCIN 40G,70000005,CDM,278,RC,C1716,HCPCS,Outpatient,,,843.57,843.57,,986.57,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,616.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,1048.23,170,,,Fee Schedule,170% of Medicare OPPS rate,1325.71,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,1079.06,175,,,Fee Schedule,175% of Medicare OPPS rate,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,863.25,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,770.76,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,616.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.09,100,,,Fee Schedule,100% of Custom Fee Schedule,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,55.09,1325.71,
BONE CEMENT W/GENTAMYCIN DEPUY 40G,69161981,CDM,278,RC,C1713,HCPCS,Outpatient,,,1059.87,1059.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.92,60,,508.74,percent of total billed charges,60% of total Billed charges for outpatient setting,899.62,84.88,,719.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.9,75,,635.92,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,50,,423.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.09,12.84,,108.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.9,80,,678.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.09,12.84,,108.87,percent of total billed charges,12.84% of total billed charges,136.09,12.84,,108.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1059.87,65,,847.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.95,35,,296.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,635.92,60,,508.74,percent of total billed charges,60% of total billed charges for outpatient setting,136.09,1059.87,
"BONE CEMENT, VERSABOND 40G/71271340",69159881,CDM,278,RC,C1713,HCPCS,Outpatient,,,658.3,658.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.98,60,,315.98,percent of total billed charges,60% of total Billed charges for outpatient setting,558.77,84.88,,447.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.73,75,,394.98,percent of total billed charges,75% of total billed charges for outpatient setting,329.15,50,,263.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.53,12.84,,67.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.64,80,,421.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.53,12.84,,67.62,percent of total billed charges,12.84% of total billed charges,84.53,12.84,,67.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,658.3,65,,526.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.41,35,,184.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,394.98,60,,315.98,percent of total billed charges,60% of total billed charges for outpatient setting,84.53,658.3,
BONE CUTTER 5MM / AR-8500BC,69162926,CDM,272,RC,,,Outpatient,,,255.23,255.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.66,70,,142.93,percent of total billed charges,70% of total billed charges for outpatient setting,216.64,84.88,,173.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.62,50,,102.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.42,75,,153.14,percent of total billed charges,75% of total billed charges for outpatient setting,178.66,70,,142.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,12.84,,26.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.18,80,,163.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,12.84,,26.22,percent of total billed charges,12.84% of total billed charges,32.77,12.84,,26.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.9,65,,132.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.33,35,,71.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,229.71,90,,183.77,percent of total billed charges,90% of total billed charges for outpatient setting,32.77,229.71,
BONE DENSITY APPENDICULAR,2400892,CDM,320,RC,77081,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,60.92,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
BONE DENSITY AXIAL SKELETON,2400891,CDM,320,RC,77080,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.25,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
BONE DENSITY DELTA RESEARCH AXIAL SKELE,2400893,CDM,320,RC,77080,HCPCS,Outpatient,,,337,252.75,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,235.9,70,,188.72,percent of total billed charges,70% of total billed charges for outpatient setting,286.05,84.88,,228.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,252.75,75,,202.2,percent of total billed charges,75% of total billed charges for outpatient setting,235.9,70,,188.72,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,43.27,12.84,,34.616,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,269.6,80,,215.68,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,43.27,12.84,,34.62,percent of total billed charges,12.84% of total billed charges,43.27,12.84,,34.62,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.25,100,,,Fee Schedule,100% of Custom Fee Schedule,303.3,90,,242.64,percent of total billed charges,90% of total billed charges for outpatient setting,43.27,303.3,
BONE FEM HCON LAT FS/A/ 32147001,69169817,CDM,278,RC,C1762,HCPCS,Outpatient,,,9000,9000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400,60,,4320,percent of total billed charges,60% of total Billed charges for outpatient setting,7639.2,84.88,,6111.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6750,75,,5400,percent of total billed charges,75% of total billed charges for outpatient setting,4500,50,,3600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7200,80,,5760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,1155.6,12.84,,924.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9450,105,,7560,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3150,35,,2520,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5400,60,,4320,percent of total billed charges,60% of total billed charges for outpatient setting,1155.6,9450,
BONE LENGTH STUDIES,2400895,CDM,320,RC,77073,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
BONE MARROW ASPIRATE,200345,CDM,360,RC,,,Outpatient,,,578.71,578.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.1,70,,324.08,percent of total billed charges,70% of total billed charges for outpatient setting,491.21,84.88,,392.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,289.36,50,,231.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.03,75,,347.22,percent of total billed charges,75% of total billed charges for outpatient setting,405.1,70,,324.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.31,12.84,,59.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.97,80,,370.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.31,12.84,,59.45,percent of total billed charges,12.84% of total billed charges,74.31,12.84,,59.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.55,35,,162.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,520.84,90,,416.67,percent of total billed charges,90% of total billed charges for outpatient setting,74.31,520.84,
BONE MARROW BIOPSY NEELE/TRO,200350,CDM,360,RC,,,Outpatient,,,578.71,578.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.1,70,,324.08,percent of total billed charges,70% of total billed charges for outpatient setting,491.21,84.88,,392.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,289.36,50,,231.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.03,75,,347.22,percent of total billed charges,75% of total billed charges for outpatient setting,405.1,70,,324.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.31,12.84,,59.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.97,80,,370.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.31,12.84,,59.45,percent of total billed charges,12.84% of total billed charges,74.31,12.84,,59.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.55,35,,162.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,520.84,90,,416.67,percent of total billed charges,90% of total billed charges for outpatient setting,74.31,520.84,
BONE MATRIX VIVIGEN 1CC / BL-1600-001,69169130,CDM,278,RC,C1763,HCPCS,Outpatient,,,2036.46,2036.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1221.88,60,,977.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1728.55,84.88,,1382.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1527.35,75,,1221.88,percent of total billed charges,75% of total billed charges for outpatient setting,1018.23,50,,814.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.48,12.84,,209.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.17,80,,1303.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.48,12.84,,209.18,percent of total billed charges,12.84% of total billed charges,261.48,12.84,,209.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2036.46,65,,1629.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.76,35,,570.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1221.88,60,,977.5,percent of total billed charges,60% of total billed charges for outpatient setting,261.48,2036.46,
BONE MATRIX VIVIGEN 5CC / BL-1500-002,69162520,CDM,278,RC,C1763,HCPCS,Outpatient,,,3825,3825,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2295,60,,1836,percent of total billed charges,60% of total Billed charges for outpatient setting,3246.66,84.88,,2597.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2868.75,75,,2295,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,50,,1530,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.13,12.84,,392.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3060,80,,2448,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.13,12.84,,392.9,percent of total billed charges,12.84% of total billed charges,491.13,12.84,,392.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4016.25,105,,3213,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,35,,1071,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2295,60,,1836,percent of total billed charges,60% of total billed charges for outpatient setting,491.13,4016.25,
BONE MILL BOWL ASSY / BM210,69161820,CDM,272,RC,,,Outpatient,,,807.84,807.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.49,70,,452.39,percent of total billed charges,70% of total billed charges for outpatient setting,685.69,84.88,,548.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,403.92,50,,323.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605.88,75,,484.7,percent of total billed charges,75% of total billed charges for outpatient setting,565.49,70,,452.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.73,12.84,,82.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.27,80,,517.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.73,12.84,,82.98,percent of total billed charges,12.84% of total billed charges,103.73,12.84,,82.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,525.1,65,,420.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.74,35,,226.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,727.06,90,,581.65,percent of total billed charges,90% of total billed charges for outpatient setting,103.73,727.06,
BONE MODEL PT SPECIFIC /00-5970-0000-10,69169405,CDM,272,RC,,,Outpatient,,,1969.8,1969.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1378.86,70,,1103.09,percent of total billed charges,70% of total billed charges for outpatient setting,1671.97,84.88,,1337.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,984.9,50,,787.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1477.35,75,,1181.88,percent of total billed charges,75% of total billed charges for outpatient setting,1378.86,70,,1103.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.92,12.84,,202.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575.84,80,,1260.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.92,12.84,,202.34,percent of total billed charges,12.84% of total billed charges,252.92,12.84,,202.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1280.37,65,,1024.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,689.43,35,,551.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1772.82,90,,1418.26,percent of total billed charges,90% of total billed charges for outpatient setting,252.92,1772.82,
BONE PLIAFX 1.0CC / BL-1800-01,69169546,CDM,278,RC,C9359,HCPCS,Outpatient,,,1360.8,1360.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,816.48,60,,653.18,percent of total billed charges,60% of total Billed charges for outpatient setting,1155.05,84.88,,924.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1020.6,75,,816.48,percent of total billed charges,75% of total billed charges for outpatient setting,680.4,50,,544.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.73,12.84,,139.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1088.64,80,,870.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.73,12.84,,139.78,percent of total billed charges,12.84% of total billed charges,174.73,12.84,,139.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1360.8,65,,1088.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.28,35,,381.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,816.48,60,,653.18,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,1360.8,
BONE PRESS W/TUBING TOBRA / BB-100,69162517,CDM,272,RC,,,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,845,65,,676,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1170,90,,936,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1170,
BONE PUTTY  DBX10CC / 038100,69162645,CDM,278,RC,C9359,HCPCS,Outpatient,,,2281.44,2281.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.86,60,,1095.09,percent of total billed charges,60% of total Billed charges for outpatient setting,1936.49,84.88,,1549.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1711.08,75,,1368.86,percent of total billed charges,75% of total billed charges for outpatient setting,1140.72,50,,912.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.94,12.84,,234.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1825.15,80,,1460.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.94,12.84,,234.35,percent of total billed charges,12.84% of total billed charges,292.94,12.84,,234.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2395.51,105,,1916.41,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.5,35,,638.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1368.86,60,,1095.09,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2395.51,
BONE PUTTY 5CC DBX  ALLOSYNC/ AR-2012-05,69169679,CDM,278,RC,C9359,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,3087,
BONE PUTTY 5CC DBX / 038050,6153018,CDM,278,RC,C9359,HCPCS,Outpatient,,,2080.93,2080.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248.56,60,,998.85,percent of total billed charges,60% of total Billed charges for outpatient setting,1766.29,84.88,,1413.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1560.7,75,,1248.56,percent of total billed charges,75% of total billed charges for outpatient setting,1040.47,50,,832.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.19,12.84,,213.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1664.74,80,,1331.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.19,12.84,,213.75,percent of total billed charges,12.84% of total billed charges,267.19,12.84,,213.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2080.93,65,,1664.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.33,35,,582.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1248.56,60,,998.85,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2080.93,
BONE PUTTY DBX 1CC / 038010,69161767,CDM,278,RC,C9359,HCPCS,Outpatient,,,576.92,576.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.15,60,,276.92,percent of total billed charges,60% of total Billed charges for outpatient setting,489.69,84.88,,391.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,432.69,75,,346.15,percent of total billed charges,75% of total billed charges for outpatient setting,288.46,50,,230.77,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.08,12.84,,59.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.54,80,,369.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.08,12.84,,59.26,percent of total billed charges,12.84% of total billed charges,74.08,12.84,,59.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,576.92,65,,461.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.92,35,,161.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,346.15,60,,276.92,percent of total billed charges,60% of total billed charges for outpatient setting,74.08,576.92,
BONE PUTTY DBX 2.5CC / 038025,69162414,CDM,278,RC,C9359,HCPCS,Outpatient,,,1265.44,1265.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.26,60,,607.41,percent of total billed charges,60% of total Billed charges for outpatient setting,1074.11,84.88,,859.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,949.08,75,,759.26,percent of total billed charges,75% of total billed charges for outpatient setting,632.72,50,,506.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.48,12.84,,129.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.35,80,,809.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.48,12.84,,129.98,percent of total billed charges,12.84% of total billed charges,162.48,12.84,,129.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1265.44,65,,1012.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.9,35,,354.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.26,60,,607.41,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,1265.44,
BONE SURVEY COMPLETE,2400905,CDM,320,RC,77075,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
BONE SURVEY LTD,2400900,CDM,320,RC,77074,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
BONE TRINITY ELITE MEDIUM / 410002,69162784,CDM,278,RC,C1762,HCPCS,Outpatient,,,4040,4040,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2424,60,,1939.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3429.15,84.88,,2743.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3030,75,,2424,percent of total billed charges,75% of total billed charges for outpatient setting,2020,50,,1616,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.74,12.84,,414.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3232,80,,2585.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.74,12.84,,414.99,percent of total billed charges,12.84% of total billed charges,518.74,12.84,,414.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4242,105,,3393.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1414,35,,1131.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2424,60,,1939.2,percent of total billed charges,60% of total billed charges for outpatient setting,518.74,4242,
BONE TRINITY ELITE SMALL / 410001,70000467,CDM,278,RC,C1762,HCPCS,Outpatient,,,1911,1911,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1146.6,60,,917.28,percent of total billed charges,60% of total Billed charges for outpatient setting,1622.06,84.88,,1297.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1433.25,75,,1146.6,percent of total billed charges,75% of total billed charges for outpatient setting,955.5,50,,764.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.37,12.84,,196.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1528.8,80,,1223.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.37,12.84,,196.3,percent of total billed charges,12.84% of total billed charges,245.37,12.84,,196.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1911,65,,1528.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.85,35,,535.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1146.6,60,,917.28,percent of total billed charges,60% of total billed charges for outpatient setting,245.37,1911,
BONE VIVIGEN FORMABLE 5CC / BL-1600-002,69162940,CDM,278,RC,C1763,HCPCS,Outpatient,,,4590,4590,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2754,60,,2203.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3895.99,84.88,,3116.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3442.5,75,,2754,percent of total billed charges,75% of total billed charges for outpatient setting,2295,50,,1836,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.36,12.84,,471.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3672,80,,2937.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.36,12.84,,471.49,percent of total billed charges,12.84% of total billed charges,589.36,12.84,,471.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4819.5,105,,3855.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1606.5,35,,1285.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2754,60,,2203.2,percent of total billed charges,60% of total billed charges for outpatient setting,589.36,4819.5,
BONE VOID FILLER 5ML / 800-4000,69162866,CDM,278,RC,C9359,HCPCS,Outpatient,,,2970,2970,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782,60,,1425.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2520.94,84.88,,2016.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2227.5,75,,1782,percent of total billed charges,75% of total billed charges for outpatient setting,1485,50,,1188,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.35,12.84,,305.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2376,80,,1900.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.35,12.84,,305.08,percent of total billed charges,12.84% of total billed charges,381.35,12.84,,305.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3118.5,105,,2494.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1039.5,35,,831.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1782,60,,1425.6,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,3118.5,
BONE WAX 2.5G / W31G,6150274,CDM,272,RC,,,Outpatient,,,29.92,29.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.94,70,,16.75,percent of total billed charges,70% of total billed charges for outpatient setting,25.4,84.88,,20.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.96,50,,11.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.44,75,,17.95,percent of total billed charges,75% of total billed charges for outpatient setting,20.94,70,,16.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.94,80,,19.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.45,65,,15.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,35,,8.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.93,90,,21.54,percent of total billed charges,90% of total billed charges for outpatient setting,3.84,26.93,
BOOST PLUS CHOCOLATE / 00043900651422,71000331,CDM,271,RC,,,Outpatient,,,11.43,11.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,84.88,,7.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.72,50,,4.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.43,65,,5.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,35,,3.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.29,90,,8.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.29,
BOOST PLUS VANILLA / 00043900811864,71000330,CDM,271,RC,,,Outpatient,,,11.43,11.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,84.88,,7.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.72,50,,4.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.43,65,,5.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,35,,3.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.29,90,,8.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.29,
BORDETELLA PERTUSSIS BY PCR,201437,CDM,302,RC,87798,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
BORDETELLA PERTUSSIS DFA,201430,CDM,302,RC,87265,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
"BORDETELLA PERTUSSIS, IGG",220605,CDM,302,RC,86615,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"BORDETELLA PERTUSSIS, IGM",220606,CDM,302,RC,86615,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
BORRELIA BURDORFERI AMP PROBE LYME DISEA,200561,CDM,306,RC,87476,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
BOTTLE 1000ML SALINE BRAUN / R5200-01,213667,CDM,272,RC,,,Outpatient,,,32.16,32.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.51,70,,18.01,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,84.88,,21.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.08,50,,12.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.12,75,,19.3,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,70,,18.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,80,,20.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.9,65,,16.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,35,,9.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.94,90,,23.15,percent of total billed charges,90% of total billed charges for outpatient setting,4.13,28.94,
BOTTLE 1000ML STERILE WATER / R5000-01,6152602,CDM,272,RC,,,Outpatient,,,15.93,15.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,84.88,,10.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.97,50,,6.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.95,75,,9.56,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,80,,10.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.35,65,,8.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.34,90,,11.47,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.34,
BOTTLE 250ML SALINE MEDLINE / PCS1650,304147,CDM,271,RC,,,Outpatient,,,11.52,11.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,9.78,84.88,,7.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.76,50,,4.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.64,75,,6.91,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,80,,7.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.49,65,,5.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,35,,3.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.37,90,,8.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.48,10.37,
BOTTLE 250ML WATER MEDLINE / PCS1550,304145,CDM,271,RC,,,Outpatient,,,11.52,11.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,9.78,84.88,,7.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.76,50,,4.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.64,75,,6.91,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,80,,7.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.49,65,,5.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,35,,3.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.37,90,,8.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.48,10.37,
BOTTLE 34OZ VASHE WOUND / 00323,1953384,CDM,272,RC,,,Outpatient,,,259,259,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.3,70,,145.04,percent of total billed charges,70% of total billed charges for outpatient setting,219.84,84.88,,175.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.5,50,,103.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.25,75,,155.4,percent of total billed charges,75% of total billed charges for outpatient setting,181.3,70,,145.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,12.84,,26.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.2,80,,165.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,12.84,,26.61,percent of total billed charges,12.84% of total billed charges,33.26,12.84,,26.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.35,65,,134.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.65,35,,72.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.1,90,,186.48,percent of total billed charges,90% of total billed charges for outpatient setting,33.26,233.1,
BOTULINUM TOXIN TYPE A 100 UNITS,3302794,CDM,636,RC,J0585,HCPCS,Outpatient,,,2219,2219,,9.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1553.3,70,,1242.64,percent of total billed charges,70% of total billed charges for outpatient setting,1883.49,84.88,,1506.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1664.25,75,,1331.4,percent of total billed charges,75% of total billed charges for outpatient setting,1553.3,70,,1242.64,percent of total billed charges,70% of total billed charges for outpatient setting,10.59,170,,,Fee Schedule,170% of Medicare OPPS rate,13.39,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.92,12.84,,227.936,percent of total billed charges,12.84% of total billed charges,10.9,175,,,Fee Schedule,175% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1775.2,80,,1420.16,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,7.78,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.92,12.84,,227.94,percent of total billed charges,12.84% of total billed charges,284.92,12.84,,227.94,percent of total billed charges,12.84% of total billed charges,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1442.35,65,,1153.88,percent of total billed charges,65% of total billed charges for outpatient setting,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.47,100,,,Fee Schedule,100% of Custom Fee Schedule,1997.1,90,,1597.68,percent of total billed charges,90% of total billed charges for outpatient setting,6.23,1997.1,
BOUGIE 15FR 70CM CRV ESCHMANN / TTI-C10,69169163,CDM,272,RC,,,Outpatient,,,45.5,45.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,70,,25.48,percent of total billed charges,70% of total billed charges for outpatient setting,38.62,84.88,,30.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,50,,18.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.13,75,,27.3,percent of total billed charges,75% of total billed charges for outpatient setting,31.85,70,,25.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.4,80,,29.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.58,65,,23.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,35,,12.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,90% of total billed charges for outpatient setting,5.84,40.95,
BOVIE BAYONETTE TIP / 0029M,69169561,CDM,272,RC,,,Outpatient,,,149.65,149.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.76,70,,83.81,percent of total billed charges,70% of total billed charges for outpatient setting,127.02,84.88,,101.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.83,50,,59.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.24,75,,89.79,percent of total billed charges,75% of total billed charges for outpatient setting,104.76,70,,83.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,12.84,,15.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.72,80,,95.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,12.84,,15.38,percent of total billed charges,12.84% of total billed charges,19.22,12.84,,15.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.27,65,,77.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.38,35,,41.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.69,90,,107.75,percent of total billed charges,90% of total billed charges for outpatient setting,19.22,134.69,
BOVIE BLADE 2.75IN / 0012AM,69161085,CDM,272,RC,,,Outpatient,,,27.16,27.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,70,,15.21,percent of total billed charges,70% of total billed charges for outpatient setting,23.05,84.88,,18.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.58,50,,10.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.37,75,,16.3,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,70,,15.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,80,,17.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.65,65,,14.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.51,35,,7.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.44,90,,19.55,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,24.44,
BOVIE BLADE EXT 4IN E-Z CLEAN / 0014AM,69161842,CDM,272,RC,,,Outpatient,,,39.68,39.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,33.68,84.88,,26.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.84,50,,15.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.76,75,,23.81,percent of total billed charges,75% of total billed charges for outpatient setting,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,12.84,,4.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.74,80,,25.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,12.84,,4.07,percent of total billed charges,12.84% of total billed charges,5.09,12.84,,4.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.79,65,,20.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.89,35,,11.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.71,90,,28.57,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,35.71,
BOVIE NEEDLE TIP INSULATED PTFE / E1465,69161843,CDM,272,RC,,,Outpatient,,,36.8,36.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.76,70,,20.61,percent of total billed charges,70% of total billed charges for outpatient setting,31.24,84.88,,24.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.4,50,,14.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.6,75,,22.08,percent of total billed charges,75% of total billed charges for outpatient setting,25.76,70,,20.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.44,80,,23.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.92,65,,19.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,35,,10.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.12,90,,26.5,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,33.12,
BRACE UNIV T SCOPE HINGED / 08814,69162467,CDM,270,RC,,,Outpatient,,,266.04,266.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.23,70,,148.98,percent of total billed charges,70% of total billed charges for outpatient setting,225.81,84.88,,180.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.02,50,,106.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.53,75,,159.62,percent of total billed charges,75% of total billed charges for outpatient setting,186.23,70,,148.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,12.84,,27.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.83,80,,170.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,12.84,,27.33,percent of total billed charges,12.84% of total billed charges,34.16,12.84,,27.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,172.93,65,,138.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.11,35,,74.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,239.44,90,,191.55,percent of total billed charges,90% of total billed charges for outpatient setting,34.16,239.44,
BREAST IMPL  605CC GEL / SCF605,69169175,CDM,278,RC,C1789,HCPCS,Outpatient,,,2190,2190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314,60,,1051.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1858.87,84.88,,1487.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1642.5,75,,1314,percent of total billed charges,75% of total billed charges for outpatient setting,1095,50,,876,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752,80,,1401.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2299.5,105,,1839.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.5,35,,613.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1314,60,,1051.2,percent of total billed charges,60% of total billed charges for outpatient setting,281.2,2299.5,
BREAST IMPL 400CC NITRAL / SRLP-400,69162585,CDM,278,RC,C1789,HCPCS,Outpatient,,,3141.76,3141.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1885.06,60,,1508.05,percent of total billed charges,60% of total Billed charges for outpatient setting,2666.73,84.88,,2133.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2356.32,75,,1885.06,percent of total billed charges,75% of total billed charges for outpatient setting,1570.88,50,,1256.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2513.41,80,,2010.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3298.85,105,,2639.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1099.62,35,,879.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1885.06,60,,1508.05,percent of total billed charges,60% of total billed charges for outpatient setting,403.4,3298.85,
BREAST IMPL 410CC SILICONE / 10712-410MP,7240372,CDM,278,RC,C1789,HCPCS,Outpatient,,,3062.5,3062.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1837.5,60,,1470,percent of total billed charges,60% of total Billed charges for outpatient setting,2599.45,84.88,,2079.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2296.88,75,,1837.5,percent of total billed charges,75% of total billed charges for outpatient setting,1531.25,50,,1225,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.23,12.84,,314.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,80,,1960,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.23,12.84,,314.58,percent of total billed charges,12.84% of total billed charges,393.23,12.84,,314.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3215.63,105,,2572.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071.88,35,,857.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1837.5,60,,1470,percent of total billed charges,60% of total billed charges for outpatient setting,393.23,3215.63,
BREAST IMPL 415CC SILICONE / SRF415,69162825,CDM,278,RC,C1789,HCPCS,Outpatient,,,3577.07,3577.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2146.24,60,,1716.99,percent of total billed charges,60% of total Billed charges for outpatient setting,3036.22,84.88,,2428.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2682.8,75,,2146.24,percent of total billed charges,75% of total billed charges for outpatient setting,1788.54,50,,1430.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.3,12.84,,367.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2861.66,80,,2289.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.3,12.84,,367.44,percent of total billed charges,12.84% of total billed charges,459.3,12.84,,367.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3755.92,105,,3004.74,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1251.97,35,,1001.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2146.24,60,,1716.99,percent of total billed charges,60% of total billed charges for outpatient setting,459.3,3755.92,
BREAST IMPL 435CC SILICONE / 10721-435MP,69169353,CDM,278,RC,C1789,HCPCS,Outpatient,,,2190,2190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314,60,,1051.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1858.87,84.88,,1487.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1642.5,75,,1314,percent of total billed charges,75% of total billed charges for outpatient setting,1095,50,,876,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752,80,,1401.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2299.5,105,,1839.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.5,35,,613.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1314,60,,1051.2,percent of total billed charges,60% of total billed charges for outpatient setting,281.2,2299.5,
BREAST IMPL 620CC SILICONE / 10721-620HP,7168785,CDM,278,RC,C1789,HCPCS,Outpatient,,,3062.5,3062.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1837.5,60,,1470,percent of total billed charges,60% of total Billed charges for outpatient setting,2599.45,84.88,,2079.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2296.88,75,,1837.5,percent of total billed charges,75% of total billed charges for outpatient setting,1531.25,50,,1225,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.23,12.84,,314.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,80,,1960,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.23,12.84,,314.58,percent of total billed charges,12.84% of total billed charges,393.23,12.84,,314.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3215.63,105,,2572.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071.88,35,,857.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1837.5,60,,1470,percent of total billed charges,60% of total billed charges for outpatient setting,393.23,3215.63,
BREAST IMPLANT  330cc,69161423,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT  330cc Saline  68-330,69161453,CDM,278,RC,,,Outpatient,,,1292.17,1292.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.3,60,,620.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1096.79,84.88,,877.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,969.13,75,,775.3,percent of total billed charges,75% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1033.74,80,,826.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1292.17,65,,1033.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.26,35,,361.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,775.3,60,,620.24,percent of total billed charges,60% of total billed charges for outpatient setting,165.91,1292.17,
BREAST IMPLANT  360cc,69161424,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT  360cc Saline  68-360,69161454,CDM,278,RC,,,Outpatient,,,1292.17,1292.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.3,60,,620.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1096.79,84.88,,877.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,969.13,75,,775.3,percent of total billed charges,75% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1033.74,80,,826.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1292.17,65,,1033.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.26,35,,361.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,775.3,60,,620.24,percent of total billed charges,60% of total billed charges for outpatient setting,165.91,1292.17,
BREAST IMPLANT  390cc,69161425,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT  390cc Saline  68-390,69161455,CDM,278,RC,,,Outpatient,,,1292.17,1292.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.3,60,,620.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1096.79,84.88,,877.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,969.13,75,,775.3,percent of total billed charges,75% of total billed charges for outpatient setting,646.09,50,,516.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1033.74,80,,826.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,165.91,12.84,,132.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1292.17,65,,1033.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.26,35,,361.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,775.3,60,,620.24,percent of total billed charges,60% of total billed charges for outpatient setting,165.91,1292.17,
BREAST IMPLANT  GEL  240cc Style 10,69161471,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT  GEL  270cc Style 10,69161472,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT  GEL  300cc Style 10,69161473,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT 230CC SILICONE/ SRL-230,69162546,CDM,278,RC,,,Outpatient,,,3141.76,3141.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1885.06,60,,1508.05,percent of total billed charges,60% of total Billed charges for outpatient setting,2666.73,84.88,,2133.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1570.88,50,,1256.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2356.32,75,,1885.06,percent of total billed charges,75% of total billed charges for outpatient setting,1570.88,50,,1256.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2513.41,80,,2010.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,403.4,12.84,,322.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3298.85,105,,2639.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1099.62,35,,879.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1885.06,60,,1508.05,percent of total billed charges,60% of total billed charges for outpatient setting,403.4,3298.85,
BREAST IMPLANT 420cc,69161426,CDM,278,RC,,,Outpatient,,,3119.05,3119.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.43,60,,1497.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2647.45,84.88,,2117.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2339.29,75,,1871.43,percent of total billed charges,75% of total billed charges for outpatient setting,1559.53,50,,1247.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2495.24,80,,1996.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,400.49,12.84,,320.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3275,105,,2620,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.67,35,,873.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.43,60,,1497.14,percent of total billed charges,60% of total billed charges for outpatient setting,400.49,3275,
BREAST IMPLANT 750CC GEL / SCX750,69169176,CDM,278,RC,C1789,HCPCS,Outpatient,,,2190,2190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314,60,,1051.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1858.87,84.88,,1487.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1642.5,75,,1314,percent of total billed charges,75% of total billed charges for outpatient setting,1095,50,,876,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752,80,,1401.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,281.2,12.84,,224.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2299.5,105,,1839.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.5,35,,613.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1314,60,,1051.2,percent of total billed charges,60% of total billed charges for outpatient setting,281.2,2299.5,
BREAST IMPLANT GEL 450CC / 10-450,69162475,CDM,278,RC,,,Outpatient,,,3508.93,3508.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2105.36,60,,1684.29,percent of total billed charges,60% of total Billed charges for outpatient setting,2978.38,84.88,,2382.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1754.47,50,,1403.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2631.7,75,,2105.36,percent of total billed charges,75% of total billed charges for outpatient setting,1754.47,50,,1403.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.55,12.84,,360.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2807.14,80,,2245.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.55,12.84,,360.44,percent of total billed charges,12.84% of total billed charges,450.55,12.84,,360.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3684.38,105,,2947.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.13,35,,982.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2105.36,60,,1684.29,percent of total billed charges,60% of total billed charges for outpatient setting,450.55,3684.38,
BREAST IMPLANT SILICONE / FF-410,69162578,CDM,278,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,60,,1152,percent of total billed charges,60% of total Billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2520,105,,2016,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1440,60,,1152,percent of total billed charges,60% of total billed charges for outpatient setting,308.16,2520,
BREAST IMPLANT SILICONE / FX-410,69162577,CDM,278,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,60,,1152,percent of total billed charges,60% of total Billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2520,105,,2016,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1440,60,,1152,percent of total billed charges,60% of total billed charges for outpatient setting,308.16,2520,
BREAST IMPLT  GEL Hi Pro  475cc Style 20,69162014,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Hi Pro  600cc Style 20,69161822,CDM,278,RC,L8600,HCPCS,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2980.89,105,,2384.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total billed charges for outpatient setting,364.52,2980.89,
BREAST IMPLT  GEL Hi Pro  650cc Style 20,69161821,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Hi Pro  750cc Style 20,69162126,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod 210cc Style 10,69161825,CDM,278,RC,L8600,HCPCS,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod 304cc Style 15,69161938,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod 339cc Style 15,69161937,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod 397cc Style 15,69161936,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod Pls 457cc Style 15,69161824,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  GEL Mod Pls 533cc Style 15,69161823,CDM,278,RC,,,Outpatient,,,3212.62,3212.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.57,60,,1542.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2726.87,84.88,,2181.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2409.47,75,,1927.58,percent of total billed charges,75% of total billed charges for outpatient setting,1606.31,50,,1285.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.1,80,,2056.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,412.5,12.84,,330,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3373.25,105,,2698.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.42,35,,899.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1927.57,60,,1542.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.5,3373.25,
BREAST IMPLT  NATRELLE 615CC / SRX-615,69169591,CDM,278,RC,C1789,HCPCS,Outpatient,,,2921.63,2921.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.98,60,,1402.38,percent of total billed charges,60% of total Billed charges for outpatient setting,2479.88,84.88,,1983.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2191.22,75,,1752.98,percent of total billed charges,75% of total billed charges for outpatient setting,1460.82,50,,1168.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2337.3,80,,1869.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3067.71,105,,2454.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.57,35,,818.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.98,60,,1402.38,percent of total billed charges,60% of total billed charges for outpatient setting,375.14,3067.71,
BREAST IMPLT 560CC INSPIRA / SSM-560,2241436,CDM,278,RC,L8600,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
BREAST IMPLT 600CC INSPIRA / SSM-600,2220149,CDM,278,RC,L8600,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
BREAST IMPLT 640CC INSPIRA / SSM-640,2241437,CDM,278,RC,L8600,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
BREAST LOC/BIOPSY TRAY,2750001,CDM,270,RC,,,Outpatient,,,201.52,201.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.06,70,,112.85,percent of total billed charges,70% of total billed charges for outpatient setting,171.05,84.88,,136.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.76,50,,80.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.14,75,,120.91,percent of total billed charges,75% of total billed charges for outpatient setting,141.06,70,,112.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.22,80,,128.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130.99,65,,104.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.53,35,,56.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.37,90,,145.1,percent of total billed charges,90% of total billed charges for outpatient setting,25.88,181.37,
BREAST PROSTHESIS PROVIDED BY MD,4500000,CDM,278,RC,L8600,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,60,,0.01,percent of total billed charges,60% of total Billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,65,,0.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,60,,0.01,percent of total billed charges,60% of total billed charges for outpatient setting,0.01,0.01,
BREAST SIZER 65810,69161826,CDM,272,RC,,,Outpatient,,,250.64,250.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.45,70,,140.36,percent of total billed charges,70% of total billed charges for outpatient setting,212.74,84.88,,170.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.98,75,,150.38,percent of total billed charges,75% of total billed charges for outpatient setting,175.45,70,,140.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.51,80,,160.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.92,65,,130.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.72,35,,70.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,225.58,90,,180.46,percent of total billed charges,90% of total billed charges for outpatient setting,32.18,225.58,
BREAST SIZER 68300,69161827,CDM,272,RC,,,Outpatient,,,250.64,250.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.45,70,,140.36,percent of total billed charges,70% of total billed charges for outpatient setting,212.74,84.88,,170.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.98,75,,150.38,percent of total billed charges,75% of total billed charges for outpatient setting,175.45,70,,140.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.51,80,,160.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.92,65,,130.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.72,35,,70.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,225.58,90,,180.46,percent of total billed charges,90% of total billed charges for outpatient setting,32.18,225.58,
BREEZA / 220,70000013,CDM,270,RC,,,Outpatient,,,33.6,33.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,70,,18.82,percent of total billed charges,70% of total billed charges for outpatient setting,28.52,84.88,,22.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.8,50,,13.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,75,,20.16,percent of total billed charges,75% of total billed charges for outpatient setting,23.52,70,,18.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,80,,21.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.84,65,,17.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,35,,9.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.24,90,,24.19,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,30.24,
BRETYLIUM (BRETYLOL) INJ 50MG/ML 10ML,3300688,CDM,250,RC,,,Outpatient,,,67.9,67.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.53,70,,38.02,percent of total billed charges,70% of total billed charges for outpatient setting,57.63,84.88,,46.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.95,50,,27.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.93,75,,40.74,percent of total billed charges,75% of total billed charges for outpatient setting,47.53,70,,38.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,12.84,,6.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.32,80,,43.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,12.84,,6.98,percent of total billed charges,12.84% of total billed charges,8.72,12.84,,6.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.14,65,,35.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,35,,19.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,61.11,90,,48.89,percent of total billed charges,90% of total billed charges for outpatient setting,8.72,61.11,
BRIDGE FORCE MODULATING / BP100-6,71000630,CDM,272,RC,,,Outpatient,,,195.8,195.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.06,70,,109.65,percent of total billed charges,70% of total billed charges for outpatient setting,166.2,84.88,,132.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,97.9,50,,78.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.85,75,,117.48,percent of total billed charges,75% of total billed charges for outpatient setting,137.06,70,,109.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,12.84,,20.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.64,80,,125.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,12.84,,20.11,percent of total billed charges,12.84% of total billed charges,25.14,12.84,,20.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.27,65,,101.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.53,35,,54.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,176.22,90,,140.98,percent of total billed charges,90% of total billed charges for outpatient setting,25.14,176.22,
BRIMONIDINE (ALPHAGAN P) OPTH SOLN:5 ML,3300689,CDM,259,RC,,,Outpatient,,,171.16,171.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.81,70,,95.85,percent of total billed charges,70% of total billed charges for outpatient setting,145.28,84.88,,116.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.58,50,,68.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.37,75,,102.7,percent of total billed charges,75% of total billed charges for outpatient setting,119.81,70,,95.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,12.84,,17.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.93,80,,109.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,12.84,,17.58,percent of total billed charges,12.84% of total billed charges,21.98,12.84,,17.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,111.25,65,,89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.91,35,,47.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.04,90,,123.23,percent of total billed charges,90% of total billed charges for outpatient setting,21.98,154.04,
BRIMONIDINE (ALPHGN) OPTH SOL 0.2%:10ML,3300690,CDM,259,RC,,,Outpatient,,,179.27,179.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.49,70,,100.39,percent of total billed charges,70% of total billed charges for outpatient setting,152.16,84.88,,121.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.64,50,,71.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.45,75,,107.56,percent of total billed charges,75% of total billed charges for outpatient setting,125.49,70,,100.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.02,12.84,,18.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.42,80,,114.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.02,12.84,,18.42,percent of total billed charges,12.84% of total billed charges,23.02,12.84,,18.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,116.53,65,,93.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.74,35,,50.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,161.34,90,,129.07,percent of total billed charges,90% of total billed charges for outpatient setting,23.02,161.34,
BRIMONIDINE TART DR OPTH 0.2% 5ML,3310576,CDM,259,RC,,,Outpatient,,,41.93,41.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.35,70,,23.48,percent of total billed charges,70% of total billed charges for outpatient setting,35.59,84.88,,28.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.97,50,,16.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.45,75,,25.16,percent of total billed charges,75% of total billed charges for outpatient setting,29.35,70,,23.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,12.84,,4.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.54,80,,26.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,12.84,,4.3,percent of total billed charges,12.84% of total billed charges,5.38,12.84,,4.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.25,65,,21.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.68,35,,11.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.74,90,,30.19,percent of total billed charges,90% of total billed charges for outpatient setting,5.38,37.74,
BRINZOLAMIDE (AZOPT) OPTH SOL 1% : 5ML,3300691,CDM,259,RC,,,Outpatient,,,74.14,74.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,62.93,84.88,,50.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.07,50,,29.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.61,75,,44.49,percent of total billed charges,75% of total billed charges for outpatient setting,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.31,80,,47.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.19,65,,38.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,35,,20.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.73,90,,53.38,percent of total billed charges,90% of total billed charges for outpatient setting,9.52,66.73,
BROMANATE ELX : 120ML,3302184,CDM,259,RC,,,Outpatient,,,8.09,8.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,84.88,,5.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.05,50,,3.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.07,75,,4.86,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,80,,5.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.26,65,,4.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,35,,2.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.28,90,,5.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.28,
BROMOCRIPTINE (PARLODEL) TAB : 2.5 MG,3300692,CDM,259,RC,,,Outpatient,,,6.69,6.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,70,,3.74,percent of total billed charges,70% of total billed charges for outpatient setting,5.68,84.88,,4.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.35,50,,2.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.02,75,,4.02,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,70,,3.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,80,,4.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.35,65,,3.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,35,,1.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.02,90,,4.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,6.02,
BROMPHENIRAMINE/PSEUDOEPHED ELIX  120ML,3301905,CDM,259,RC,,,Outpatient,,,15.27,15.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,70,,8.55,percent of total billed charges,70% of total billed charges for outpatient setting,12.96,84.88,,10.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.64,50,,6.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.45,75,,9.16,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,70,,8.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.84,,1.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,80,,9.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.84,,1.57,percent of total billed charges,12.84% of total billed charges,1.96,12.84,,1.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.93,65,,7.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.34,35,,4.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.74,90,,10.99,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,13.74,
BRONCH KITS1 PACK,3302719,CDM,250,RC,,,Outpatient,,,312.47,312.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.73,70,,174.98,percent of total billed charges,70% of total billed charges for outpatient setting,265.22,84.88,,212.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.24,50,,124.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.35,75,,187.48,percent of total billed charges,75% of total billed charges for outpatient setting,218.73,70,,174.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.12,12.84,,32.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.98,80,,199.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.12,12.84,,32.1,percent of total billed charges,12.84% of total billed charges,40.12,12.84,,32.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.11,65,,162.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.36,35,,87.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.22,90,,224.98,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,281.22,
BROVIAC 6.6FR SINGLE LUMEN / 0600544,69169324,CDM,272,RC,C1894,HCPCS,Outpatient,,,2053.8,2053.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437.66,70,,1150.13,percent of total billed charges,70% of total billed charges for outpatient setting,1743.27,84.88,,1394.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.35,75,,1232.28,percent of total billed charges,75% of total billed charges for outpatient setting,1437.66,70,,1150.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.71,12.84,,210.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.04,80,,1314.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.71,12.84,,210.97,percent of total billed charges,12.84% of total billed charges,263.71,12.84,,210.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1334.97,65,,1067.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.83,35,,575.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1848.42,90,,1478.74,percent of total billed charges,90% of total billed charges for outpatient setting,263.71,1848.42,
BRUCELLA AB TOTAL,201442,CDM,302,RC,86622,HCPCS,Outpatient,,,40.19,36.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,70,,22.5,percent of total billed charges,70% of total billed charges for outpatient setting,34.11,84.88,,27.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.14,75,,24.11,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,70,,22.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.15,80,,25.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,100,,,Fee Schedule,100% of Custom Fee Schedule,36.17,90,,28.94,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,36.17,
BRUSH BRONCH CYTOLOGY,6050133,CDM,272,RC,,,Outpatient,,,86.52,86.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.56,70,,48.45,percent of total billed charges,70% of total billed charges for outpatient setting,73.44,84.88,,58.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.26,50,,34.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.89,75,,51.91,percent of total billed charges,75% of total billed charges for outpatient setting,60.56,70,,48.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.11,12.84,,8.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.22,80,,55.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.11,12.84,,8.89,percent of total billed charges,12.84% of total billed charges,11.11,12.84,,8.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.24,65,,44.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,35,,24.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,77.87,90,,62.3,percent of total billed charges,90% of total billed charges for outpatient setting,11.11,77.87,
BRUSH MICROBIOLOGY / 4310,6050134,CDM,272,RC,,,Outpatient,,,148,148,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.6,70,,82.88,percent of total billed charges,70% of total billed charges for outpatient setting,125.62,84.88,,100.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,74,50,,59.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111,75,,88.8,percent of total billed charges,75% of total billed charges for outpatient setting,103.6,70,,82.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.4,80,,94.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.2,65,,76.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.8,35,,41.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.2,90,,106.56,percent of total billed charges,90% of total billed charges for outpatient setting,19,133.2,
BRUSH URETERAL 5FRX67CM STR / 040000,69162609,CDM,272,RC,,,Outpatient,,,59.58,59.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.79,50,,23.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,12.84,,6.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,12.84,,6.12,percent of total billed charges,12.84% of total billed charges,7.65,12.84,,6.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.73,65,,30.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.85,35,,16.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,7.65,53.62,
BSS (STERILE IRRIGATING SOLN) 15 ML,3302709,CDM,259,RC,,,Outpatient,,,31.45,31.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.02,70,,17.62,percent of total billed charges,70% of total billed charges for outpatient setting,26.69,84.88,,21.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.73,50,,12.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.59,75,,18.87,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,70,,17.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.04,12.84,,3.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.16,80,,20.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.04,12.84,,3.23,percent of total billed charges,12.84% of total billed charges,4.04,12.84,,3.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.44,65,,16.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.01,35,,8.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.31,90,,22.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.04,28.31,
BSS (STERILE IRRIGATING SOLN) 500ML,3302693,CDM,259,RC,,,Outpatient,,,120.4,120.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.28,70,,67.42,percent of total billed charges,70% of total billed charges for outpatient setting,102.2,84.88,,81.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.2,50,,48.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.3,75,,72.24,percent of total billed charges,75% of total billed charges for outpatient setting,84.28,70,,67.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,12.84,,12.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.32,80,,77.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,12.84,,12.37,percent of total billed charges,12.84% of total billed charges,15.46,12.84,,12.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78.26,65,,62.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,35,,33.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108.36,90,,86.69,percent of total billed charges,90% of total billed charges for outpatient setting,15.46,108.36,
BSS 15CC / 100064610,6150520,CDM,270,RC,,,Outpatient,,,30.16,30.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.6,84.88,,20.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.08,50,,12.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.62,75,,18.1,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.13,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.6,65,,15.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,35,,8.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,3.87,27.14,
BSS PLAIN 500CC BAG / 0065179540,69169274,CDM,272,RC,,,Outpatient,,,38.5,38.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,32.68,84.88,,26.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.25,50,,15.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,75,,23.1,percent of total billed charges,75% of total billed charges for outpatient setting,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,80,,24.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.03,65,,20.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,35,,10.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.65,
BSS PLAIN 500CC BOTTLE / 0065-0795-50,6150510,CDM,272,RC,,,Outpatient,,,202.46,202.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.72,70,,113.38,percent of total billed charges,70% of total billed charges for outpatient setting,171.85,84.88,,137.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.23,50,,80.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.85,75,,121.48,percent of total billed charges,75% of total billed charges for outpatient setting,141.72,70,,113.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,12.84,,20.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.97,80,,129.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,12.84,,20.8,percent of total billed charges,12.84% of total billed charges,26,12.84,,20.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.6,65,,105.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.86,35,,56.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.21,90,,145.77,percent of total billed charges,90% of total billed charges for outpatient setting,26,182.21,
BSS PLUS (STERILE IRRIGATING SOLN) 500ML,3302694,CDM,259,RC,,,Outpatient,,,345.32,345.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.72,70,,193.38,percent of total billed charges,70% of total billed charges for outpatient setting,293.11,84.88,,234.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,172.66,50,,138.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.99,75,,207.19,percent of total billed charges,75% of total billed charges for outpatient setting,241.72,70,,193.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.34,12.84,,35.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.26,80,,221.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.34,12.84,,35.47,percent of total billed charges,12.84% of total billed charges,44.34,12.84,,35.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.46,65,,179.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,35,,96.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,310.79,90,,248.63,percent of total billed charges,90% of total billed charges for outpatient setting,44.34,310.79,
BSS SOLN. EPI. 0.3MG 500MLS,3302713,CDM,259,RC,,,Outpatient,,,103.12,103.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,70,,57.74,percent of total billed charges,70% of total billed charges for outpatient setting,87.53,84.88,,70.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.56,50,,41.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.34,75,,61.87,percent of total billed charges,75% of total billed charges for outpatient setting,72.18,70,,57.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,12.84,,10.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.5,80,,66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,12.84,,10.59,percent of total billed charges,12.84% of total billed charges,13.24,12.84,,10.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.03,65,,53.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.09,35,,28.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.81,90,,74.25,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,92.81,
BSS/EPI.0.3MG/VANC.15MG/FORT.20MG 500ML,3302692,CDM,259,RC,,,Outpatient,,,192.23,192.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.56,70,,107.65,percent of total billed charges,70% of total billed charges for outpatient setting,163.16,84.88,,130.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,96.12,50,,76.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.17,75,,115.34,percent of total billed charges,75% of total billed charges for outpatient setting,134.56,70,,107.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,12.84,,19.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.78,80,,123.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,12.84,,19.74,percent of total billed charges,12.84% of total billed charges,24.68,12.84,,19.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,124.95,65,,99.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.28,35,,53.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.01,90,,138.41,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,173.01,
BSS/INDOMETHACIN/SOLUCORTEF/FORT/VANC,3302714,CDM,259,RC,,,Outpatient,,,260.55,260.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.39,70,,145.91,percent of total billed charges,70% of total billed charges for outpatient setting,221.15,84.88,,176.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.28,50,,104.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.41,75,,156.33,percent of total billed charges,75% of total billed charges for outpatient setting,182.39,70,,145.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,12.84,,26.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.44,80,,166.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,12.84,,26.76,percent of total billed charges,12.84% of total billed charges,33.45,12.84,,26.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,169.36,65,,135.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.19,35,,72.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,234.5,90,,187.6,percent of total billed charges,90% of total billed charges for outpatient setting,33.45,234.5,
BST TISSUE MARKER GEL MARK ULTRA CORE,69169093,CDM,272,RC,,,Outpatient,,,270.2,270.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.14,70,,151.31,percent of total billed charges,70% of total billed charges for outpatient setting,229.35,84.88,,183.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,135.1,50,,108.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.65,75,,162.12,percent of total billed charges,75% of total billed charges for outpatient setting,189.14,70,,151.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.69,12.84,,27.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.16,80,,172.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.69,12.84,,27.75,percent of total billed charges,12.84% of total billed charges,34.69,12.84,,27.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.63,65,,140.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.57,35,,75.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,243.18,90,,194.54,percent of total billed charges,90% of total billed charges for outpatient setting,34.69,243.18,
BUDESONIDE 0 .5mg/2ML NEB(PULMICORT GEN),3302857,CDM,259,RC,J7626,HCPCS,Outpatient,,,38.72,38.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,70,,21.68,percent of total billed charges,70% of total billed charges for outpatient setting,32.87,84.88,,26.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.04,75,,23.23,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,70,,21.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,80,,24.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.17,65,,20.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,100,,,Fee Schedule,100% of Custom Fee Schedule,34.85,90,,27.88,percent of total billed charges,90% of total billed charges for outpatient setting,1.13,34.85,
BUGBEE ELECTRODE 5 FR X 58CM(RED),6150605,CDM,270,RC,,,Outpatient,,,416.64,416.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.65,70,,233.32,percent of total billed charges,70% of total billed charges for outpatient setting,353.64,84.88,,282.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,208.32,50,,166.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,312.48,75,,249.98,percent of total billed charges,75% of total billed charges for outpatient setting,291.65,70,,233.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.5,12.84,,42.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.31,80,,266.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.5,12.84,,42.8,percent of total billed charges,12.84% of total billed charges,53.5,12.84,,42.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,270.82,65,,216.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.82,35,,116.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,374.98,90,,299.98,percent of total billed charges,90% of total billed charges for outpatient setting,53.5,374.98,
BULB SYRINGE / 4172,6150016,CDM,272,RC,,,Outpatient,,,6.51,6.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,70,,3.65,percent of total billed charges,70% of total billed charges for outpatient setting,5.53,84.88,,4.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.26,50,,2.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.88,75,,3.9,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,70,,3.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,80,,4.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.23,65,,3.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,35,,1.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.86,90,,4.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.84,5.86,
BUMETANIDE (BUMEX) INJ 0.25 MG/ML 4ML,3300695,CDM,250,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUMETANIDE (BUMEX) TAB : 1 MG,3300696,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BUMETANIDE (BUMEX) TAB 1MG,3300697,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
BUMETANIDE (BUMEX)INJ 0.25 MG/ML2ML,3300694,CDM,250,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUN,200610,CDM,300,RC,84520,HCPCS,Outpatient,,,17.78,16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.45,70,,9.96,percent of total billed charges,70% of total billed charges for outpatient setting,15.09,84.88,,12.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.34,75,,10.67,percent of total billed charges,75% of total billed charges for outpatient setting,12.45,70,,9.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,80,,11.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.76,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of Custom Fee Schedule,16,90,,12.8,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,16,
BUPIVA 0.5% MPF(SENSORCAINE) INJ  30ML,3300699,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.25% + EPI 10ML INJ,3302609,CDM,250,RC,J3490,HCPCS,Outpatient,,,49.62,49.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.73,70,,27.78,percent of total billed charges,70% of total billed charges for outpatient setting,42.12,84.88,,33.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.81,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.22,75,,29.78,percent of total billed charges,75% of total billed charges for outpatient setting,34.73,70,,27.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,12.84,,5.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,80,,31.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,6.37,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.25,65,,25.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.37,35,,13.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.66,90,,35.73,percent of total billed charges,90% of total billed charges for outpatient setting,6.37,44.66,
BUPIVACAINE 0.25% + EPI 30ML INJ,3300704,CDM,250,RC,,,Outpatient,,,67.13,67.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.99,70,,37.59,percent of total billed charges,70% of total billed charges for outpatient setting,56.98,84.88,,45.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.57,50,,26.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.35,75,,40.28,percent of total billed charges,75% of total billed charges for outpatient setting,46.99,70,,37.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.7,80,,42.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.63,65,,34.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.5,35,,18.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.42,90,,48.34,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,60.42,
BUPIVACAINE 0.25% + EPI INJ 10ml UD Chg,3314087,CDM,250,RC,,,Outpatient,,,28.8,28.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,70,,16.13,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,84.88,,19.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.4,50,,11.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,75,,17.28,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,70,,16.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,80,,18.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.72,65,,14.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,35,,8.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.92,90,,20.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.92,
BUPIVACAINE 0.25% plain 30ML INJ,3300700,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.25% plain MPF 30ML INJ,3300698,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.25% plain SDV 10ML INJ,3302638,CDM,636,RC,J0665,HCPCS,Outpatient,,,3.24,3.24,JZ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.5% + EPI 10ML INJ,3300703,CDM,250,RC,,,Outpatient,,,50.9,50.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.63,70,,28.5,percent of total billed charges,70% of total billed charges for outpatient setting,43.2,84.88,,34.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.45,50,,20.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.18,75,,30.54,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,70,,28.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.72,80,,32.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.09,65,,26.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,35,,14.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.81,90,,36.65,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.81,
BUPIVACAINE 0.5% + EPI 30ML VIAL,3302962,CDM,259,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
BUPIVACAINE 0.5% + EPI 50ML VIAL,3313059,CDM,259,RC,,,Outpatient,,,115.44,115.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.81,70,,64.65,percent of total billed charges,70% of total billed charges for outpatient setting,97.99,84.88,,78.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.72,50,,46.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.58,75,,69.26,percent of total billed charges,75% of total billed charges for outpatient setting,80.81,70,,64.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,12.84,,11.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.35,80,,73.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,14.82,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.04,65,,60.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.4,35,,32.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.9,90,,83.12,percent of total billed charges,90% of total billed charges for outpatient setting,14.82,103.9,
BUPIVACAINE 0.5% plain 10ML INJ,3300701,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.5% plain 30ML SDV,3303287,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.5% plain MDV 10ml UD Chg,3314132,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.75% + EPI 30ML INJ,3313720,CDM,250,RC,,,Outpatient,,,78.42,78.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.89,70,,43.91,percent of total billed charges,70% of total billed charges for outpatient setting,66.56,84.88,,53.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.21,50,,31.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.82,75,,47.06,percent of total billed charges,75% of total billed charges for outpatient setting,54.89,70,,43.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.07,12.84,,8.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.74,80,,50.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.07,12.84,,8.06,percent of total billed charges,12.84% of total billed charges,10.07,12.84,,8.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.97,65,,40.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,35,,21.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.58,90,,56.46,percent of total billed charges,90% of total billed charges for outpatient setting,10.07,70.58,
BUPIVACAINE 0.75% plain 10 ML INJ,3300702,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE 0.75% plain 30 ML SDV INJ,3314073,CDM,250,RC,J3490,HCPCS,Outpatient,,,38.01,38.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.61,70,,21.29,percent of total billed charges,70% of total billed charges for outpatient setting,32.26,84.88,,25.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.51,75,,22.81,percent of total billed charges,75% of total billed charges for outpatient setting,26.61,70,,21.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,12.84,,3.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.41,80,,24.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,4.88,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.71,65,,19.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.3,35,,10.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.21,90,,27.37,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,34.21,
BUPIVACAINE 0.75%(SPINAL) INJ 2 ML,3307970,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPIVACAINE EPI 0.5%(SENSORCNE) INJ :5ML,3300705,CDM,250,RC,,,Outpatient,,,7.82,7.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,70,,4.38,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,84.88,,5.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.91,50,,3.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.87,75,,4.7,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,70,,4.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.26,80,,5.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.08,65,,4.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.74,35,,2.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.04,90,,5.63,percent of total billed charges,90% of total billed charges for outpatient setting,1,7.04,
BUPIVACAINE LIPOSOME (EXPAREL)1.3% 10ML,3313479,CDM,636,RC,C9290,HCPCS,Outpatient,,,858.96,858.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.27,70,,481.02,percent of total billed charges,70% of total billed charges for outpatient setting,729.09,84.88,,583.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,644.22,75,,515.38,percent of total billed charges,75% of total billed charges for outpatient setting,601.27,70,,481.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.29,12.84,,88.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,687.17,80,,549.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.29,12.84,,88.23,percent of total billed charges,12.84% of total billed charges,110.29,12.84,,88.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,558.32,65,,446.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,100,,,Fee Schedule,100% of Custom Fee Schedule,773.06,90,,618.45,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,773.06,
BUPIVACAINE LIPOSOME (EXPAREL)1.3% 20ML,3305224,CDM,636,RC,C9290,HCPCS,Outpatient,,,1460.64,1460.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.45,70,,817.96,percent of total billed charges,70% of total billed charges for outpatient setting,1239.79,84.88,,991.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1095.48,75,,876.38,percent of total billed charges,75% of total billed charges for outpatient setting,1022.45,70,,817.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.55,12.84,,150.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.51,80,,934.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.55,12.84,,150.04,percent of total billed charges,12.84% of total billed charges,187.55,12.84,,150.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,949.42,65,,759.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,100,,,Fee Schedule,100% of Custom Fee Schedule,1314.58,90,,1051.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,1314.58,
BUPIVACANE EPI 0.5%(SENSORCNE)INJ 10ML,3300706,CDM,250,RC,,,Outpatient,,,94.97,94.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.48,70,,53.18,percent of total billed charges,70% of total billed charges for outpatient setting,80.61,84.88,,64.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.49,50,,37.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.23,75,,56.98,percent of total billed charges,75% of total billed charges for outpatient setting,66.48,70,,53.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.98,80,,60.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.73,65,,49.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,35,,26.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.47,90,,68.38,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,85.47,
BUPRENORPHINE (BUPRENEX) 0.3MG/ML,3302745,CDM,636,RC,J0592,HCPCS,Outpatient,,,17.19,17.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,14.59,84.88,,11.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.89,75,,10.31,percent of total billed charges,75% of total billed charges for outpatient setting,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,80,,11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.17,65,,8.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.99,100,,,Fee Schedule,100% of Custom Fee Schedule,15.47,90,,12.38,percent of total billed charges,90% of total billed charges for outpatient setting,2.21,15.47,
BUPROPION HCL (genWELLBUTRIN) XL 150MG,3303028,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUPROPION HCL (WELLBUTRIN) TAB 100 MG,3300711,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUPROPION HCL (WELLBUTRIN) TAB 75 MG,3300708,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUPROPION HCL (WELLBUTRIN) TAB: 100 MG,3300709,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
BUPROPION HCL (WELLBUTRIN)SR 150MG,3303239,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUPROPION HCL (ZYBAN) TAB 100 MG,3300707,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUPROPION HCL (ZYBAN) TAB 150 MG,3300710,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUR 2.0MM COOLCUT SBR SJ / AR-7200SR,69162041,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
BUR 3MM ROUND MED / 277-010-230,6152713,CDM,272,RC,,,Outpatient,,,107.82,107.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.47,70,,60.38,percent of total billed charges,70% of total billed charges for outpatient setting,91.52,84.88,,73.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.91,50,,43.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.87,75,,64.7,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,70,,60.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,12.84,,11.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.26,80,,69.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,12.84,,11.07,percent of total billed charges,12.84% of total billed charges,13.84,12.84,,11.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.08,65,,56.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,35,,30.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.04,90,,77.63,percent of total billed charges,90% of total billed charges for outpatient setting,13.84,97.04,
BUR 4.0 ROUND1608-6-95,6152704,CDM,270,RC,,,Outpatient,,,135.19,135.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,114.75,84.88,,91.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.6,50,,54.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.39,75,,81.11,percent of total billed charges,75% of total billed charges for outpatient setting,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.15,80,,86.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.87,65,,70.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.32,35,,37.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.67,90,,97.34,percent of total billed charges,90% of total billed charges for outpatient setting,17.36,121.67,
BUR 4MM DIAMOND / 1608-006-095,69169242,CDM,272,RC,,,Outpatient,,,406.35,406.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.45,70,,227.56,percent of total billed charges,70% of total billed charges for outpatient setting,344.91,84.88,,275.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.18,50,,162.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.76,75,,243.81,percent of total billed charges,75% of total billed charges for outpatient setting,284.45,70,,227.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,12.84,,41.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.08,80,,260.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,12.84,,41.74,percent of total billed charges,12.84% of total billed charges,52.18,12.84,,41.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.13,65,,211.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.22,35,,113.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.72,90,,292.58,percent of total billed charges,90% of total billed charges for outpatient setting,52.18,365.72,
BUR 4MM EGG / 1608-002-035,69169123,CDM,272,RC,,,Outpatient,,,433.99,433.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.79,70,,243.03,percent of total billed charges,70% of total billed charges for outpatient setting,368.37,84.88,,294.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,217,50,,173.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.49,75,,260.39,percent of total billed charges,75% of total billed charges for outpatient setting,303.79,70,,243.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.72,12.84,,44.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.19,80,,277.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.72,12.84,,44.58,percent of total billed charges,12.84% of total billed charges,55.72,12.84,,44.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,282.09,65,,225.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.9,35,,121.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,390.59,90,,312.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.72,390.59,
BUR 4MM ROUND / 277-010-240,6152032,CDM,272,RC,,,Outpatient,,,107.82,107.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.47,70,,60.38,percent of total billed charges,70% of total billed charges for outpatient setting,91.52,84.88,,73.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.91,50,,43.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.87,75,,64.7,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,70,,60.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,12.84,,11.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.26,80,,69.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,12.84,,11.07,percent of total billed charges,12.84% of total billed charges,13.84,12.84,,11.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.08,65,,56.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,35,,30.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.04,90,,77.63,percent of total billed charges,90% of total billed charges for outpatient setting,13.84,97.04,
BUR EGG 4MM/1608-002-035,6151047,CDM,272,RC,,,Outpatient,,,233.15,233.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.21,70,,130.57,percent of total billed charges,70% of total billed charges for outpatient setting,197.9,84.88,,158.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.58,50,,93.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.86,75,,139.89,percent of total billed charges,75% of total billed charges for outpatient setting,163.21,70,,130.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.94,12.84,,23.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.52,80,,149.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.94,12.84,,23.95,percent of total billed charges,12.84% of total billed charges,29.94,12.84,,23.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.55,65,,121.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,35,,65.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,209.84,90,,167.87,percent of total billed charges,90% of total billed charges for outpatient setting,29.94,209.84,
BUR OVAL 5.0MM / H9103RH,69161477,CDM,272,RC,,,Outpatient,,,256.27,256.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.39,70,,143.51,percent of total billed charges,70% of total billed charges for outpatient setting,217.52,84.88,,174.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.14,50,,102.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.2,75,,153.76,percent of total billed charges,75% of total billed charges for outpatient setting,179.39,70,,143.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,12.84,,26.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.02,80,,164.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,12.84,,26.33,percent of total billed charges,12.84% of total billed charges,32.91,12.84,,26.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.58,65,,133.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.69,35,,71.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.64,90,,184.51,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,230.64,
BURN MATRIX 7X10CM CYTAL /BMM0710,69162831,CDM,278,RC,Q4166,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,17.73,2415,
BURR 4.0MM OVAL / AR-8400OBE,71000319,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
BURR 5.0MM OVAL FLUSH CUT / AR-8500RFOE,71000640,CDM,272,RC,,,Outpatient,,,424.2,424.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,360.06,84.88,,288.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.1,50,,169.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,75,,254.52,percent of total billed charges,75% of total billed charges for outpatient setting,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.36,80,,271.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.73,65,,220.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.47,35,,118.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.78,90,,305.42,percent of total billed charges,90% of total billed charges for outpatient setting,54.47,381.78,
BURR 5.5MM OVAL FLUSH CUT / AR-8550RFOE,69162778,CDM,272,RC,,,Outpatient,,,424.2,424.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,360.06,84.88,,288.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.1,50,,169.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,75,,254.52,percent of total billed charges,75% of total billed charges for outpatient setting,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.36,80,,271.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.73,65,,220.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.47,35,,118.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.78,90,,305.42,percent of total billed charges,90% of total billed charges for outpatient setting,54.47,381.78,
BURR 5MM OVAL / AR-8500OBE,69161148,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
BURR 5MM OVAL CLCUT  AR-8500COE,69162244,CDM,272,RC,,,Outpatient,,,285.52,285.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.86,70,,159.89,percent of total billed charges,70% of total billed charges for outpatient setting,242.35,84.88,,193.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,142.76,50,,114.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.14,75,,171.31,percent of total billed charges,75% of total billed charges for outpatient setting,199.86,70,,159.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.66,12.84,,29.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.42,80,,182.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.66,12.84,,29.33,percent of total billed charges,12.84% of total billed charges,36.66,12.84,,29.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,185.59,65,,148.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.93,35,,79.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,256.97,90,,205.58,percent of total billed charges,90% of total billed charges for outpatient setting,36.66,256.97,
BURR OVAL 5MM  FLUSH CUT / AR-8500FOE,69162401,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
BURR ROUND 5MM/ AR-8500RBE,69162925,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
BURR SIDE-CUTTING,6150559,CDM,272,RC,,,Outpatient,,,269.06,269.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.34,70,,150.67,percent of total billed charges,70% of total billed charges for outpatient setting,228.38,84.88,,182.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.53,50,,107.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.8,75,,161.44,percent of total billed charges,75% of total billed charges for outpatient setting,188.34,70,,150.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.55,12.84,,27.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.25,80,,172.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.55,12.84,,27.64,percent of total billed charges,12.84% of total billed charges,34.55,12.84,,27.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174.89,65,,139.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.17,35,,75.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.15,90,,193.72,percent of total billed charges,90% of total billed charges for outpatient setting,34.55,242.15,
BURR STANDARD MILL / 00-5927-050-00,71000292,CDM,272,RC,,,Outpatient,,,592,592,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.4,70,,331.52,percent of total billed charges,70% of total billed charges for outpatient setting,502.49,84.88,,401.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,296,50,,236.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,444,75,,355.2,percent of total billed charges,75% of total billed charges for outpatient setting,414.4,70,,331.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.01,12.84,,60.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.6,80,,378.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.01,12.84,,60.81,percent of total billed charges,12.84% of total billed charges,76.01,12.84,,60.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,384.8,65,,307.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.2,35,,165.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,532.8,90,,426.24,percent of total billed charges,90% of total billed charges for outpatient setting,76.01,532.8,
"BUSPAR DIVIDOSE TAB 15MG {15MG, TABLET,",3303185,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUSPIRONE (BUSPAR)15MG TAB,3303063,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUSPIRONE (genericBUSPAR) 10MG TAB,3300713,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
BUSPIRONE HCL (BUSPAR) TAB 5 MG,3300712,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
BUSPIRONE HCL (BUSPAR) TAB: 10 MG,3300714,CDM,259,RC,,,Outpatient,,,4.25,4.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,3.61,84.88,,2.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.13,50,,1.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.19,75,,2.55,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,80,,2.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.76,65,,2.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,35,,1.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.83,90,,3.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.83,
BUTALBITAL COMPOUND: FIORICET,3302832,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BUTALBITAL COMPOUND: FIORINAL CIII,3303290,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
BUTORPHANOL TARTRATE 2 MG/ML,3302717,CDM,636,RC,J0595,HCPCS,Outpatient,,,43.67,43.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,37.07,84.88,,29.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.75,75,,26.2,percent of total billed charges,75% of total billed charges for outpatient setting,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.94,80,,27.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.39,65,,22.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,100,,,Fee Schedule,100% of Custom Fee Schedule,39.3,90,,31.44,percent of total billed charges,90% of total billed charges for outpatient setting,2.59,39.3,
BUTORPHANOL TARTRATE(STADOL) 1 MG/ML,3303341,CDM,636,RC,J0595,HCPCS,Outpatient,,,43.67,43.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,37.07,84.88,,29.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.75,75,,26.2,percent of total billed charges,75% of total billed charges for outpatient setting,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.94,80,,27.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.39,65,,22.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,100,,,Fee Schedule,100% of Custom Fee Schedule,39.3,90,,31.44,percent of total billed charges,90% of total billed charges for outpatient setting,2.59,39.3,
BUTTERFLY VENT TUBE 1.27MM SNGL / 240073,69161274,CDM,272,RC,,,Outpatient,,,217.5,217.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.25,70,,121.8,percent of total billed charges,70% of total billed charges for outpatient setting,184.61,84.88,,147.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.75,50,,87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.13,75,,130.5,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,70,,121.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.93,12.84,,22.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174,80,,139.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.93,12.84,,22.34,percent of total billed charges,12.84% of total billed charges,27.93,12.84,,22.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.38,65,,113.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.13,35,,60.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,195.75,90,,156.6,percent of total billed charges,90% of total billed charges for outpatient setting,27.93,195.75,
BUTTERFLY VENT TUBE 1.32MM SNGL / 240074,71000446,CDM,272,RC,,,Outpatient,,,206.65,206.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.66,70,,115.73,percent of total billed charges,70% of total billed charges for outpatient setting,175.4,84.88,,140.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.33,50,,82.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.99,75,,123.99,percent of total billed charges,75% of total billed charges for outpatient setting,144.66,70,,115.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.53,12.84,,21.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.32,80,,132.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.53,12.84,,21.22,percent of total billed charges,12.84% of total billed charges,26.53,12.84,,21.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.32,65,,107.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.33,35,,57.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,185.99,90,,148.79,percent of total billed charges,90% of total billed charges for outpatient setting,26.53,185.99,
BUTTON 1.27 SHEEHY WHITE / 70145780,71000549,CDM,360,RC,,,Outpatient,,,94.5,94.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,70,,52.92,percent of total billed charges,70% of total billed charges for outpatient setting,80.21,84.88,,64.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.25,50,,37.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.88,75,,56.7,percent of total billed charges,75% of total billed charges for outpatient setting,66.15,70,,52.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.13,12.84,,9.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,80,,60.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.13,12.84,,9.7,percent of total billed charges,12.84% of total billed charges,12.13,12.84,,9.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,35,,26.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.05,90,,68.04,percent of total billed charges,90% of total billed charges for outpatient setting,12.13,85.05,
BUTTON ENDO / MAJ-210,7600440,CDM,272,RC,,,Outpatient,,,26.24,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.37,70,,14.7,percent of total billed charges,70% of total billed charges for outpatient setting,22.27,84.88,,17.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.12,50,,10.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.68,75,,15.74,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,70,,14.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.99,80,,16.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.06,65,,13.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,35,,7.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.62,90,,18.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.37,23.62,
BUTTON ORCA OLYMPUS / SUV-617-50,2258080,CDM,272,RC,,,Outpatient,,,55.65,55.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.96,70,,31.17,percent of total billed charges,70% of total billed charges for outpatient setting,47.24,84.88,,37.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.83,50,,22.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.74,75,,33.39,percent of total billed charges,75% of total billed charges for outpatient setting,38.96,70,,31.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.52,80,,35.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.17,65,,28.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,35,,15.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.09,90,,40.07,percent of total billed charges,90% of total billed charges for outpatient setting,7.15,50.09,
BUTTON SUCTION /MH438,69191593,CDM,272,RC,,,Outpatient,,,347.59,347.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.31,70,,194.65,percent of total billed charges,70% of total billed charges for outpatient setting,295.03,84.88,,236.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.8,50,,139.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.69,75,,208.55,percent of total billed charges,75% of total billed charges for outpatient setting,243.31,70,,194.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.63,12.84,,35.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.07,80,,222.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.63,12.84,,35.7,percent of total billed charges,12.84% of total billed charges,44.63,12.84,,35.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,225.93,65,,180.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.66,35,,97.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,312.83,90,,250.26,percent of total billed charges,90% of total billed charges for outpatient setting,44.63,312.83,
BUTTON SUCTION /MH443,7600445,CDM,272,RC,,,Outpatient,,,345.86,345.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.1,70,,193.68,percent of total billed charges,70% of total billed charges for outpatient setting,293.57,84.88,,234.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,172.93,50,,138.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.4,75,,207.52,percent of total billed charges,75% of total billed charges for outpatient setting,242.1,70,,193.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.41,12.84,,35.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.69,80,,221.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.41,12.84,,35.53,percent of total billed charges,12.84% of total billed charges,44.41,12.84,,35.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.81,65,,179.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,35,,96.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.27,90,,249.02,percent of total billed charges,90% of total billed charges for outpatient setting,44.41,311.27,
BYSTOLIC 5 MG TABLET (NEBIVOLOL),3303347,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
C1-ESTERASE INHIBITOR ANTIGEN,220744,CDM,302,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
C1-ESTERASE INHIBITOR FUNCTIONAL,220828,CDM,302,RC,86161,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
CA 125,220388,CDM,300,RC,86316,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,84.29,
CA 15-3,220364,CDM,300,RC,86300,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,84.29,
CA 19-9,220365,CDM,300,RC,86316,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,84.29,
CA 27-29,220395,CDM,300,RC,86300,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,84.29,
CA CARB (OYSTER SHELL) TAB 125MG,3300719,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CA CARB MAG (ASPIRIN BUFF) TAB:,3300716,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CA CARB VIT D (CALCIUM) TAB 600 MG,3300717,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CA CARB VIT D (CALCIUM) TAB:,3300718,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CABLE 1.7MM W/ CRIMP / 298.801.01S,70000412,CDM,271,RC,C1713,HCPCS,Outpatient,,,2140.63,2140.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.44,70,,1198.75,percent of total billed charges,70% of total billed charges for outpatient setting,1816.97,84.88,,1453.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1605.47,75,,1284.38,percent of total billed charges,75% of total billed charges for outpatient setting,1498.44,70,,1198.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.86,12.84,,219.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1712.5,80,,1370,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.86,12.84,,219.89,percent of total billed charges,12.84% of total billed charges,274.86,12.84,,219.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1391.41,65,,1113.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.22,35,,599.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1926.57,90,,1541.26,percent of total billed charges,90% of total billed charges for outpatient setting,274.86,1926.57,
CABLE FOR PACEMAKER / 5833S,6151022,CDM,270,RC,,,Outpatient,,,142.03,142.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,120.56,84.88,,96.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.02,50,,56.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.52,75,,85.22,percent of total billed charges,75% of total billed charges for outpatient setting,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.62,80,,90.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.32,65,,73.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.71,35,,39.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.83,90,,102.26,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,127.83,
CABLE MULTI LEAD SNAP / 355531,70000049,CDM,272,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,90,,622.94,percent of total billed charges,90% of total billed charges for outpatient setting,111.09,778.68,
CABLE PACEMAKER / 5833SL,69160144,CDM,272,RC,,,Outpatient,,,305.29,305.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.7,70,,170.96,percent of total billed charges,70% of total billed charges for outpatient setting,259.13,84.88,,207.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,152.65,50,,122.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.97,75,,183.18,percent of total billed charges,75% of total billed charges for outpatient setting,213.7,70,,170.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,12.84,,31.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.23,80,,195.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,12.84,,31.36,percent of total billed charges,12.84% of total billed charges,39.2,12.84,,31.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,198.44,65,,158.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.85,35,,85.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,274.76,90,,219.81,percent of total billed charges,90% of total billed charges for outpatient setting,39.2,274.76,
CABLE SPECTRA 2X8 2FT / SC-4108,70000140,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
CABLE STAPLER 45 ENDOWRIST 381182,69161682,CDM,272,RC,,,Outpatient,,,20.06,20.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,70,,11.23,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,84.88,,13.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.03,50,,8.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.05,75,,12.04,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,70,,11.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,80,,12.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,65,,10.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,35,,5.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.05,90,,14.44,percent of total billed charges,90% of total billed charges for outpatient setting,2.58,18.05,
CABLE STIMULATION TEST / 357501,70000526,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
CABLE TWIST LOCK / 357625,70000525,CDM,272,RC,,,Outpatient,,,346.08,346.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.26,70,,193.81,percent of total billed charges,70% of total billed charges for outpatient setting,293.75,84.88,,235,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.04,50,,138.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.56,75,,207.65,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,70,,193.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,12.84,,35.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.86,80,,221.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,12.84,,35.55,percent of total billed charges,12.84% of total billed charges,44.44,12.84,,35.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.95,65,,179.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,35,,96.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.47,90,,249.18,percent of total billed charges,90% of total billed charges for outpatient setting,44.44,311.47,
CADD 69IN SET TUBING / 21-7115-24,69191594,CDM,270,RC,,,Outpatient,,,46.82,46.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,70,,26.22,percent of total billed charges,70% of total billed charges for outpatient setting,39.74,84.88,,31.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.41,50,,18.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.12,75,,28.1,percent of total billed charges,75% of total billed charges for outpatient setting,32.77,70,,26.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.46,80,,29.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.43,65,,24.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.39,35,,13.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.14,90,,33.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,42.14,
CADMIUM,201495,CDM,301,RC,82300,HCPCS,Outpatient,,,106.38,95.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,70,,59.58,percent of total billed charges,70% of total billed charges for outpatient setting,90.3,84.88,,72.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.79,75,,63.83,percent of total billed charges,75% of total billed charges for outpatient setting,74.47,70,,59.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.1,80,,68.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,33.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.9,100,,,Fee Schedule,100% of Custom Fee Schedule,95.74,90,,76.59,percent of total billed charges,90% of total billed charges for outpatient setting,23.64,95.74,
CAFFEINE/SOD BENZ 250/CC INJ,3302877,CDM,250,RC,,,Outpatient,,,77.34,77.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.14,70,,43.31,percent of total billed charges,70% of total billed charges for outpatient setting,65.65,84.88,,52.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.67,50,,30.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.01,75,,46.41,percent of total billed charges,75% of total billed charges for outpatient setting,54.14,70,,43.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.93,12.84,,7.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.87,80,,49.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.93,12.84,,7.94,percent of total billed charges,12.84% of total billed charges,9.93,12.84,,7.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.27,65,,40.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,35,,21.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.61,90,,55.69,percent of total billed charges,90% of total billed charges for outpatient setting,9.93,69.61,
CAGE 4.5X12M ACTILIF  / ACF124506-14,69169383,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
CAGE 6.5X12MM ACTILIF / ACF126506-14,69169460,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
CAGE 7.5 X 12MM ACTILIF / ACF127506-14,69169300,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
CAGE 9X50MM TRANSCON  375.329,69162376,CDM,278,RC,,,Outpatient,,,13200,13200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7920,60,,6336,percent of total billed charges,60% of total Billed charges for outpatient setting,11204.16,84.88,,8963.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6600,50,,5280,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9900,75,,7920,percent of total billed charges,75% of total billed charges for outpatient setting,6600,50,,5280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1694.88,12.84,,1355.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10560,80,,8448,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1694.88,12.84,,1355.9,percent of total billed charges,12.84% of total billed charges,1694.88,12.84,,1355.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13860,105,,11088,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4620,35,,3696,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7920,60,,6336,percent of total billed charges,60% of total billed charges for outpatient setting,1694.88,13860,
CAGE CALIBER 10-15X22MM / 194.222,69162393,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 10-15X26MM  194.226,69162307,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 10X26MM/12-17MM/ 194.926,69169140,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 12-17x26MM  194.326,69162300,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 15 DEG 11-15X22MM / 194.822,69162394,CDM,278,RC,,,Outpatient,,,11000,11000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6600,60,,5280,percent of total billed charges,60% of total Billed charges for outpatient setting,9336.8,84.88,,7469.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,5500,50,,4400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8250,75,,6600,percent of total billed charges,75% of total billed charges for outpatient setting,5500,50,,4400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.4,12.84,,1129.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8800,80,,7040,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.4,12.84,,1129.92,percent of total billed charges,12.84% of total billed charges,1412.4,12.84,,1129.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11550,105,,9240,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3850,35,,3080,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6600,60,,5280,percent of total billed charges,60% of total billed charges for outpatient setting,1412.4,11550,
CAGE CALIBER 7-10X22 / 194.510,69162172,CDM,278,RC,C1821,HCPCS,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 7-10X22 / 194.511,69162405,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 8-12X22 / 194.122,69162178,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 8-12X26 / 194.126,69162069,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 9-13 / 194.422,69162247,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 9-13 / 194.611,69162149,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE CALIBER 9-13X22 / 194.610,69161965,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
CAGE COALITION 5MM LARGE / 384.105,69162331,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
CAGE COLONIAL 5MM LG / 365.405,69162068,CDM,278,RC,C1821,HCPCS,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
CAGE COLONIAL 6MM LG / 365.406,69161946,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
CAGE COLONIAL 7MM LG / 365.407,69161944,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
CAGE COLONIAL 8MM LG / 365.408,69161992,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
CAGE COLONIAL 9MM LG / 365.409,69162620,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
CALADRYL LOTION 177ML,3302983,CDM,259,RC,,,Outpatient,,,33.79,33.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.65,70,,18.92,percent of total billed charges,70% of total billed charges for outpatient setting,28.68,84.88,,22.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.9,50,,13.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.34,75,,20.27,percent of total billed charges,75% of total billed charges for outpatient setting,23.65,70,,18.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.34,12.84,,3.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.03,80,,21.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.34,12.84,,3.47,percent of total billed charges,12.84% of total billed charges,4.34,12.84,,3.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.96,65,,17.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,35,,9.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.41,90,,24.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.34,30.41,
CALAMINE LOTION 120ML,3300720,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CALCANEUS 2+ VWS BILAT,2400447,CDM,320,RC,73650,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
CALCANEUS 2+ VWS LEFT,2400446,CDM,320,RC,73650,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
CALCANEUS 2+ VWS RIGHT,2400445,CDM,320,RC,73650,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
CALCARB 600 CALCIUM CARBONATE,3302876,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CALCIPOTRIENE (DOVONEX) CRM: 60 GM,3300721,CDM,259,RC,,,Outpatient,,,308.66,308.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.06,70,,172.85,percent of total billed charges,70% of total billed charges for outpatient setting,261.99,84.88,,209.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,154.33,50,,123.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.5,75,,185.2,percent of total billed charges,75% of total billed charges for outpatient setting,216.06,70,,172.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.63,12.84,,31.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.93,80,,197.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.63,12.84,,31.7,percent of total billed charges,12.84% of total billed charges,39.63,12.84,,31.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,200.63,65,,160.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.03,35,,86.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,277.79,90,,222.23,percent of total billed charges,90% of total billed charges for outpatient setting,39.63,277.79,
CALCITONIN,220161,CDM,302,RC,82308,HCPCS,Outpatient,,,120.56,108.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.39,70,,67.51,percent of total billed charges,70% of total billed charges for outpatient setting,102.33,84.88,,81.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,90.42,75,,72.34,percent of total billed charges,75% of total billed charges for outpatient setting,84.39,70,,67.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.45,80,,77.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,39.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.79,100,,,Fee Schedule,100% of Custom Fee Schedule,108.5,90,,86.8,percent of total billed charges,90% of total billed charges for outpatient setting,26.79,108.5,
CALCITONIN (MIACALCIN) 200 U/D SOL 2ML,3300723,CDM,259,RC,,,Outpatient,,,115.5,115.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.85,70,,64.68,percent of total billed charges,70% of total billed charges for outpatient setting,98.04,84.88,,78.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.75,50,,46.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.63,75,,69.3,percent of total billed charges,75% of total billed charges for outpatient setting,80.85,70,,64.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.83,12.84,,11.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.4,80,,73.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.83,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,14.83,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.08,65,,60.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.43,35,,32.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.95,90,,83.16,percent of total billed charges,90% of total billed charges for outpatient setting,14.83,103.95,
CALCITRIOL (ROCALTROL) CAP 0.25 MCG,3300724,CDM,259,RC,,,Outpatient,,,3.27,3.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,70,,1.83,percent of total billed charges,70% of total billed charges for outpatient setting,2.78,84.88,,2.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.64,50,,1.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.45,75,,1.96,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,70,,1.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.62,80,,2.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.13,65,,1.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,35,,0.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.94,90,,2.35,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.94,
CALCIUM,200440,CDM,300,RC,82310,HCPCS,Outpatient,,,23.22,20.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,19.71,84.88,,15.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.42,75,,13.94,percent of total billed charges,75% of total billed charges for outpatient setting,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,80,,14.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,100,,,Fee Schedule,100% of Custom Fee Schedule,20.9,90,,16.72,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,20.9,
CALCIUM 500MG +D (OYS CAL+D) TAB,3303249,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CALCIUM 600 + D TAB,3303152,CDM,259,RC,,,Outpatient,,,12.47,12.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,10.58,84.88,,8.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.35,75,,7.48,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,35,,3.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.22,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.22,
CALCIUM ACET (PHOSLO) TAB 667 MG,3300725,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CALCIUM CARB (OS CAL) TAB 1250MG,3300728,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CALCIUM CARB (OYS CAL) TAB 500 MG,3300727,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CALCIUM CARB CHEW (ANTACID) FLAVOR,3300726,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CALCIUM CARB XS (TUMS XS) CHEW :,3300729,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CALCIUM CARB(genericTUMS) TAB 500MG,3300731,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CALCIUM CARBONATE (ANTACID) CHEW ASST:,3300730,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CALCIUM CARBONATE 1250MG/5ML SUSP,3303325,CDM,259,RC,,,Outpatient,,,24.86,24.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.4,70,,13.92,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,84.88,,16.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.43,50,,9.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.65,75,,14.92,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,70,,13.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.89,80,,15.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.16,65,,12.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,35,,6.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.37,90,,17.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.19,22.37,
CALCIUM CARBONATE EX (TUMS) CHEW : TOPIC,3300732,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CALCIUM CARBONATE TAB: 500 MG,3300733,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CALCIUM CITRATE (CITRACAL)/VIT D TAB,3303326,CDM,259,RC,,,Outpatient,,,6.74,6.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.72,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.37,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,80,,4.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.38,65,,3.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.07,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.07,
CALCIUM CL 10% INJ 10ML SYRINGE,3300734,CDM,250,RC,,,Outpatient,,,61.3,61.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,70,,34.33,percent of total billed charges,70% of total billed charges for outpatient setting,52.03,84.88,,41.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.65,50,,24.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.98,75,,36.78,percent of total billed charges,75% of total billed charges for outpatient setting,42.91,70,,34.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,12.84,,6.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.04,80,,39.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,7.87,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.85,65,,31.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.46,35,,17.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.17,90,,44.14,percent of total billed charges,90% of total billed charges for outpatient setting,7.87,55.17,
CALCIUM DISOD VERSEN INJ 5 ML:,3300735,CDM,250,RC,,,Outpatient,,,125.13,125.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,70,,70.07,percent of total billed charges,70% of total billed charges for outpatient setting,106.21,84.88,,84.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.57,50,,50.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.85,75,,75.08,percent of total billed charges,75% of total billed charges for outpatient setting,87.59,70,,70.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,12.84,,12.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.1,80,,80.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,12.84,,12.86,percent of total billed charges,12.84% of total billed charges,16.07,12.84,,12.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.33,65,,65.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.8,35,,35.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.62,90,,90.1,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,112.62,
CALCIUM GLUC 10% INJ : 10 ML,3300736,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CALCIUM GLUC 10% INJ 10 ML,3300737,CDM,636,RC,J0610,HCPCS,Outpatient,,,55.44,55.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.81,70,,31.05,percent of total billed charges,70% of total billed charges for outpatient setting,47.06,84.88,,37.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.58,75,,33.26,percent of total billed charges,75% of total billed charges for outpatient setting,38.81,70,,31.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,12.84,,5.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.35,80,,35.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,7.12,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.04,65,,28.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,100,,,Fee Schedule,100% of Custom Fee Schedule,49.9,90,,39.92,percent of total billed charges,90% of total billed charges for outpatient setting,3.61,49.9,
CALCIUM MAG POT (EYESTREAM) SOL,3300739,CDM,259,RC,,,Outpatient,,,27.46,27.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,70,,15.38,percent of total billed charges,70% of total billed charges for outpatient setting,23.31,84.88,,18.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.73,50,,10.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.6,75,,16.48,percent of total billed charges,75% of total billed charges for outpatient setting,19.22,70,,15.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,12.84,,2.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.97,80,,17.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,12.84,,2.82,percent of total billed charges,12.84% of total billed charges,3.53,12.84,,2.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.85,65,,14.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.61,35,,7.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.71,90,,19.77,percent of total billed charges,90% of total billed charges for outpatient setting,3.53,24.71,
CALCIUM POLYCARB (FIBERCON) CAP 625 MG,3300738,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
"CALCIUM,RANDOM URINE",220199,CDM,301,RC,82340,HCPCS,Outpatient,,,27.14,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,70,,15.2,percent of total billed charges,70% of total billed charges for outpatient setting,23.04,84.88,,18.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.36,75,,16.29,percent of total billed charges,75% of total billed charges for outpatient setting,19,70,,15.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,80,,17.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.44,100,,,Fee Schedule,100% of Custom Fee Schedule,24.43,90,,19.54,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,24.43,
CALCULUS SPECTROSCOPY,220792,CDM,301,RC,82365,HCPCS,Outpatient,,,58.05,52.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,49.27,84.88,,39.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.54,75,,34.83,percent of total billed charges,75% of total billed charges for outpatient setting,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,80,,37.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.83,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,100,,,Fee Schedule,100% of Custom Fee Schedule,52.25,90,,41.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,52.25,
CALPROTECTIN STOOL,222006,CDM,301,RC,83993,HCPCS,Outpatient,,,88.34,79.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,74.98,84.88,,59.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.26,75,,53.01,percent of total billed charges,75% of total billed charges for outpatient setting,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.67,80,,56.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,100,,,Fee Schedule,100% of Custom Fee Schedule,79.51,90,,63.61,percent of total billed charges,90% of total billed charges for outpatient setting,19.63,79.51,
CANCELLED CASE,6161000,CDM,360,RC,,,Outpatient,,,2272.75,2272.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1590.93,70,,1272.74,percent of total billed charges,70% of total billed charges for outpatient setting,1929.11,84.88,,1543.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,1136.38,50,,909.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1704.56,75,,1363.65,percent of total billed charges,75% of total billed charges for outpatient setting,1590.93,70,,1272.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.82,12.84,,233.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1818.2,80,,1454.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.82,12.84,,233.46,percent of total billed charges,12.84% of total billed charges,291.82,12.84,,233.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.46,35,,636.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2045.48,90,,1636.38,percent of total billed charges,90% of total billed charges for outpatient setting,291.82,2045.48,
CANCELLED ENDOSCOPY PROCEDURE,6000160,CDM,360,RC,,,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.5,35,,94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,43.11,302.15,
"CANCELLOUS CHIPS, 5CC 400140",69161933,CDM,278,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
CANDESARTAN CILEXTL (ATACAND) TAB 16MG,3300740,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CANDESARTAN CILEXTL (ATACAND) TAB 32MG,3303211,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CANDESARTAN CILEXTL (ATACAND) TAB 4MG,3303179,CDM,259,RC,,,Outpatient,,,12.95,12.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,10.99,84.88,,8.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.48,50,,5.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.71,75,,7.77,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.36,80,,8.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.42,65,,6.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,35,,3.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.66,90,,9.33,percent of total billed charges,90% of total billed charges for outpatient setting,1.66,11.66,
CANNISTER IMPLOSION PROOF / 49942,69159183,CDM,270,RC,,,Outpatient,,,50.69,50.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.48,70,,28.38,percent of total billed charges,70% of total billed charges for outpatient setting,43.03,84.88,,34.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.35,50,,20.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.02,75,,30.42,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,70,,28.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,12.84,,5.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.55,80,,32.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,12.84,,5.21,percent of total billed charges,12.84% of total billed charges,6.51,12.84,,5.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.95,65,,26.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.74,35,,14.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.62,90,,36.5,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,45.62,
CANNULA  7MM X 7CM TWIST IN / AR-6570,69161769,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 100MM X 22GX10MM TIP/SL-C1010-22,69169622,CDM,272,RC,,,Outpatient,,,88.2,88.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,74.86,84.88,,59.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.1,50,,35.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.15,75,,52.92,percent of total billed charges,75% of total billed charges for outpatient setting,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,80,,56.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.33,65,,45.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.87,35,,24.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.38,90,,63.5,percent of total billed charges,90% of total billed charges for outpatient setting,11.32,79.38,
CANNULA 10FT NASAL W/CO2 / 4707-10-10-25,5050092,CDM,270,RC,,,Outpatient,,,10.71,10.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,84.88,,7.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.36,50,,4.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,75,,6.42,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,80,,6.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.96,65,,5.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,35,,3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.64,90,,7.71,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.64,
CANNULA 10MM 3CM PASSPORT / AR6592-10-30,69161928,CDM,272,RC,,,Outpatient,,,173.04,173.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,84.88,,117.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.52,50,,69.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.78,75,,103.82,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.43,80,,110.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.48,65,,89.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.56,35,,48.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,90,,124.59,percent of total billed charges,90% of total billed charges for outpatient setting,22.22,155.74,
CANNULA 13FT NASAL O2 / 4707-13-13-25,70000820,CDM,270,RC,,,Outpatient,,,10.71,10.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,84.88,,7.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.36,50,,4.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,75,,6.42,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,80,,6.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.96,65,,5.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,35,,3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.64,90,,7.71,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.64,
CANNULA 14FT NASAL MALE / 4950-14-14-25,1916662,CDM,270,RC,,,Outpatient,,,9.27,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,84.88,,6.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.64,50,,3.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.95,75,,5.56,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,80,,5.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.03,65,,4.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,35,,2.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.34,90,,6.67,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.34,
CANNULA 150MM X 20GX10MM TIP/SL-C1510-20,69169623,CDM,272,RC,,,Outpatient,,,88.2,88.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,74.86,84.88,,59.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.1,50,,35.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.15,75,,52.92,percent of total billed charges,75% of total billed charges for outpatient setting,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,80,,56.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.33,65,,45.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.87,35,,24.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.38,90,,63.5,percent of total billed charges,90% of total billed charges for outpatient setting,11.32,79.38,
CANNULA 30G 4MM ANT CHAMBER / 8065420020,299453,CDM,272,RC,,,Outpatient,,,28.56,28.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,70,,15.99,percent of total billed charges,70% of total billed charges for outpatient setting,24.24,84.88,,19.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.28,50,,11.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.42,75,,17.14,percent of total billed charges,75% of total billed charges for outpatient setting,19.99,70,,15.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.85,80,,18.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.56,65,,14.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,35,,8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.7,90,,20.56,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,25.7,
CANNULA 30G ANTERIOR CHAMBER 5MM/ ED7105,69169524,CDM,272,RC,,,Outpatient,,,18.43,18.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,70,,10.32,percent of total billed charges,70% of total billed charges for outpatient setting,15.64,84.88,,12.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.22,50,,7.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.82,75,,11.06,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,70,,10.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.74,80,,11.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.98,65,,9.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,35,,5.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.59,90,,13.27,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,16.59,
CANNULA 4MMX22CM / PAL-406LS,69162696,CDM,272,RC,,,Outpatient,,,242,242,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.4,70,,135.52,percent of total billed charges,70% of total billed charges for outpatient setting,205.41,84.88,,164.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,121,50,,96.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.5,75,,145.2,percent of total billed charges,75% of total billed charges for outpatient setting,169.4,70,,135.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.07,12.84,,24.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.6,80,,154.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.07,12.84,,24.86,percent of total billed charges,12.84% of total billed charges,31.07,12.84,,24.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.3,65,,125.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.7,35,,67.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,217.8,90,,174.24,percent of total billed charges,90% of total billed charges for outpatient setting,31.07,217.8,
CANNULA 4MMX30CM / PAL-406LL,69162695,CDM,272,RC,,,Outpatient,,,266.8,266.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,226.46,84.88,,181.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.4,50,,106.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.1,75,,160.08,percent of total billed charges,75% of total billed charges for outpatient setting,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.44,80,,170.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.42,65,,138.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.12,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.12,
CANNULA 5.75MM 7CM NON THRD CR / AR-6560,71000499,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 5.75MM 7CM THRD CRYSTAL  AR-6562,71000447,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 5MMX22CM / PAL-506LS,69162773,CDM,272,RC,,,Outpatient,,,266.8,266.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,226.46,84.88,,181.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.4,50,,106.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.1,75,,160.08,percent of total billed charges,75% of total billed charges for outpatient setting,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.44,80,,170.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.42,65,,138.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.12,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.12,
CANNULA 5MMX22CM MERCEDES / PAL-504LS,69169861,CDM,272,RC,,,Outpatient,,,242,242,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.4,70,,135.52,percent of total billed charges,70% of total billed charges for outpatient setting,205.41,84.88,,164.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,121,50,,96.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.5,75,,145.2,percent of total billed charges,75% of total billed charges for outpatient setting,169.4,70,,135.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.07,12.84,,24.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.6,80,,154.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.07,12.84,,24.86,percent of total billed charges,12.84% of total billed charges,31.07,12.84,,24.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.3,65,,125.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.7,35,,67.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,217.8,90,,174.24,percent of total billed charges,90% of total billed charges for outpatient setting,31.07,217.8,
CANNULA 5MMX30CM / PAL-506LL,69169859,CDM,272,RC,,,Outpatient,,,266.8,266.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,226.46,84.88,,181.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.4,50,,106.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.1,75,,160.08,percent of total billed charges,75% of total billed charges for outpatient setting,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.44,80,,170.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.42,65,,138.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.12,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.12,
CANNULA 7MM 11CM PT THRD / AR-6577-11,71000829,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 7MM PART THRD / AR-6567,69161714,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 8.25MM 7CM PARTIAL / AR-6566,71000448,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CANNULA 8.25X7MM TWIST-IN    AR-6530,69160717,CDM,272,RC,,,Outpatient,,,135.19,135.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,114.75,84.88,,91.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.6,50,,54.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.39,75,,81.11,percent of total billed charges,75% of total billed charges for outpatient setting,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.15,80,,86.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.87,65,,70.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.32,35,,37.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.67,90,,97.34,percent of total billed charges,90% of total billed charges for outpatient setting,17.36,121.67,
CANNULA 8.25X9MMTWIST-IN / AR-6540,69161449,CDM,272,RC,,,Outpatient,,,162.23,162.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,70,,90.85,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,84.88,,110.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.12,50,,64.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.67,75,,97.34,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,70,,90.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,12.84,,16.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.78,80,,103.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,12.84,,16.66,percent of total billed charges,12.84% of total billed charges,20.83,12.84,,16.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.45,65,,84.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,35,,45.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.01,90,,116.81,percent of total billed charges,90% of total billed charges for outpatient setting,20.83,146.01,
CANNULA 8MM 3CM PASSPORT / AR-6592-08-30,71000567,CDM,272,RC,,,Outpatient,,,168,168,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.6,70,,94.08,percent of total billed charges,70% of total billed charges for outpatient setting,142.6,84.88,,114.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,84,50,,67.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,75,,100.8,percent of total billed charges,75% of total billed charges for outpatient setting,117.6,70,,94.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.57,12.84,,17.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,80,,107.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.57,12.84,,17.26,percent of total billed charges,12.84% of total billed charges,21.57,12.84,,17.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.2,65,,87.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,35,,47.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,90,,120.96,percent of total billed charges,90% of total billed charges for outpatient setting,21.57,151.2,
CANNULA 8MM 4CM PASSPORT / AR-6592-08-40,69162240,CDM,272,RC,,,Outpatient,,,173.04,173.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,84.88,,117.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.52,50,,69.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.78,75,,103.82,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.43,80,,110.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.48,65,,89.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.56,35,,48.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,90,,124.59,percent of total billed charges,90% of total billed charges for outpatient setting,22.22,155.74,
CANNULA COUNTERSINK 4.0 / 702473,70000330,CDM,272,RC,,,Outpatient,,,1583.32,1583.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.32,70,,886.66,percent of total billed charges,70% of total billed charges for outpatient setting,1343.92,84.88,,1075.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,791.66,50,,633.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1187.49,75,,949.99,percent of total billed charges,75% of total billed charges for outpatient setting,1108.32,70,,886.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,12.84,,162.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1266.66,80,,1013.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,12.84,,162.64,percent of total billed charges,12.84% of total billed charges,203.3,12.84,,162.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1029.16,65,,823.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.16,35,,443.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1424.99,90,,1139.99,percent of total billed charges,90% of total billed charges for outpatient setting,203.3,1424.99,
CANNULA CRVD 7' TUBE/ HCS4511B,70000822,CDM,270,RC,,,Outpatient,,,2.93,2.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,70,,1.64,percent of total billed charges,70% of total billed charges for outpatient setting,2.49,84.88,,1.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.47,50,,1.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.2,75,,1.76,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,70,,1.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,80,,1.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.9,65,,1.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,35,,0.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.64,90,,2.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.38,2.64,
CANNULA CRVD N-FLAIR TIP W/14IN,245000,CDM,270,RC,,,Outpatient,,,5.93,5.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,70,,3.32,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.97,50,,2.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.45,75,,3.56,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,70,,3.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.34,90,,4.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.34,
CANNULA CRVD NON-FLAIR TIP / 0556,5050006,CDM,270,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,70,,1.68,percent of total billed charges,70% of total billed charges for outpatient setting,2.55,84.88,,2.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.5,50,,1.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.25,75,,1.8,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,70,,1.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.4,80,,1.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.95,65,,1.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,35,,0.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.7,90,,2.16,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.7,
CANNULA CURETTE 4MM SEMIRIGID/ MX624,69160499,CDM,272,RC,,,Outpatient,,,50.9,50.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.63,70,,28.5,percent of total billed charges,70% of total billed charges for outpatient setting,43.2,84.88,,34.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.45,50,,20.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.18,75,,30.54,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,70,,28.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.72,80,,32.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.09,65,,26.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,35,,14.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.81,90,,36.65,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.81,
CANNULA CURETTE 7MM SEMI RIGID/ MX627,69161479,CDM,272,RC,,,Outpatient,,,41.18,41.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,34.95,84.88,,27.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.59,50,,16.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.89,75,,24.71,percent of total billed charges,75% of total billed charges for outpatient setting,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.94,80,,26.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.77,65,,21.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,35,,11.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.06,90,,29.65,percent of total billed charges,90% of total billed charges for outpatient setting,5.29,37.06,
CANNULA SPATULA 3MM / PAL-30S3,69169142,CDM,272,RC,,,Outpatient,,,266.8,266.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,226.46,84.88,,181.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.4,50,,106.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.1,75,,160.08,percent of total billed charges,75% of total billed charges for outpatient setting,186.76,70,,149.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.44,80,,170.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.42,65,,138.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.12,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.12,
CANNULA TRIPLEDAM 8.25MMX7CM / AR-6530TD,69162333,CDM,272,RC,,,Outpatient,,,173.04,173.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,84.88,,117.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.52,50,,69.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.78,75,,103.82,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.43,80,,110.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.48,65,,89.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.56,35,,48.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,90,,124.59,percent of total billed charges,90% of total billed charges for outpatient setting,22.22,155.74,
CANNULA TWIST-IN NOTCHED / AR-6530N,69162239,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
CAP CREO LOCKING / 1119.0000,69161730,CDM,278,RC,C1713,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,60,,144,percent of total billed charges,60% of total Billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,300,65,,240,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,60,,144,percent of total billed charges,60% of total billed charges for outpatient setting,38.52,300,
CAPSAICIN CREAM 45GM:,3300741,CDM,259,RC,,,Outpatient,,,44.48,44.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,37.75,84.88,,30.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.24,50,,17.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.36,75,,26.69,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.58,80,,28.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.91,65,,23.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.57,35,,12.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.03,90,,32.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.71,40.03,
CAPSAICIN CREAM 60GM:,3300742,CDM,259,RC,,,Outpatient,,,26.82,26.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,22.76,84.88,,18.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.41,50,,10.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.12,75,,16.1,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.46,80,,17.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.43,65,,13.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,35,,7.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.14,90,,19.31,percent of total billed charges,90% of total billed charges for outpatient setting,3.44,24.14,
CAPSULAR TENSION RING 13/11/ CTR11R,69162052,CDM,278,RC,L8699,HCPCS,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,60,,288,percent of total billed charges,60% of total Billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600,65,,480,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360,60,,288,percent of total billed charges,60% of total billed charges for outpatient setting,77.04,600,
CAPTOPRIL 12.5MG TAB,3300743,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CAPTOPRIL 25MG TAB,3300745,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CAPTOPRIL HCT 50/25 TAB:,3303083,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CAPTOPRIL TAB: 25 MG,3300744,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CARBACHOL (ISOPTO) OPTH SOL 3% 15ML,3300746,CDM,259,RC,,,Outpatient,,,107.37,107.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.16,70,,60.13,percent of total billed charges,70% of total billed charges for outpatient setting,91.14,84.88,,72.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.69,50,,42.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.53,75,,64.42,percent of total billed charges,75% of total billed charges for outpatient setting,75.16,70,,60.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,12.84,,11.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,80,,68.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,12.84,,11.03,percent of total billed charges,12.84% of total billed charges,13.79,12.84,,11.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.79,65,,55.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,35,,30.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.63,90,,77.3,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,96.63,
CARBAMAZEPINE (TEGRETOL) CHEW: 100MG,3300749,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CARBAMAZEPINE (TEGRETOL) TAB :200 MG,3300747,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CARBAMAZEPINE (TEGRETOL) TAB 200 MG,3300748,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARBAMEZEPINE,220333,CDM,300,RC,80156,HCPCS,Outpatient,,,65.57,59.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,55.66,84.88,,44.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.18,75,,39.34,percent of total billed charges,75% of total billed charges for outpatient setting,45.9,70,,36.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.46,80,,41.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,59.01,90,,47.21,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,59.01,
CARBAMIDE PEROXIDE (DEBROX)OTIC SOL:15ML,3300751,CDM,259,RC,,,Outpatient,,,5.92,5.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.96,50,,2.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.44,75,,3.55,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.33,90,,4.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.33,
CARBAMIDE PEROXIDE(DEBROX) OTIC SOL:15ML,3300750,CDM,259,RC,,,Outpatient,,,8.09,8.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,84.88,,5.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.05,50,,3.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.07,75,,4.86,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,80,,5.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.26,65,,4.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,35,,2.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.28,90,,5.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.28,
CARBIDOPA 10/100 (SINEMET) TAB,3300754,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARBIDOPA 25/100 (SINEMET) TAB :,3300752,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CARBIDOPA 25/100 (SINEMET) TAB : U/D,3300753,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CARBIDOPA 25/250 (SINEMET) TAB,3300756,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARBIDOPA 50-200 (SINEMET) TAB U/D,3300758,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARBIDOPA CR 25/100 (SINEMET ) TAB : U/D,3300757,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CARBIDOPA/LEVO 25/100 (genSINEMET) TAB,3300755,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARBOCAINE (MEPIVICAINE)2% 20 ML SDV,3302775,CDM,250,RC,,,Outpatient,,,15.17,15.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,84.88,,10.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.59,50,,6.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.38,75,,9.1,percent of total billed charges,75% of total billed charges for outpatient setting,10.62,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,80,,9.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.86,65,,7.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.31,35,,4.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.65,90,,10.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.95,13.65,
CARBOCAINE (MEPIVICAINE)2% 50 ML MDV,3305384,CDM,250,RC,,,Outpatient,,,25.73,25.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.01,70,,14.41,percent of total billed charges,70% of total billed charges for outpatient setting,21.84,84.88,,17.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.87,50,,10.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.3,75,,15.44,percent of total billed charges,75% of total billed charges for outpatient setting,18.01,70,,14.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.58,80,,16.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.72,65,,13.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,35,,7.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.16,90,,18.53,percent of total billed charges,90% of total billed charges for outpatient setting,3.3,23.16,
CARBOCAINE(MEPIVICAINE)1% 20 ML SDV,3302774,CDM,250,RC,,,Outpatient,,,54.57,54.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.2,70,,30.56,percent of total billed charges,70% of total billed charges for outpatient setting,46.32,84.88,,37.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.29,50,,21.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,75,,32.74,percent of total billed charges,75% of total billed charges for outpatient setting,38.2,70,,30.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,12.84,,5.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,80,,34.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,12.84,,5.61,percent of total billed charges,12.84% of total billed charges,7.01,12.84,,5.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.47,65,,28.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.1,35,,15.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.11,90,,39.29,percent of total billed charges,90% of total billed charges for outpatient setting,7.01,49.11,
CARBON FIB. ROD 8MM DIST. RAD FIXATION,69162094,CDM,272,RC,,,Outpatient,,,893.4,893.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.38,70,,500.3,percent of total billed charges,70% of total billed charges for outpatient setting,758.32,84.88,,606.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,446.7,50,,357.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,670.05,75,,536.04,percent of total billed charges,75% of total billed charges for outpatient setting,625.38,70,,500.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.71,12.84,,91.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.72,80,,571.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.71,12.84,,91.77,percent of total billed charges,12.84% of total billed charges,114.71,12.84,,91.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580.71,65,,464.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.69,35,,250.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,804.06,90,,643.25,percent of total billed charges,90% of total billed charges for outpatient setting,114.71,804.06,
"CARDIOVERSION, EXTERNAL",6050500,CDM,480,RC,92960,HCPCS,Outpatient,,,852.27,852.27,,805.43,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,596.59,70,,477.27,percent of total billed charges,70% of total billed charges for outpatient setting,723.41,84.88,,578.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,713.01,50,,570.41,percent of total billed charges,50% of total Billed charges for outpatient setting,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,639.2,75,,511.36,percent of total billed charges,75% of total billed charges for outpatient setting,596.59,70,,477.27,percent of total billed charges,70% of total billed charges for outpatient setting,855.78,170,,,Fee Schedule,170% of Medicare OPPS rate,1082.3,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,109.43,12.84,,87.544,percent of total billed charges,12.84% of total billed charges,880.94,175,,,Fee Schedule,175% of Medicare OPPS rate,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,681.82,80,,545.46,percent of total billed charges,80% of total billed charges for outpatient setting,704.76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,629.25,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,109.43,12.84,,87.54,percent of total billed charges,12.84% of total billed charges,109.43,12.84,,87.54,percent of total billed charges,12.84% of total billed charges,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,503.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,525.12,100,,,Fee Schedule,100% of Custom Fee Schedule,767.04,90,,613.63,percent of total billed charges,90% of total billed charges for outpatient setting,109.43,1082.3,
CARDIZEM LA 360 MG,3303033,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARIMUNE NF (12 GRAMS) 200 ML,3303027,CDM,250,RC,J1566,HCPCS,Outpatient,,,913.52,913.52,,118.4,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,639.46,70,,511.57,percent of total billed charges,70% of total billed charges for outpatient setting,775.4,84.88,,620.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,685.14,75,,548.11,percent of total billed charges,75% of total billed charges for outpatient setting,639.46,70,,511.57,percent of total billed charges,70% of total billed charges for outpatient setting,125.8,170,,,Fee Schedule,170% of Medicare OPPS rate,159.1,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,117.3,12.84,,93.84,percent of total billed charges,12.84% of total billed charges,129.5,175,,,Fee Schedule,175% of Medicare OPPS rate,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,730.82,80,,584.66,percent of total billed charges,80% of total billed charges for outpatient setting,103.6,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,92.5,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,117.3,12.84,,93.84,percent of total billed charges,12.84% of total billed charges,117.3,12.84,,93.84,percent of total billed charges,12.84% of total billed charges,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,593.79,65,,475.03,percent of total billed charges,65% of total billed charges for outpatient setting,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,74,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.84,100,,,Fee Schedule,100% of Custom Fee Schedule,822.17,90,,657.74,percent of total billed charges,90% of total billed charges for outpatient setting,43.84,822.17,
CARISOPRODOL (SOMA) 350 MG TAB,3303131,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CARMEX 0.35 OZ,3303043,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARNITINE TOTAL AND FREE,220102,CDM,301,RC,83789,HCPCS,Outpatient,,,108.5,97.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.95,70,,60.76,percent of total billed charges,70% of total billed charges for outpatient setting,92.09,84.88,,73.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,81.38,75,,65.1,percent of total billed charges,75% of total billed charges for outpatient setting,75.95,70,,60.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.8,80,,69.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,97.65,90,,78.12,percent of total billed charges,90% of total billed charges for outpatient setting,24.11,97.65,
CAROTENE BETA,200942,CDM,300,RC,82380,HCPCS,Outpatient,,,41.49,37.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.04,70,,23.23,percent of total billed charges,70% of total billed charges for outpatient setting,35.22,84.88,,28.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.12,75,,24.9,percent of total billed charges,75% of total billed charges for outpatient setting,29.04,70,,23.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.19,80,,26.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,100,,,Fee Schedule,100% of Custom Fee Schedule,37.34,90,,29.87,percent of total billed charges,90% of total billed charges for outpatient setting,9.22,37.34,
CARPAL TUNNEL TOME / 200060,6152184,CDM,270,RC,,,Outpatient,,,790.36,790.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.25,70,,442.6,percent of total billed charges,70% of total billed charges for outpatient setting,670.86,84.88,,536.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,395.18,50,,316.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.77,75,,474.22,percent of total billed charges,75% of total billed charges for outpatient setting,553.25,70,,442.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.48,12.84,,81.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.29,80,,505.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.48,12.84,,81.18,percent of total billed charges,12.84% of total billed charges,101.48,12.84,,81.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,513.73,65,,410.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.63,35,,221.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,711.32,90,,569.06,percent of total billed charges,90% of total billed charges for outpatient setting,101.48,711.32,
CARTRIDGE ARGON GAS / MINARGC,1925084,CDM,272,RC,,,Outpatient,,,102,102,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.4,70,,57.12,percent of total billed charges,70% of total billed charges for outpatient setting,86.58,84.88,,69.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,51,50,,40.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,75,,61.2,percent of total billed charges,75% of total billed charges for outpatient setting,71.4,70,,57.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,80,,65.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.3,65,,53.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,35,,28.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.8,90,,73.44,percent of total billed charges,90% of total billed charges for outpatient setting,13.1,91.8,
CARTRIDGE CO2 GAS / MINCO2C,1925085,CDM,272,RC,,,Outpatient,,,77,77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.9,70,,43.12,percent of total billed charges,70% of total billed charges for outpatient setting,65.36,84.88,,52.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.5,50,,30.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,75,,46.2,percent of total billed charges,75% of total billed charges for outpatient setting,53.9,70,,43.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,12.84,,7.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,80,,49.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,12.84,,7.91,percent of total billed charges,12.84% of total billed charges,9.89,12.84,,7.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.05,65,,40.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,35,,21.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.3,90,,55.44,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,69.3,
CARVEDILOL (COREG) CR TAB:10 MG,3303258,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CARVEDILOL (COREG) TAB 12.5 MG,3303265,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARVEDILOL (COREG) TAB 6.25 MG,3300759,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CARVEDILOL (genericCOREG) 3.125 MG TAB,3302826,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CASANTHR DOC (PERI COLACE) CAP U/D,3300760,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CASCARA LIQUID 30ML,3302910,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CASSETTE RESERVOIR 250ML,3309097,CDM,250,RC,,,Outpatient,,,92.97,92.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.08,70,,52.06,percent of total billed charges,70% of total billed charges for outpatient setting,78.91,84.88,,63.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.49,50,,37.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.73,75,,55.78,percent of total billed charges,75% of total billed charges for outpatient setting,65.08,70,,52.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.38,80,,59.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,11.94,12.84,,9.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.43,65,,48.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.54,35,,26.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.67,90,,66.94,percent of total billed charges,90% of total billed charges for outpatient setting,11.94,83.67,
CASSETTE RESERVOIR 50ML,3309098,CDM,250,RC,,,Outpatient,,,37.85,37.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,32.13,84.88,,25.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.93,50,,15.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.39,75,,22.71,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,80,,24.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.6,65,,19.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,35,,10.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.07,90,,27.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,34.07,
CAST 2 IN FIBERGLASS / SCS7345801,69162486,CDM,270,RC,,,Outpatient,,,9.93,9.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,70,,5.56,percent of total billed charges,70% of total billed charges for outpatient setting,8.43,84.88,,6.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.97,50,,3.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.45,75,,5.96,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,70,,5.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,80,,6.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.45,65,,5.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.48,35,,2.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.94,90,,7.15,percent of total billed charges,90% of total billed charges for outpatient setting,1.28,8.94,
CAST PADDING 3IN STERILE / 30-320,69160127,CDM,272,RC,,,Outpatient,,,23.84,23.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,70,,13.35,percent of total billed charges,70% of total billed charges for outpatient setting,20.24,84.88,,16.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.92,50,,9.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.88,75,,14.3,percent of total billed charges,75% of total billed charges for outpatient setting,16.69,70,,13.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.07,80,,15.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.5,65,,12.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,35,,6.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.46,90,,17.17,percent of total billed charges,90% of total billed charges for outpatient setting,3.06,21.46,
CAST PADDING 4IN STERILE / 30-321,6153120,CDM,272,RC,,,Outpatient,,,22.95,22.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.48,84.88,,15.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.48,50,,9.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,75,,13.77,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,80,,14.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.92,65,,11.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,35,,6.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,2.95,20.66,
CAST PADDING 6IN STER / 30-322,6153121,CDM,272,RC,,,Outpatient,,,36.72,36.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,31.17,84.88,,24.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.36,50,,14.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.54,75,,22.03,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,80,,23.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.87,65,,19.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,35,,10.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.05,90,,26.44,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,33.05,
CASTOR OIL :  2 OZ,3300764,CDM,259,RC,,,Outpatient,,,5.47,5.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.64,84.88,,3.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.74,50,,2.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.38,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.56,65,,2.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.92,90,,3.94,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.92,
CASTOR OIL 30 ML,3303035,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CASTOR OIL UNFLAVORED: 60ML,3300763,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CAT SCRATCH DISEASE AB PROFILE,220110,CDM,300,RC,86611,HCPCS,Outpatient,,,45.81,41.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,84.88,,31.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.36,75,,27.49,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,80,,29.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,100,,,Fee Schedule,100% of Custom Fee Schedule,41.23,90,,32.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,41.23,
CATECHOLAMINES  24 HR URINE,220109,CDM,301,RC,82384,HCPCS,Outpatient,,,113.63,102.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,70,,63.63,percent of total billed charges,70% of total billed charges for outpatient setting,96.45,84.88,,77.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.22,75,,68.18,percent of total billed charges,75% of total billed charges for outpatient setting,79.54,70,,63.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.9,80,,72.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.87,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.89,100,,,Fee Schedule,100% of Custom Fee Schedule,102.27,90,,81.82,percent of total billed charges,90% of total billed charges for outpatient setting,25.25,102.27,
CATECHOLAMINES PLASMA,220825,CDM,301,RC,82384,HCPCS,Outpatient,,,113.63,102.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,70,,63.63,percent of total billed charges,70% of total billed charges for outpatient setting,96.45,84.88,,77.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.22,75,,68.18,percent of total billed charges,75% of total billed charges for outpatient setting,79.54,70,,63.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.9,80,,72.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.87,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.89,100,,,Fee Schedule,100% of Custom Fee Schedule,102.27,90,,81.82,percent of total billed charges,90% of total billed charges for outpatient setting,25.25,102.27,
CATETER 18 FR COUDE RU20518,6150247,CDM,272,RC,,,Outpatient,,,142.6,142.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.82,70,,79.86,percent of total billed charges,70% of total billed charges for outpatient setting,121.04,84.88,,96.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.3,50,,57.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.95,75,,85.56,percent of total billed charges,75% of total billed charges for outpatient setting,99.82,70,,79.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,12.84,,14.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.08,80,,91.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,12.84,,14.65,percent of total billed charges,12.84% of total billed charges,18.31,12.84,,14.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.69,65,,74.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.91,35,,39.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.34,90,,102.67,percent of total billed charges,90% of total billed charges for outpatient setting,18.31,128.34,
CATH 10FR RED RUBBER / 8887660101,6150445,CDM,272,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CATH 12FR RED RUBBER / 8412,6150244,CDM,272,RC,,,Outpatient,,,19.8,19.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,16.81,84.88,,13.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.9,50,,7.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,75,,11.88,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,80,,12.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.87,65,,10.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.93,35,,5.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.82,90,,14.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,17.82,
CATH 14FR RED RUBBER // DYND13514,6150245,CDM,272,RC,,,Outpatient,,,3.94,3.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,70,,2.21,percent of total billed charges,70% of total billed charges for outpatient setting,3.34,84.88,,2.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.97,50,,1.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.96,75,,2.37,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,70,,2.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,80,,2.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.56,65,,2.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,35,,1.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.55,90,,2.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.51,3.55,
CATH 20G 1IN IV AUTOGUARD / 381433,2450041,CDM,272,RC,,,Outpatient,,,16.11,16.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,13.67,84.88,,10.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.06,50,,6.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.08,75,,9.66,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,80,,10.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.47,65,,8.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,35,,4.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.5,90,,11.6,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,14.5,
CATH 20G 1IN IV JELCO / 405720,761690,CDM,272,RC,,,Outpatient,,,19.89,19.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.92,70,,11.14,percent of total billed charges,70% of total billed charges for outpatient setting,16.88,84.88,,13.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.95,50,,7.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.92,75,,11.94,percent of total billed charges,75% of total billed charges for outpatient setting,13.92,70,,11.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,12.84,,2.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,80,,12.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,12.84,,2.04,percent of total billed charges,12.84% of total billed charges,2.55,12.84,,2.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.93,65,,10.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,35,,5.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.9,90,,14.32,percent of total billed charges,90% of total billed charges for outpatient setting,2.55,17.9,
CATH 20G 1IN IV PROTECT / 3057,6150312,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATH 20G 2IN IV INTROCAN / 4242010-02,7861804,CDM,272,RC,,,Outpatient,,,15.12,15.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,70,,8.46,percent of total billed charges,70% of total billed charges for outpatient setting,12.83,84.88,,10.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.56,50,,6.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.34,75,,9.07,percent of total billed charges,75% of total billed charges for outpatient setting,10.58,70,,8.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,80,,9.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.83,65,,7.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,35,,4.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.61,90,,10.89,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,13.61,
CATH 20G 2IN IV RAD / 386874,71000916,CDM,272,RC,,,Outpatient,,,23.4,23.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.38,70,,13.1,percent of total billed charges,70% of total billed charges for outpatient setting,19.86,84.88,,15.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.7,50,,9.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.55,75,,14.04,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,70,,13.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,80,,14.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.21,65,,12.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,35,,6.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.06,90,,16.85,percent of total billed charges,90% of total billed charges for outpatient setting,3,21.06,
CATH 22G 1IN IV PROTECT / 3050,6150309,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATH 24FR 30ML 3WAY SIMPLASTIC / 570624,69162420,CDM,272,RC,,,Outpatient,,,146.1,146.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.27,70,,81.82,percent of total billed charges,70% of total billed charges for outpatient setting,124.01,84.88,,99.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.05,50,,58.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.58,75,,87.66,percent of total billed charges,75% of total billed charges for outpatient setting,102.27,70,,81.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.76,12.84,,15.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.88,80,,93.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.76,12.84,,15.01,percent of total billed charges,12.84% of total billed charges,18.76,12.84,,15.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.97,65,,75.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.14,35,,40.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,90,,105.19,percent of total billed charges,90% of total billed charges for outpatient setting,18.76,131.49,
CATH 24G 0.75IN IV PROTECT / 3053,5150095,CDM,272,RC,,,Outpatient,,,15.84,15.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.09,70,,8.87,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,84.88,,10.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.92,50,,6.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.88,75,,9.5,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,70,,8.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,12.84,,1.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.67,80,,10.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.03,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.3,65,,8.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.54,35,,4.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.26,90,,11.41,percent of total billed charges,90% of total billed charges for outpatient setting,2.03,14.26,
CATH 3-WAY 22FR 30CC SIL / 73022SI,69162922,CDM,272,RC,A4346,HCPCS,Outpatient,,,70.63,70.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,70,,39.55,percent of total billed charges,70% of total billed charges for outpatient setting,59.95,84.88,,47.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.97,75,,42.38,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,70,,39.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,12.84,,7.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,80,,45.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,12.84,,7.26,percent of total billed charges,12.84% of total billed charges,9.07,12.84,,7.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.91,65,,36.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.57,90,,50.86,percent of total billed charges,90% of total billed charges for outpatient setting,9.07,63.57,
CATH 4 FR OLIVE FILIFORM HEYMN / 136904,69162047,CDM,272,RC,,,Outpatient,,,42.42,42.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.69,70,,23.75,percent of total billed charges,70% of total billed charges for outpatient setting,36.01,84.88,,28.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.21,50,,16.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.82,75,,25.46,percent of total billed charges,75% of total billed charges for outpatient setting,29.69,70,,23.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.45,12.84,,4.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.94,80,,27.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.45,12.84,,4.36,percent of total billed charges,12.84% of total billed charges,5.45,12.84,,4.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.57,65,,22.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,35,,11.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.18,90,,30.54,percent of total billed charges,90% of total billed charges for outpatient setting,5.45,38.18,
CATH 4 FR SPIRAL FILIFORM HEYMN / 137904,69162048,CDM,272,RC,,,Outpatient,,,178.45,178.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,151.47,84.88,,121.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.23,50,,71.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.84,75,,107.07,percent of total billed charges,75% of total billed charges for outpatient setting,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,12.84,,18.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.76,80,,114.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,12.84,,18.33,percent of total billed charges,12.84% of total billed charges,22.91,12.84,,18.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.99,65,,92.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.46,35,,49.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.61,90,,128.49,percent of total billed charges,90% of total billed charges for outpatient setting,22.91,160.61,
CATH 8FR RED RUBBER / 8408,6150444,CDM,272,RC,,,Outpatient,,,9.54,9.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,84.88,,6.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.77,50,,3.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.16,75,,5.73,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,80,,6.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.2,65,,4.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,35,,2.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.59,90,,6.87,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.59,
CATH CHOLANGIOGRAPHY W/INTRO /C1002,6150394,CDM,272,RC,,,Outpatient,,,294.17,294.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,70,,164.74,percent of total billed charges,70% of total billed charges for outpatient setting,249.69,84.88,,199.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,147.09,50,,117.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.63,75,,176.5,percent of total billed charges,75% of total billed charges for outpatient setting,205.92,70,,164.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.34,80,,188.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,191.21,65,,152.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.96,35,,82.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,264.75,90,,211.8,percent of total billed charges,90% of total billed charges for outpatient setting,37.77,264.75,
CATH EMBLCTMY 3FR 40cm/GREEN/ 120403F,6150875,CDM,272,RC,C1757,HCPCS,Outpatient,,,243.06,243.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.14,70,,136.11,percent of total billed charges,70% of total billed charges for outpatient setting,206.31,84.88,,165.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.3,75,,145.84,percent of total billed charges,75% of total billed charges for outpatient setting,170.14,70,,136.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.21,12.84,,24.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.45,80,,155.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.21,12.84,,24.97,percent of total billed charges,12.84% of total billed charges,31.21,12.84,,24.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.99,65,,126.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.07,35,,68.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,218.75,90,,175,percent of total billed charges,90% of total billed charges for outpatient setting,31.21,218.75,
CATH EMBLCTMY 3FR 80CM GREEN / 120803F,6152167,CDM,272,RC,C1757,HCPCS,Outpatient,,,822.68,822.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.88,70,,460.7,percent of total billed charges,70% of total billed charges for outpatient setting,698.29,84.88,,558.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.01,75,,493.61,percent of total billed charges,75% of total billed charges for outpatient setting,575.88,70,,460.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.63,12.84,,84.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.14,80,,526.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.63,12.84,,84.5,percent of total billed charges,12.84% of total billed charges,105.63,12.84,,84.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.74,65,,427.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.94,35,,230.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,740.41,90,,592.33,percent of total billed charges,90% of total billed charges for outpatient setting,105.63,740.41,
CATH EMBLCTMY 4FR 40cm RED 120404F,6150876,CDM,272,RC,C1757,HCPCS,Outpatient,,,357.59,357.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.31,70,,200.25,percent of total billed charges,70% of total billed charges for outpatient setting,303.52,84.88,,242.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.19,75,,214.55,percent of total billed charges,75% of total billed charges for outpatient setting,250.31,70,,200.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.91,12.84,,36.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.07,80,,228.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.91,12.84,,36.73,percent of total billed charges,12.84% of total billed charges,45.91,12.84,,36.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.43,65,,185.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.16,35,,100.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.83,90,,257.46,percent of total billed charges,90% of total billed charges for outpatient setting,45.91,321.83,
CATH EMBLCTMY 4FR 80CM RED / 120804F,6152168,CDM,272,RC,C1757,HCPCS,Outpatient,,,821.72,821.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.2,70,,460.16,percent of total billed charges,70% of total billed charges for outpatient setting,697.48,84.88,,557.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.29,75,,493.03,percent of total billed charges,75% of total billed charges for outpatient setting,575.2,70,,460.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.51,12.84,,84.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.38,80,,525.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.51,12.84,,84.41,percent of total billed charges,12.84% of total billed charges,105.51,12.84,,84.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.12,65,,427.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.6,35,,230.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,739.55,90,,591.64,percent of total billed charges,90% of total billed charges for outpatient setting,105.51,739.55,
CATH ESOPHAGEAL CRE 10-12MM / 5835,70000556,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
CATH ESOPHAGEAL CRE 12-15MM / 5836,70000557,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
CATH ESOPHAGEAL CRE 15-18MM / 5837,69160954,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
CATH HEMATURIA 3WAY 24FR 30CC / 2557H24,70000152,CDM,272,RC,,,Outpatient,,,96.71,96.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.7,70,,54.16,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,84.88,,65.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.36,50,,38.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.53,75,,58.02,percent of total billed charges,75% of total billed charges for outpatient setting,67.7,70,,54.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.42,12.84,,9.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.37,80,,61.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.42,12.84,,9.94,percent of total billed charges,12.84% of total billed charges,12.42,12.84,,9.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.86,65,,50.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,35,,27.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.04,90,,69.63,percent of total billed charges,90% of total billed charges for outpatient setting,12.42,87.04,
CATH IV 18G 1.75IN JELCO / 4054,69161976,CDM,272,RC,,,Outpatient,,,19.35,19.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,16.42,84.88,,13.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.68,50,,7.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.51,75,,11.61,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,80,,12.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.58,65,,10.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,35,,5.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.42,90,,13.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.48,17.42,
CATH IV PROTECT 18GX1.25IN / 305506,5050134,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATH PLACEMENT; EA ADD'L 2ND OR 3RD ORD,2200496,CDM,481,RC,,,Outpatient,,,62.49,62.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.74,70,,34.99,percent of total billed charges,70% of total billed charges for outpatient setting,53.04,84.88,,42.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.25,50,,25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.87,75,,37.5,percent of total billed charges,75% of total billed charges for outpatient setting,43.74,70,,34.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,12.84,,6.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,80,,39.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,12.84,,6.42,percent of total billed charges,12.84% of total billed charges,8.02,12.84,,6.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.87,35,,17.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.24,90,,44.99,percent of total billed charges,90% of total billed charges for outpatient setting,8.02,56.24,
CATH PLACEMENT; NONSELECT (AORTA),2200485,CDM,481,RC,,,Outpatient,,,337.46,337.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,286.44,84.88,,229.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,168.73,50,,134.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.1,75,,202.48,percent of total billed charges,75% of total billed charges for outpatient setting,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.97,80,,215.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.11,35,,94.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.71,90,,242.97,percent of total billed charges,90% of total billed charges for outpatient setting,43.33,303.71,
CATH PLACEMENT; SELECT 1ST ORDER,2200705,CDM,481,RC,,,Outpatient,,,337.46,337.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,286.44,84.88,,229.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,168.73,50,,134.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.1,75,,202.48,percent of total billed charges,75% of total billed charges for outpatient setting,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.97,80,,215.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.11,35,,94.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.71,90,,242.97,percent of total billed charges,90% of total billed charges for outpatient setting,43.33,303.71,
CATH PLACEMENT; SELECT 2ND ORDER,2200495,CDM,481,RC,,,Outpatient,,,399.95,399.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.97,70,,223.98,percent of total billed charges,70% of total billed charges for outpatient setting,339.48,84.88,,271.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,199.98,50,,159.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.96,75,,239.97,percent of total billed charges,75% of total billed charges for outpatient setting,279.97,70,,223.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.96,80,,255.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.98,35,,111.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,359.96,90,,287.97,percent of total billed charges,90% of total billed charges for outpatient setting,51.35,359.96,
CATH PLACEMENT; SELECT 3RD ORD,2200500,CDM,481,RC,,,Outpatient,,,462.44,462.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.71,70,,258.97,percent of total billed charges,70% of total billed charges for outpatient setting,392.52,84.88,,314.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,231.22,50,,184.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.83,75,,277.46,percent of total billed charges,75% of total billed charges for outpatient setting,323.71,70,,258.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.38,12.84,,47.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.95,80,,295.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.38,12.84,,47.5,percent of total billed charges,12.84% of total billed charges,59.38,12.84,,47.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.85,35,,129.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,416.2,90,,332.96,percent of total billed charges,90% of total billed charges for outpatient setting,59.38,416.2,
CATH PLACEMENT; SUP/INF VENA CAVA,2200486,CDM,481,RC,,,Outpatient,,,337.46,337.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,286.44,84.88,,229.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,168.73,50,,134.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.1,75,,202.48,percent of total billed charges,75% of total billed charges for outpatient setting,236.22,70,,188.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.97,80,,215.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.11,35,,94.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.71,90,,242.97,percent of total billed charges,90% of total billed charges for outpatient setting,43.33,303.71,
CATH TRAY IN OUT 14FR / 3141,6150459,CDM,272,RC,,,Outpatient,,,24.39,24.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,70,,13.66,percent of total billed charges,70% of total billed charges for outpatient setting,20.7,84.88,,16.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.2,50,,9.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.29,75,,14.63,percent of total billed charges,75% of total billed charges for outpatient setting,17.07,70,,13.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,12.84,,2.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.51,80,,15.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,12.84,,2.5,percent of total billed charges,12.84% of total billed charges,3.13,12.84,,2.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.85,65,,12.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,35,,6.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.95,90,,17.56,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,21.95,
CATH URETERAL 10FR CONE TIP / G14665,69161860,CDM,272,RC,,,Outpatient,,,98.07,98.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.65,70,,54.92,percent of total billed charges,70% of total billed charges for outpatient setting,83.24,84.88,,66.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.04,50,,39.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.55,75,,58.84,percent of total billed charges,75% of total billed charges for outpatient setting,68.65,70,,54.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.46,80,,62.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.75,65,,51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,35,,27.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.26,90,,70.61,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,88.26,
CATH URETERAL 4FR LT FLEXITIP / 021204,69161583,CDM,272,RC,,,Outpatient,,,98.42,98.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,83.54,84.88,,66.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.21,50,,39.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,75,,59.06,percent of total billed charges,75% of total billed charges for outpatient setting,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,80,,62.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.97,65,,51.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,35,,27.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.58,90,,70.86,percent of total billed charges,90% of total billed charges for outpatient setting,12.64,88.58,
CATH URETERAL 4FR OPEN END / 020014,69162603,CDM,272,RC,,,Outpatient,,,98.56,98.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.99,70,,55.19,percent of total billed charges,70% of total billed charges for outpatient setting,83.66,84.88,,66.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.28,50,,39.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.92,75,,59.14,percent of total billed charges,75% of total billed charges for outpatient setting,68.99,70,,55.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,12.84,,10.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.85,80,,63.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,12.84,,10.13,percent of total billed charges,12.84% of total billed charges,12.66,12.84,,10.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.06,65,,51.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.5,35,,27.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.7,90,,70.96,percent of total billed charges,90% of total billed charges for outpatient setting,12.66,88.7,
CATH URETERAL 4FR Right FLEXITIP 021104,69161582,CDM,272,RC,,,Outpatient,,,98.49,98.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,83.6,84.88,,66.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.25,50,,39.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.87,75,,59.1,percent of total billed charges,75% of total billed charges for outpatient setting,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.79,80,,63.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.02,65,,51.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,35,,27.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.64,90,,70.91,percent of total billed charges,90% of total billed charges for outpatient setting,12.65,88.64,
CATH URETERAL 5FR FLEXITIP OPEN ENDED,6150772,CDM,272,RC,,,Outpatient,,,105.84,105.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.09,70,,59.27,percent of total billed charges,70% of total billed charges for outpatient setting,89.84,84.88,,71.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.92,50,,42.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.38,75,,63.5,percent of total billed charges,75% of total billed charges for outpatient setting,74.09,70,,59.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.67,80,,67.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.8,65,,55.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.04,35,,29.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.26,90,,76.21,percent of total billed charges,90% of total billed charges for outpatient setting,13.59,95.26,
CATH URETERAL 5FR OLIVE TIP,6150775,CDM,272,RC,,,Outpatient,,,64.03,64.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.82,70,,35.86,percent of total billed charges,70% of total billed charges for outpatient setting,54.35,84.88,,43.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.02,50,,25.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.02,75,,38.42,percent of total billed charges,75% of total billed charges for outpatient setting,44.82,70,,35.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.22,80,,40.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.62,65,,33.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,35,,17.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.63,90,,46.1,percent of total billed charges,90% of total billed charges for outpatient setting,8.22,57.63,
CATH URETERAL 5FR W/8FR CONE / G14663,69162024,CDM,272,RC,,,Outpatient,,,102.97,102.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.08,70,,57.66,percent of total billed charges,70% of total billed charges for outpatient setting,87.4,84.88,,69.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.49,50,,41.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.23,75,,61.78,percent of total billed charges,75% of total billed charges for outpatient setting,72.08,70,,57.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.38,80,,65.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.93,65,,53.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.04,35,,28.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.67,90,,74.14,percent of total billed charges,90% of total billed charges for outpatient setting,13.22,92.67,
CATH URETERAL 6FR CONE TIP/024606,70000681,CDM,272,RC,,,Outpatient,,,98.42,98.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,83.54,84.88,,66.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.21,50,,39.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,75,,59.06,percent of total billed charges,75% of total billed charges for outpatient setting,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,80,,62.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.97,65,,51.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,35,,27.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.58,90,,70.86,percent of total billed charges,90% of total billed charges for outpatient setting,12.64,88.58,
CATH URETERAL 6FR FLEXITIP OPEN ENDED,69161602,CDM,272,RC,,,Outpatient,,,102.97,102.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.08,70,,57.66,percent of total billed charges,70% of total billed charges for outpatient setting,87.4,84.88,,69.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.49,50,,41.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.23,75,,61.78,percent of total billed charges,75% of total billed charges for outpatient setting,72.08,70,,57.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.38,80,,65.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.93,65,,53.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.04,35,,28.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.67,90,,74.14,percent of total billed charges,90% of total billed charges for outpatient setting,13.22,92.67,
CATH URETERAL 7FR FLEXITIP OPEN ENDED,6150774,CDM,272,RC,,,Outpatient,,,110.31,110.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,93.63,84.88,,74.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.16,50,,44.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.73,75,,66.18,percent of total billed charges,75% of total billed charges for outpatient setting,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.25,80,,70.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.7,65,,57.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.61,35,,30.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.28,90,,79.42,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,99.28,
CATH URETERAL 8FR OPEN END / G14456,6153058,CDM,272,RC,,,Outpatient,,,84.49,84.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.14,70,,47.31,percent of total billed charges,70% of total billed charges for outpatient setting,71.72,84.88,,57.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.25,50,,33.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.37,75,,50.7,percent of total billed charges,75% of total billed charges for outpatient setting,59.14,70,,47.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.59,80,,54.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.92,65,,43.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,35,,23.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.04,90,,60.83,percent of total billed charges,90% of total billed charges for outpatient setting,10.85,76.04,
CATH URETERAL OPN END 5FR / G15943,70000465,CDM,272,RC,,,Outpatient,,,84.86,84.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,70,,47.52,percent of total billed charges,70% of total billed charges for outpatient setting,72.03,84.88,,57.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.43,50,,33.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.65,75,,50.92,percent of total billed charges,75% of total billed charges for outpatient setting,59.4,70,,47.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.89,80,,54.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.16,65,,44.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,35,,23.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.37,90,,61.1,percent of total billed charges,90% of total billed charges for outpatient setting,10.9,76.37,
CATH URETERAL OPN END 5FR / G17161,70000464,CDM,272,RC,,,Outpatient,,,84.86,84.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,70,,47.52,percent of total billed charges,70% of total billed charges for outpatient setting,72.03,84.88,,57.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.43,50,,33.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.65,75,,50.92,percent of total billed charges,75% of total billed charges for outpatient setting,59.4,70,,47.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.89,80,,54.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,10.9,12.84,,8.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.16,65,,44.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,35,,23.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.37,90,,61.1,percent of total billed charges,90% of total billed charges for outpatient setting,10.9,76.37,
CATHETER 10FR 2-WAY SIL / 165810,69162623,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER 12FR 2-WAY SIL / 165812,69162624,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER 12FR 9IN TROCAR / 8888561027,71000404,CDM,272,RC,,,Outpatient,,,108.48,108.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.94,70,,60.75,percent of total billed charges,70% of total billed charges for outpatient setting,92.08,84.88,,73.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.24,50,,43.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.36,75,,65.09,percent of total billed charges,75% of total billed charges for outpatient setting,75.94,70,,60.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,12.84,,11.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.78,80,,69.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,12.84,,11.14,percent of total billed charges,12.84% of total billed charges,13.93,12.84,,11.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.51,65,,56.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.97,35,,30.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.63,90,,78.1,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,97.63,
CATHETER 14FR COUDE / 0168L14,69162724,CDM,272,RC,,,Outpatient,,,49.84,49.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,84.88,,33.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.92,50,,19.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.38,75,,29.9,percent of total billed charges,75% of total billed charges for outpatient setting,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,80,,31.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.4,65,,25.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,35,,13.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.86,90,,35.89,percent of total billed charges,90% of total billed charges for outpatient setting,6.4,44.86,
CATHETER 16 FR COUDE 2 WAY / PS20516,6150246,CDM,272,RC,,,Outpatient,,,142.6,142.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.82,70,,79.86,percent of total billed charges,70% of total billed charges for outpatient setting,121.04,84.88,,96.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.3,50,,57.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.95,75,,85.56,percent of total billed charges,75% of total billed charges for outpatient setting,99.82,70,,79.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,12.84,,14.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.08,80,,91.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,12.84,,14.65,percent of total billed charges,12.84% of total billed charges,18.31,12.84,,14.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.69,65,,74.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.91,35,,39.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.34,90,,102.67,percent of total billed charges,90% of total billed charges for outpatient setting,18.31,128.34,
CATHETER 16FR COUDE / 0168L16,6151071,CDM,272,RC,,,Outpatient,,,49.84,49.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,84.88,,33.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.92,50,,19.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.38,75,,29.9,percent of total billed charges,75% of total billed charges for outpatient setting,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,80,,31.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.4,65,,25.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,35,,13.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.86,90,,35.89,percent of total billed charges,90% of total billed charges for outpatient setting,6.4,44.86,
CATHETER 16FR RED RUBBER // DYND13516,6152223,CDM,272,RC,,,Outpatient,,,3.9,3.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,70,,2.18,percent of total billed charges,70% of total billed charges for outpatient setting,3.31,84.88,,2.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.95,50,,1.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.93,75,,2.34,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,70,,2.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,12.84,,0.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,80,,2.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,12.84,,0.4,percent of total billed charges,12.84% of total billed charges,0.5,12.84,,0.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.54,65,,2.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.37,35,,1.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.51,90,,2.81,percent of total billed charges,90% of total billed charges for outpatient setting,0.5,3.51,
CATHETER 18FR 2-WAY 30ML IC / 0166SI18,69169519,CDM,272,RC,,,Outpatient,,,45.78,45.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,70,,25.64,percent of total billed charges,70% of total billed charges for outpatient setting,38.86,84.88,,31.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.89,50,,18.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.34,75,,27.47,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,70,,25.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.88,12.84,,4.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,80,,29.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.88,12.84,,4.7,percent of total billed charges,12.84% of total billed charges,5.88,12.84,,4.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.76,65,,23.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.02,35,,12.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.2,90,,32.96,percent of total billed charges,90% of total billed charges for outpatient setting,5.88,41.2,
CATHETER 18FR 2WAY 5ML / 0165L18,6150972,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 18FR COUDE  / 0168L18,6151072,CDM,272,RC,,,Outpatient,,,49.84,49.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,84.88,,33.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.92,50,,19.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.38,75,,29.9,percent of total billed charges,75% of total billed charges for outpatient setting,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,80,,31.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.4,65,,25.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,35,,13.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.86,90,,35.89,percent of total billed charges,90% of total billed charges for outpatient setting,6.4,44.86,
CATHETER 18FR RED RUBBER / PRU118,6153023,CDM,272,RC,,,Outpatient,,,30.9,30.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,70,,17.3,percent of total billed charges,70% of total billed charges for outpatient setting,26.23,84.88,,20.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.45,50,,12.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,75,,18.54,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,70,,17.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,80,,19.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.09,65,,16.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.82,35,,8.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.81,90,,22.25,percent of total billed charges,90% of total billed charges for outpatient setting,3.97,27.81,
CATHETER 18FR TRAY FOLEY / 3718,69160937,CDM,272,RC,,,Outpatient,,,48.93,48.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.25,70,,27.4,percent of total billed charges,70% of total billed charges for outpatient setting,41.53,84.88,,33.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.47,50,,19.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.7,75,,29.36,percent of total billed charges,75% of total billed charges for outpatient setting,34.25,70,,27.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.28,12.84,,5.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.14,80,,31.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.28,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.28,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.8,65,,25.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.13,35,,13.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.04,90,,35.23,percent of total billed charges,90% of total billed charges for outpatient setting,6.28,44.04,
CATHETER 2 WAY 5CC 20FR / 0165L20,6150973,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 2 WAY 5CC 22FR / 0165L22,6150974,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 2 WAY 5CC 24FR / 0165L24,6150975,CDM,272,RC,,,Outpatient,,,14.4,14.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,84.88,,9.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.2,50,,5.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,75,,8.64,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,80,,9.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.36,65,,7.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,35,,4.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.96,90,,10.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,12.96,
CATHETER 20 FR RED RUBBER /PRU120,6153024,CDM,272,RC,,,Outpatient,,,27.32,27.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.12,70,,15.3,percent of total billed charges,70% of total billed charges for outpatient setting,23.19,84.88,,18.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.66,50,,10.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.49,75,,16.39,percent of total billed charges,75% of total billed charges for outpatient setting,19.12,70,,15.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,80,,17.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.76,65,,14.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,35,,7.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.59,90,,19.67,percent of total billed charges,90% of total billed charges for outpatient setting,3.51,24.59,
CATHETER 20FR 5ML COUDE / 0168L20,69159360,CDM,272,RC,,,Outpatient,,,49.84,49.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,84.88,,33.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.92,50,,19.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.38,75,,29.9,percent of total billed charges,75% of total billed charges for outpatient setting,34.89,70,,27.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,80,,31.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,6.4,12.84,,5.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.4,65,,25.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,35,,13.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.86,90,,35.89,percent of total billed charges,90% of total billed charges for outpatient setting,6.4,44.86,
CATHETER 22FR 30ML 3-WAY / 0167L22,6151077,CDM,272,RC,,,Outpatient,,,49.98,49.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,42.42,84.88,,33.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.99,50,,19.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.49,75,,29.99,percent of total billed charges,75% of total billed charges for outpatient setting,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,80,,31.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.49,65,,25.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,35,,13.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.98,90,,35.98,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,44.98,
CATHETER 22FR COUDE   / 0168L22,5150215,CDM,272,RC,,,Outpatient,,,51.3,51.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.91,70,,28.73,percent of total billed charges,70% of total billed charges for outpatient setting,43.54,84.88,,34.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.65,50,,20.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,75,,30.78,percent of total billed charges,75% of total billed charges for outpatient setting,35.91,70,,28.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,12.84,,5.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,80,,32.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,12.84,,5.27,percent of total billed charges,12.84% of total billed charges,6.59,12.84,,5.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.35,65,,26.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.96,35,,14.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.17,90,,36.94,percent of total billed charges,90% of total billed charges for outpatient setting,6.59,46.17,
CATHETER 24FR 30ML 3WAY SIL / DYND11576,69162920,CDM,272,RC,,,Outpatient,,,59.15,59.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.41,70,,33.13,percent of total billed charges,70% of total billed charges for outpatient setting,50.21,84.88,,40.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.58,50,,23.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.36,75,,35.49,percent of total billed charges,75% of total billed charges for outpatient setting,41.41,70,,33.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.32,80,,37.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.45,65,,30.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,35,,16.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.24,90,,42.59,percent of total billed charges,90% of total billed charges for outpatient setting,7.59,53.24,
CATHETER 26FR 30ML 3WAY SIL / 8887665262,69169901,CDM,272,RC,,,Outpatient,,,94.92,94.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,80.57,84.88,,64.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.46,50,,37.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.19,75,,56.95,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.94,80,,60.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.7,65,,49.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,35,,26.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.43,90,,68.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,85.43,
CATHETER 2-WAY 10FR / 165PL10,6153078,CDM,272,RC,,,Outpatient,,,38.71,38.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,70,,21.68,percent of total billed charges,70% of total billed charges for outpatient setting,32.86,84.88,,26.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.36,50,,15.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.03,75,,23.22,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,70,,21.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.97,80,,24.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.16,65,,20.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,35,,10.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.84,90,,27.87,percent of total billed charges,90% of total billed charges for outpatient setting,4.97,34.84,
CATHETER 2WAY 30CC 20FR / 0166L20,6153098,CDM,272,RC,,,Outpatient,,,25.68,25.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.98,70,,14.38,percent of total billed charges,70% of total billed charges for outpatient setting,21.8,84.88,,17.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.84,50,,10.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.26,75,,15.41,percent of total billed charges,75% of total billed charges for outpatient setting,17.98,70,,14.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.54,80,,16.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,3.3,12.84,,2.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.69,65,,13.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,35,,7.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.11,90,,18.49,percent of total billed charges,90% of total billed charges for outpatient setting,3.3,23.11,
CATHETER 2WAY 30CC 22FR / 0166L22,6153099,CDM,272,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,15.28,84.88,,12.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,9,50,,7.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,75,,10.8,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,80,,11.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.7,65,,9.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,35,,5.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.2,90,,12.96,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,16.2,
CATHETER 2-WAY 5CC 12FR / 0165L12,6153080,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 2-WAY 5CC 14FR / 0165L14,6152752,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 2-WAY 5CC 16FR / 0165L16,6153048,CDM,272,RC,,,Outpatient,,,14.67,14.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.45,84.88,,9.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,75,,8.8,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.2,90,,10.56,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.2,
CATHETER 2-WAY 8FR / 0165PL08,6153079,CDM,272,RC,,,Outpatient,,,38.64,38.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.05,70,,21.64,percent of total billed charges,70% of total billed charges for outpatient setting,32.8,84.88,,26.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.32,50,,15.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.98,75,,23.18,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,70,,21.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.91,80,,24.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.12,65,,20.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.52,35,,10.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.78,90,,27.82,percent of total billed charges,90% of total billed charges for outpatient setting,4.96,34.78,
CATHETER 3-WAY 18FRX30CC  / 0167L18,229308,CDM,272,RC,,,Outpatient,,,118.62,118.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,70,,66.42,percent of total billed charges,70% of total billed charges for outpatient setting,100.68,84.88,,80.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.31,50,,47.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.97,75,,71.18,percent of total billed charges,75% of total billed charges for outpatient setting,83.03,70,,66.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,12.84,,12.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.9,80,,75.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,12.84,,12.18,percent of total billed charges,12.84% of total billed charges,15.23,12.84,,12.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.1,65,,61.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.52,35,,33.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.76,90,,85.41,percent of total billed charges,90% of total billed charges for outpatient setting,15.23,106.76,
CATHETER 3-WAY 18FRX5CC / 0119L18,366370,CDM,272,RC,,,Outpatient,,,49.7,49.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,70,,27.83,percent of total billed charges,70% of total billed charges for outpatient setting,42.19,84.88,,33.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.85,50,,19.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.28,75,,29.82,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,70,,27.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.38,12.84,,5.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.76,80,,31.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.38,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,6.38,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.31,65,,25.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.4,35,,13.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.73,90,,35.78,percent of total billed charges,90% of total billed charges for outpatient setting,6.38,44.73,
CATHETER 3-WAY 20FRX30CC / 0167L20,366407,CDM,272,RC,,,Outpatient,,,49.98,49.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,42.42,84.88,,33.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.99,50,,19.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.49,75,,29.99,percent of total billed charges,75% of total billed charges for outpatient setting,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,80,,31.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.49,65,,25.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,35,,13.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.98,90,,35.98,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,44.98,
CATHETER 3-WAY 20FRX5CC / 0119L20,366338,CDM,272,RC,,,Outpatient,,,117.36,117.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.15,70,,65.72,percent of total billed charges,70% of total billed charges for outpatient setting,99.62,84.88,,79.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.68,50,,46.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.02,75,,70.42,percent of total billed charges,75% of total billed charges for outpatient setting,82.15,70,,65.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.07,12.84,,12.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.89,80,,75.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.07,12.84,,12.06,percent of total billed charges,12.84% of total billed charges,15.07,12.84,,12.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.28,65,,61.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.08,35,,32.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.62,90,,84.5,percent of total billed charges,90% of total billed charges for outpatient setting,15.07,105.62,
CATHETER 3-WAY 24FRX30CC / 0167L24,6151078,CDM,272,RC,,,Outpatient,,,49.98,49.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,42.42,84.88,,33.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.99,50,,19.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.49,75,,29.99,percent of total billed charges,75% of total billed charges for outpatient setting,34.99,70,,27.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,80,,31.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.49,65,,25.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,35,,13.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.98,90,,35.98,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,44.98,
CATHETER 3-WAY 26FRX30CC / 0167L26,6151079,CDM,272,RC,,,Outpatient,,,50.26,50.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,42.66,84.88,,34.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.13,50,,20.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.7,75,,30.16,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.21,80,,32.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.67,65,,26.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.59,35,,14.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.23,90,,36.18,percent of total billed charges,90% of total billed charges for outpatient setting,6.45,45.23,
CATHETER COUDE 14FR SILICONE / DYND11591,69162726,CDM,272,RC,,,Outpatient,,,84.75,84.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.33,70,,47.46,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,84.88,,57.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.38,50,,33.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.56,75,,50.85,percent of total billed charges,75% of total billed charges for outpatient setting,59.33,70,,47.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,12.84,,8.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.8,80,,54.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,12.84,,8.7,percent of total billed charges,12.84% of total billed charges,10.88,12.84,,8.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.09,65,,44.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.66,35,,23.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.28,90,,61.02,percent of total billed charges,90% of total billed charges for outpatient setting,10.88,76.28,
CATHETER COUDE 16FR SILICONE / 0170SI16,69162168,CDM,272,RC,,,Outpatient,,,119.51,119.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.66,70,,66.93,percent of total billed charges,70% of total billed charges for outpatient setting,101.44,84.88,,81.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.76,50,,47.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.63,75,,71.7,percent of total billed charges,75% of total billed charges for outpatient setting,83.66,70,,66.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.35,12.84,,12.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,80,,76.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.35,12.84,,12.28,percent of total billed charges,12.84% of total billed charges,15.35,12.84,,12.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.68,65,,62.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.83,35,,33.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,107.56,90,,86.05,percent of total billed charges,90% of total billed charges for outpatient setting,15.35,107.56,
CATHETER LEG STRAP / 8887600149,6152198,CDM,272,RC,,,Outpatient,,,20.65,20.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.46,70,,11.57,percent of total billed charges,70% of total billed charges for outpatient setting,17.53,84.88,,14.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.33,50,,8.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.49,75,,12.39,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,70,,11.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.52,80,,13.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,65,,10.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.23,35,,5.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.59,90,,14.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.65,18.59,
CATHETER PASSER SUTURELESS CONNECTOR,70000054,CDM,272,RC,C1787,HCPCS,Outpatient,,,423.95,423.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,359.85,84.88,,287.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.96,75,,254.37,percent of total billed charges,75% of total billed charges for outpatient setting,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.16,80,,271.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.57,65,,220.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.38,35,,118.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.56,90,,305.25,percent of total billed charges,90% of total billed charges for outpatient setting,54.44,381.56,
CATHETER PLUG / 1600,6151204,CDM,272,RC,,,Outpatient,,,3.57,3.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,70,,2,percent of total billed charges,70% of total billed charges for outpatient setting,3.03,84.88,,2.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.79,50,,1.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.68,75,,2.14,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,70,,2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,12.84,,0.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,80,,2.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,12.84,,0.37,percent of total billed charges,12.84% of total billed charges,0.46,12.84,,0.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.32,65,,1.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,35,,1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.21,90,,2.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.46,3.21,
CATHETER SILICONE 14FR 2-WAY / 165814,69162625,CDM,272,RC,,,Outpatient,,,24.93,24.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.45,70,,13.96,percent of total billed charges,70% of total billed charges for outpatient setting,21.16,84.88,,16.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.47,50,,9.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.7,75,,14.96,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,70,,13.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,80,,15.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.2,65,,12.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,35,,6.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.44,90,,17.95,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,22.44,
CATHETER SILICONE 16FR 2-WAY / 165816,69162626,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER SILICONE 18FR 2-WAY / 165818,69160296,CDM,272,RC,,,Outpatient,,,24.93,24.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.45,70,,13.96,percent of total billed charges,70% of total billed charges for outpatient setting,21.16,84.88,,16.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.47,50,,9.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.7,75,,14.96,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,70,,13.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,80,,15.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.2,65,,12.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,35,,6.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.44,90,,17.95,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,22.44,
CATHETER SILICONE 20FR 2-WAY / 165820,69162918,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER SILICONE 22FR 2-WAY / 165822,69162919,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER SILICONE 24FR 2-WAY / 165822,69162921,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER SILICONE 8FR 2 WAY / 165808,69162622,CDM,272,RC,,,Outpatient,,,22.16,22.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,18.81,84.88,,15.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.08,50,,8.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.62,75,,13.3,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,70,,12.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,80,,14.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,65,,11.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,35,,6.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.94,90,,15.95,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.94,
CATHETER SUPRAPUBIC 14FR SET / G30405,70000445,CDM,272,RC,,,Outpatient,,,376.44,376.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.51,70,,210.81,percent of total billed charges,70% of total billed charges for outpatient setting,319.52,84.88,,255.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,188.22,50,,150.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.33,75,,225.86,percent of total billed charges,75% of total billed charges for outpatient setting,263.51,70,,210.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.33,12.84,,38.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.15,80,,240.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.33,12.84,,38.66,percent of total billed charges,12.84% of total billed charges,48.33,12.84,,38.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,244.69,65,,195.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.75,35,,105.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,338.8,90,,271.04,percent of total billed charges,90% of total billed charges for outpatient setting,48.33,338.8,
CATHETER TEXAS / PK96B,5150245,CDM,272,RC,,,Outpatient,,,8.7,8.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,70,,4.87,percent of total billed charges,70% of total billed charges for outpatient setting,7.38,84.88,,5.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.35,50,,3.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.53,75,,5.22,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,70,,4.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,80,,5.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.66,65,,4.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,35,,2.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.83,90,,6.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.12,7.83,
CATHETER TRAY 16FR LATEX FREE / A300416A,5050154,CDM,272,RC,,,Outpatient,,,95.76,95.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.03,70,,53.62,percent of total billed charges,70% of total billed charges for outpatient setting,81.28,84.88,,65.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.88,50,,38.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,75,,57.46,percent of total billed charges,75% of total billed charges for outpatient setting,67.03,70,,53.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.61,80,,61.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.24,65,,49.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.52,35,,26.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.18,90,,68.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.3,86.18,
CATHETER TRAY FOLEY 16FR / 899616,6150476,CDM,272,RC,,,Outpatient,,,40.18,40.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,70,,22.5,percent of total billed charges,70% of total billed charges for outpatient setting,34.1,84.88,,27.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.09,50,,16.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.14,75,,24.11,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,70,,22.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,12.84,,4.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.14,80,,25.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,12.84,,4.13,percent of total billed charges,12.84% of total billed charges,5.16,12.84,,4.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.12,65,,20.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.06,35,,11.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.16,90,,28.93,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,36.16,
CATHETER TRAY LF FOLEY 16FR / 720016,70000038,CDM,272,RC,,,Outpatient,,,58.67,58.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.07,70,,32.86,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,84.88,,39.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.34,50,,23.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44,75,,35.2,percent of total billed charges,75% of total billed charges for outpatient setting,41.07,70,,32.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.53,12.84,,6.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.94,80,,37.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.53,12.84,,6.02,percent of total billed charges,12.84% of total billed charges,7.53,12.84,,6.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.14,65,,30.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,35,,16.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.8,90,,42.24,percent of total billed charges,90% of total billed charges for outpatient setting,7.53,52.8,
CATHFLO ACTIVASE 2 MG,3303191,CDM,636,RC,J2997,HCPCS,Outpatient,,,333.96,333.96,,140.84,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233.77,70,,187.02,percent of total billed charges,70% of total billed charges for outpatient setting,283.47,84.88,,226.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,97.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,250.47,75,,200.38,percent of total billed charges,75% of total billed charges for outpatient setting,233.77,70,,187.02,percent of total billed charges,70% of total billed charges for outpatient setting,149.65,170,,,Fee Schedule,170% of Medicare OPPS rate,189.26,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.88,12.84,,34.304,percent of total billed charges,12.84% of total billed charges,154.05,175,,,Fee Schedule,175% of Medicare OPPS rate,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,267.17,80,,213.74,percent of total billed charges,80% of total billed charges for outpatient setting,123.24,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,110.03,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.88,12.84,,34.3,percent of total billed charges,12.84% of total billed charges,42.88,12.84,,34.3,percent of total billed charges,12.84% of total billed charges,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,217.07,65,,173.66,percent of total billed charges,65% of total billed charges for outpatient setting,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,88.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,70.92,100,,,Fee Schedule,100% of Custom Fee Schedule,300.56,90,,240.45,percent of total billed charges,90% of total billed charges for outpatient setting,42.88,300.56,
CATH-SECURE DUAL TAB / 5445-4,69160726,CDM,271,RC,,,Outpatient,,,14.94,14.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.46,70,,8.37,percent of total billed charges,70% of total billed charges for outpatient setting,12.68,84.88,,10.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.47,50,,5.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,75,,8.97,percent of total billed charges,75% of total billed charges for outpatient setting,10.46,70,,8.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.92,12.84,,1.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,80,,9.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.92,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,1.92,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.71,65,,7.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.23,35,,4.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.45,90,,10.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.92,13.45,
CAUTERY BLADE 2.75IN E-Z CLEAN / 0012A,6152016,CDM,272,RC,,,Outpatient,,,27.89,27.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.52,70,,15.62,percent of total billed charges,70% of total billed charges for outpatient setting,23.67,84.88,,18.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.95,50,,11.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.92,75,,16.74,percent of total billed charges,75% of total billed charges for outpatient setting,19.52,70,,15.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.31,80,,17.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.13,65,,14.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.76,35,,7.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.1,90,,20.08,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,25.1,
CAUTERY COATED BLD ROCKER SWT / E2350H,6152585,CDM,272,RC,,,Outpatient,,,47.04,47.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,39.93,84.88,,31.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.52,50,,18.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.28,75,,28.22,percent of total billed charges,75% of total billed charges for outpatient setting,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.63,80,,30.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.58,65,,24.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,35,,13.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.34,90,,33.87,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,42.34,
CAUTERY EXTENSION COATED / 0014,6152638,CDM,272,RC,,,Outpatient,,,9.27,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,84.88,,6.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.64,50,,3.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.95,75,,5.56,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,80,,5.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.03,65,,4.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,35,,2.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.34,90,,6.67,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.34,
CAUTERY FINE TIP 23G/OPHTHALMIC / 221265,69162721,CDM,272,RC,,,Outpatient,,,187.86,187.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.5,70,,105.2,percent of total billed charges,70% of total billed charges for outpatient setting,159.46,84.88,,127.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,93.93,50,,75.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.9,75,,112.72,percent of total billed charges,75% of total billed charges for outpatient setting,131.5,70,,105.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,12.84,,19.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.29,80,,120.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,12.84,,19.3,percent of total billed charges,12.84% of total billed charges,24.12,12.84,,19.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122.11,65,,97.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.75,35,,52.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.07,90,,135.26,percent of total billed charges,90% of total billed charges for outpatient setting,24.12,169.07,
CAUTERY LOW TEMP/8065004605,6152596,CDM,272,RC,,,Outpatient,,,153.38,153.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,70,,85.9,percent of total billed charges,70% of total billed charges for outpatient setting,130.19,84.88,,104.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.69,50,,61.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.04,75,,92.03,percent of total billed charges,75% of total billed charges for outpatient setting,107.37,70,,85.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,12.84,,15.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.7,80,,98.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,12.84,,15.75,percent of total billed charges,12.84% of total billed charges,19.69,12.84,,15.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.7,65,,79.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.68,35,,42.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.04,90,,110.43,percent of total billed charges,90% of total billed charges for outpatient setting,19.69,138.04,
CAUTERY NEEDLE TIP / 0013,6152598,CDM,272,RC,,,Outpatient,,,29.62,29.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,70,,16.58,percent of total billed charges,70% of total billed charges for outpatient setting,25.14,84.88,,20.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.81,50,,11.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.22,75,,17.78,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,70,,16.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,80,,18.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,3.8,12.84,,3.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.25,65,,15.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,35,,8.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.66,90,,21.33,percent of total billed charges,90% of total billed charges for outpatient setting,3.8,26.66,
CAUTERY PENCIL W/HOLDER(PEN41),6150568,CDM,272,RC,,,Outpatient,,,57.08,57.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,70,,31.97,percent of total billed charges,70% of total billed charges for outpatient setting,48.45,84.88,,38.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.54,50,,22.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.81,75,,34.25,percent of total billed charges,75% of total billed charges for outpatient setting,39.96,70,,31.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.66,80,,36.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.1,65,,29.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,35,,15.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.37,90,,41.1,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,51.37,
CAUTERY PLUMEPEN 10FT / PLPUL2020,7035801,CDM,272,RC,,,Outpatient,,,125.88,125.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.12,70,,70.5,percent of total billed charges,70% of total billed charges for outpatient setting,106.85,84.88,,85.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.94,50,,50.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.41,75,,75.53,percent of total billed charges,75% of total billed charges for outpatient setting,88.12,70,,70.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.16,12.84,,12.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.7,80,,80.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.16,12.84,,12.93,percent of total billed charges,12.84% of total billed charges,16.16,12.84,,12.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.82,65,,65.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.06,35,,35.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.29,90,,90.63,percent of total billed charges,90% of total billed charges for outpatient setting,16.16,113.29,
CCP CYCLIC CITRULLINATED PEPTIDE,220294,CDM,302,RC,86200,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,46.7,
CD20,201563,CDM,310,RC,88182,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,41.69,178.52,
CD4 CD8 RATIO PROFILE,220146,CDM,302,RC,86360,HCPCS,Outpatient,,,211.41,190.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,179.44,84.88,,143.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,158.56,75,,126.85,percent of total billed charges,75% of total billed charges for outpatient setting,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.13,80,,135.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,68.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.34,100,,,Fee Schedule,100% of Custom Fee Schedule,190.27,90,,152.22,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,190.27,
CD4 PERCENT AND ABSOLUTE,201420,CDM,302,RC,86361,HCPCS,Outpatient,,,120.51,108.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.36,70,,67.49,percent of total billed charges,70% of total billed charges for outpatient setting,102.29,84.88,,81.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,90.38,75,,72.3,percent of total billed charges,75% of total billed charges for outpatient setting,84.36,70,,67.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.41,80,,77.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.18,100,,,Fee Schedule,100% of Custom Fee Schedule,108.46,90,,86.77,percent of total billed charges,90% of total billed charges for outpatient setting,26.78,108.46,
CE  SEGMENTAL PRESSURE,2600046,CDM,921,RC,93923,HCPCS,Outpatient,,,636,636,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
CE ANKLE/BRACHIAL INDICES (ABI),2600351,CDM,921,RC,93922,HCPCS,Outpatient,,,636,636,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
CE COLOR FLOW,2600022,CDM,480,RC,93325,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
CE DOPPLER ECHO COMPLETE (ADD ON),2600021,CDM,480,RC,93320,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
CE DOPPLER ECHO FLW -UP/LIMITED (ADD ON),2600014,CDM,480,RC,93321,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
CE ECHO COMPLETE W/DOPPLER & COLOR FLOW,2600012,CDM,483,RC,93306,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
CE ECHO FOLLOW UP OR LIMITED STUDY,2600013,CDM,483,RC,93308,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.19,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,642.14,
CE EVENT MONITORING,2600102,CDM,731,RC,93271,HCPCS,Outpatient,,,361.5,361.5,,143.93,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,152.93,170,,,Fee Schedule,170% of Medicare OPPS rate,193.41,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,157.41,175,,,Fee Schedule,175% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,125.94,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,112.45,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,137.78,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE EVENT MONITORING HOOKUP,2600104,CDM,731,RC,93270,HCPCS,Outpatient,,,361.5,361.5,,53.38,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,56.72,170,,,Fee Schedule,170% of Medicare OPPS rate,71.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,58.39,175,,,Fee Schedule,175% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,46.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,41.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,33.36,325.35,
CE HOLTER MONITOR HOOKUP,2600103,CDM,731,RC,93225,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE PATCH MONITOR 7-15 DAYS RECORDING,2600095,CDM,731,RC,93246,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE PATCH MONITOR 72 HOUR,2600116,CDM,731,RC,93242,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE PATCH MONITOR 96+ HOUR,2600112,CDM,731,RC,93242,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE PATCH MONITOR UP TO 48 HOUR,2600117,CDM,731,RC,93225,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
CE STRESS ECHO TEST,2600015,CDM,483,RC,93350,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
CE TTE W/CONTRAST 2D & CF W/DOP ECHO,2610025,CDM,483,RC,C8929,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
CE TTE W/CONTRAST 2D LMT,2610023,CDM,483,RC,C8924,HCPCS,Outpatient,,,1141.31,1141.31,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,595.47,100,,,Fee Schedule,100% of Custom Fee Schedule,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,146.54,1027.18,
CE TTE W/CONTRAST 2D REST & W/STR,2610024,CDM,483,RC,C8930,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
CEA,220390,CDM,300,RC,82378,HCPCS,Outpatient,,,85.32,76.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.72,70,,47.78,percent of total billed charges,70% of total billed charges for outpatient setting,72.42,84.88,,57.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,63.99,75,,51.19,percent of total billed charges,75% of total billed charges for outpatient setting,59.72,70,,47.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.26,80,,54.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.97,100,,,Fee Schedule,100% of Custom Fee Schedule,76.79,90,,61.43,percent of total billed charges,90% of total billed charges for outpatient setting,18.96,76.79,
CEFACLOR (CECLOR) CAP 250 MG,3300766,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CEFACLOR (CECLOR) SUSP 250MG/5ML 75ML,3300765,CDM,259,RC,,,Outpatient,,,54.3,54.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.01,70,,30.41,percent of total billed charges,70% of total billed charges for outpatient setting,46.09,84.88,,36.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.15,50,,21.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,75,,32.58,percent of total billed charges,75% of total billed charges for outpatient setting,38.01,70,,30.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,12.84,,5.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,80,,34.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,12.84,,5.58,percent of total billed charges,12.84% of total billed charges,6.97,12.84,,5.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.3,65,,28.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,35,,15.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.87,90,,39.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.97,48.87,
CEFADROXIL HYD (DURICEF) CAP 500 MG,3300767,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CEFAZOLIN (genericANCEF) 500MG INJ,3302990,CDM,636,RC,J0690,HCPCS,Outpatient,,,93.35,93.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.35,70,,52.28,percent of total billed charges,70% of total billed charges for outpatient setting,79.24,84.88,,63.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.01,75,,56.01,percent of total billed charges,75% of total billed charges for outpatient setting,65.35,70,,52.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,12.84,,9.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.68,80,,59.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,12.84,,9.59,percent of total billed charges,12.84% of total billed charges,11.99,12.84,,9.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.68,65,,48.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,84.02,90,,67.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,84.02,
CEFAZOLIN (genericANCEF)VIAL 1 GM,3300769,CDM,636,RC,J0690,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CEFAZOLIN (genericANCEF)VIAL 2 GM,3313998,CDM,636,RC,J0690,HCPCS,Outpatient,,,35.34,35.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,70,,19.79,percent of total billed charges,70% of total billed charges for outpatient setting,30,84.88,,24,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.51,75,,21.21,percent of total billed charges,75% of total billed charges for outpatient setting,24.74,70,,19.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,12.84,,3.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.27,80,,22.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,12.84,,3.63,percent of total billed charges,12.84% of total billed charges,4.54,12.84,,3.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.97,65,,18.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,31.81,90,,25.45,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,31.81,
CEFAZOLIN (genericANCEF)VIAL 3 GM,3314215,CDM,636,RC,J0690,HCPCS,Outpatient,,,39.84,39.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,70,,22.31,percent of total billed charges,70% of total billed charges for outpatient setting,33.82,84.88,,27.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.88,75,,23.9,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,70,,22.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,80,,25.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.9,65,,20.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,35.86,90,,28.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,35.86,
CEFAZOLIN SOD (ANCEF) INJ : 1GM,3300768,CDM,250,RC,,,Outpatient,,,5.19,5.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,70,,2.9,percent of total billed charges,70% of total billed charges for outpatient setting,4.41,84.88,,3.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.6,50,,2.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.89,75,,3.11,percent of total billed charges,75% of total billed charges for outpatient setting,3.63,70,,2.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,80,,3.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.37,65,,2.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,35,,1.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.67,90,,3.74,percent of total billed charges,90% of total billed charges for outpatient setting,0.67,4.67,
CEFAZOLIN SOD (ANCEF) INJ : 1GM,3300770,CDM,250,RC,,,Outpatient,,,279.83,279.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.88,70,,156.7,percent of total billed charges,70% of total billed charges for outpatient setting,237.52,84.88,,190.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,139.92,50,,111.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.87,75,,167.9,percent of total billed charges,75% of total billed charges for outpatient setting,195.88,70,,156.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.93,12.84,,28.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.86,80,,179.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.93,12.84,,28.74,percent of total billed charges,12.84% of total billed charges,35.93,12.84,,28.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,181.89,65,,145.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.94,35,,78.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,251.85,90,,201.48,percent of total billed charges,90% of total billed charges for outpatient setting,35.93,251.85,
CEFAZOLIN SOD (ANCEF) INJ : 1GM,3300771,CDM,250,RC,,,Outpatient,,,450.19,450.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.13,70,,252.1,percent of total billed charges,70% of total billed charges for outpatient setting,382.12,84.88,,305.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,225.1,50,,180.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.64,75,,270.11,percent of total billed charges,75% of total billed charges for outpatient setting,315.13,70,,252.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.8,12.84,,46.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.15,80,,288.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.8,12.84,,46.24,percent of total billed charges,12.84% of total billed charges,57.8,12.84,,46.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,292.62,65,,234.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.57,35,,126.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.17,90,,324.14,percent of total billed charges,90% of total billed charges for outpatient setting,57.8,405.17,
CEFAZOLIN/D5W IVPB 1GM/50ML,3309005,CDM,250,RC,J0690,HCPCS,Outpatient,,,35.39,35.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.77,70,,19.82,percent of total billed charges,70% of total billed charges for outpatient setting,30.04,84.88,,24.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.54,75,,21.23,percent of total billed charges,75% of total billed charges for outpatient setting,24.77,70,,19.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,12.84,,3.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,80,,22.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,12.84,,3.63,percent of total billed charges,12.84% of total billed charges,4.54,12.84,,3.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23,65,,18.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,31.85,90,,25.48,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,31.85,
CEFAZOLIN/D5W IVPB 2GM/50ML,3302752,CDM,250,RC,J0690,HCPCS,Outpatient,,,53.91,53.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.92,12.84,,5.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.92,12.84,,5.54,percent of total billed charges,12.84% of total billed charges,6.92,12.84,,5.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.04,65,,28.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,48.52,
CEFEPIME (genericMAXIPIME) 1GM VIAL,3303310,CDM,636,RC,J0692,HCPCS,Outpatient,,,36.86,36.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,31.29,84.88,,25.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.65,75,,22.12,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,80,,23.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.96,65,,19.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,100,,,Fee Schedule,100% of Custom Fee Schedule,33.17,90,,26.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,33.17,
CEFEPIME (genericMAXIPIME) 2GM VIAL,3303223,CDM,636,RC,J0692,HCPCS,Outpatient,,,36.12,36.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.28,70,,20.22,percent of total billed charges,70% of total billed charges for outpatient setting,30.66,84.88,,24.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.09,75,,21.67,percent of total billed charges,75% of total billed charges for outpatient setting,25.28,70,,20.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.9,80,,23.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.48,65,,18.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,100,,,Fee Schedule,100% of Custom Fee Schedule,32.51,90,,26.01,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,32.51,
CEFOBID(CEFOPERAZONE)2 GRAM: INJ,3302682,CDM,250,RC,,,Outpatient,,,104.17,104.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.92,70,,58.34,percent of total billed charges,70% of total billed charges for outpatient setting,88.42,84.88,,70.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.09,50,,41.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.13,75,,62.5,percent of total billed charges,75% of total billed charges for outpatient setting,72.92,70,,58.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.38,12.84,,10.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.34,80,,66.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.38,12.84,,10.7,percent of total billed charges,12.84% of total billed charges,13.38,12.84,,10.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.71,65,,54.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.46,35,,29.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.75,90,,75,percent of total billed charges,90% of total billed charges for outpatient setting,13.38,93.75,
CEFOTAN 2GM INJ:,3302586,CDM,250,RC,,,Outpatient,,,103.89,103.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.72,70,,58.18,percent of total billed charges,70% of total billed charges for outpatient setting,88.18,84.88,,70.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.95,50,,41.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.92,75,,62.34,percent of total billed charges,75% of total billed charges for outpatient setting,72.72,70,,58.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,12.84,,10.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.11,80,,66.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,12.84,,10.67,percent of total billed charges,12.84% of total billed charges,13.34,12.84,,10.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.53,65,,54.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.36,35,,29.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.5,90,,74.8,percent of total billed charges,90% of total billed charges for outpatient setting,13.34,93.5,
CEFOTAXIME (CLAFORAN) INJ : 1GM,3300774,CDM,250,RC,,,Outpatient,,,34.58,34.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,29.35,84.88,,23.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.29,50,,13.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.94,75,,20.75,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,80,,22.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.48,65,,17.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,35,,9.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.12,90,,24.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.44,31.12,
CEFOTAXIME (CLAFORAN) INJ 1GM,3300773,CDM,636,RC,J0698,HCPCS,Outpatient,,,65.31,65.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,84.88,,44.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.98,75,,39.18,percent of total billed charges,75% of total billed charges for outpatient setting,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,80,,41.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.45,65,,33.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,100,,,Fee Schedule,100% of Custom Fee Schedule,58.78,90,,47.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.45,58.78,
CEFOTAXIME (CLAFORAN) INJ 2GM,3300772,CDM,636,RC,J0698,HCPCS,Outpatient,,,128.09,128.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.66,70,,71.73,percent of total billed charges,70% of total billed charges for outpatient setting,108.72,84.88,,86.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,96.07,75,,76.86,percent of total billed charges,75% of total billed charges for outpatient setting,89.66,70,,71.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.47,80,,81.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.26,65,,66.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,100,,,Fee Schedule,100% of Custom Fee Schedule,115.28,90,,92.22,percent of total billed charges,90% of total billed charges for outpatient setting,2.45,115.28,
CEFOTAXIME/NS IVPB 1GM/50ML,3302743,CDM,250,RC,,,Outpatient,,,113.43,113.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,96.28,84.88,,77.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.72,50,,45.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.07,75,,68.06,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,80,,72.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.73,65,,58.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,35,,31.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.09,90,,81.67,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.09,
CEFOTAXIME/NS IVPB 2GM/50 ML,3302711,CDM,250,RC,,,Outpatient,,,113.43,113.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,96.28,84.88,,77.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.72,50,,45.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.07,75,,68.06,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,80,,72.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.73,65,,58.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,35,,31.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.09,90,,81.67,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.09,
CEFOTETAN/CEFOTAN INJ  2GM,3300776,CDM,250,RC,J3490,HCPCS,Outpatient,,,68.82,68.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,58.41,84.88,,46.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.62,75,,41.3,percent of total billed charges,75% of total billed charges for outpatient setting,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,12.84,,7.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.06,80,,44.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,12.84,,7.07,percent of total billed charges,12.84% of total billed charges,8.84,12.84,,7.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.73,65,,35.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.09,35,,19.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,61.94,90,,49.55,percent of total billed charges,90% of total billed charges for outpatient setting,8.84,61.94,
CEFOTETAN/CEFOTAN INJ 1GM,3300775,CDM,250,RC,J3490,HCPCS,Outpatient,,,67.38,67.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.17,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,57.19,84.88,,45.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.54,75,,40.43,percent of total billed charges,75% of total billed charges for outpatient setting,47.17,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.9,80,,43.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.8,65,,35.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.58,35,,18.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.64,90,,48.51,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,60.64,
CEFOXITIN (genMEFOXIN)  1GM VIAL,3302777,CDM,636,RC,J0694,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,5.55,
CEFOXITIN (genMEFOXIN)  2GM VIAL,3314362,CDM,636,RC,J0694,HCPCS,Outpatient,,,35.25,35.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,70,,19.74,percent of total billed charges,70% of total billed charges for outpatient setting,29.92,84.88,,23.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.44,75,,21.15,percent of total billed charges,75% of total billed charges for outpatient setting,24.68,70,,19.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,12.84,,3.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.2,80,,22.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,4.53,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.91,65,,18.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,100,,,Fee Schedule,100% of Custom Fee Schedule,31.73,90,,25.38,percent of total billed charges,90% of total billed charges for outpatient setting,4.53,31.73,
CEFPODOXIME (VANTIN) TAB 200MG,3300778,CDM,259,RC,,,Outpatient,,,13.55,13.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,11.5,84.88,,9.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.78,50,,5.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.16,75,,8.13,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,80,,8.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.81,65,,7.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,35,,3.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.2,90,,9.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.2,
CEFPODOXIME (VANTIN) TAB100MG,3300777,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CEFPROZIL(CEFZIL) 250 MG: TAB,3302696,CDM,259,RC,,,Outpatient,,,21.74,21.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,70,,12.18,percent of total billed charges,70% of total billed charges for outpatient setting,18.45,84.88,,14.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.87,50,,8.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.31,75,,13.05,percent of total billed charges,75% of total billed charges for outpatient setting,15.22,70,,12.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.79,12.84,,2.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,80,,13.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.79,12.84,,2.23,percent of total billed charges,12.84% of total billed charges,2.79,12.84,,2.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.13,65,,11.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.61,35,,6.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.57,90,,15.66,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,19.57,
CEFTAZIDIME PENTAHYD (FORTAZ0) INJ : 6GM,3300780,CDM,250,RC,,,Outpatient,,,133.98,133.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.79,70,,75.03,percent of total billed charges,70% of total billed charges for outpatient setting,113.72,84.88,,90.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.99,50,,53.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.49,75,,80.39,percent of total billed charges,75% of total billed charges for outpatient setting,93.79,70,,75.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.2,12.84,,13.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.18,80,,85.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.2,12.84,,13.76,percent of total billed charges,12.84% of total billed charges,17.2,12.84,,13.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.09,65,,69.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.89,35,,37.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.58,90,,96.46,percent of total billed charges,90% of total billed charges for outpatient setting,17.2,120.58,
CEFTAZIDIME(genericFORTAZ) INJ  1GM,3300779,CDM,636,RC,J0713,HCPCS,Outpatient,,,24.81,24.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.37,70,,13.9,percent of total billed charges,70% of total billed charges for outpatient setting,21.06,84.88,,16.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.61,75,,14.89,percent of total billed charges,75% of total billed charges for outpatient setting,17.37,70,,13.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,80,,15.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.13,65,,12.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,100,,,Fee Schedule,100% of Custom Fee Schedule,22.33,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,22.33,
CEFTAZIDIME(genericFORTAZ) INJ  2GM,3313975,CDM,636,RC,J0713,HCPCS,Outpatient,,,37.96,37.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,32.22,84.88,,25.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.47,75,,22.78,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.37,80,,24.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.67,65,,19.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,100,,,Fee Schedule,100% of Custom Fee Schedule,34.16,90,,27.33,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,34.16,
CEFTIZOXIME (CEFIZOX) INJ : 2GM,3300781,CDM,250,RC,,,Outpatient,,,64.81,64.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,70,,36.3,percent of total billed charges,70% of total billed charges for outpatient setting,55.01,84.88,,44.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.41,50,,25.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.61,75,,38.89,percent of total billed charges,75% of total billed charges for outpatient setting,45.37,70,,36.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,12.84,,6.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.85,80,,41.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,12.84,,6.66,percent of total billed charges,12.84% of total billed charges,8.32,12.84,,6.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.13,65,,33.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.68,35,,18.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.33,90,,46.66,percent of total billed charges,90% of total billed charges for outpatient setting,8.32,58.33,
CEFTRIAXONE (genericROCEPHIN)  INJ 1GM,3302517,CDM,636,RC,J0696,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CEFTRIAXONE (genericROCEPHIN) 250MG,3300782,CDM,250,RC,,,Outpatient,,,43.4,43.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,70,,24.3,percent of total billed charges,70% of total billed charges for outpatient setting,36.84,84.88,,29.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.7,50,,17.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.55,75,,26.04,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,70,,24.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.72,80,,27.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.21,65,,22.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,35,,12.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.06,90,,31.25,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,39.06,
CEFTRIAXONE (genericROCEPHIN) 2GM VIAL,3300784,CDM,250,RC,J0696,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CEFTRIAXONE INJ 250MG,3302518,CDM,250,RC,,,Outpatient,,,47.87,47.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.51,70,,26.81,percent of total billed charges,70% of total billed charges for outpatient setting,40.63,84.88,,32.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.94,50,,19.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.9,75,,28.72,percent of total billed charges,75% of total billed charges for outpatient setting,33.51,70,,26.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.15,12.84,,4.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.3,80,,30.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.15,12.84,,4.92,percent of total billed charges,12.84% of total billed charges,6.15,12.84,,4.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.12,65,,24.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,35,,13.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.08,90,,34.46,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,43.08,
CEFTRIAXONE(genericROCEPHIN) 500MG INJ,3302614,CDM,250,RC,J0696,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CEFUROXIME (CEFTIN) TAB 250 MG,3300786,CDM,259,RC,,,Outpatient,,,13.39,13.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.7,50,,5.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.04,75,,8.03,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,80,,8.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.7,65,,6.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.05,90,,9.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.05,
CEFUROXIME (CEFTIN) TAB: 500 MG,3300785,CDM,259,RC,,,Outpatient,,,23.87,23.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,70,,13.37,percent of total billed charges,70% of total billed charges for outpatient setting,20.26,84.88,,16.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.94,50,,9.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.9,75,,14.32,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,70,,13.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.1,80,,15.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.52,65,,12.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,35,,6.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.48,90,,17.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.06,21.48,
CEFUROXIME (CEFTIN) TAB: 500mg,3304496,CDM,259,RC,,,Outpatient,,,13.39,13.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.7,50,,5.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.04,75,,8.03,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,80,,8.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.7,65,,6.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.05,90,,9.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.05,
CEFUROXIME (ZINACEF GENERIC) INJ 750 MG,3300787,CDM,250,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
CEFUROXIME (ZINACEF)1.5 GM: VIAL,3300788,CDM,636,RC,J0697,HCPCS,Outpatient,,,161.87,161.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.31,70,,90.65,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,84.88,,109.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,121.4,75,,97.12,percent of total billed charges,75% of total billed charges for outpatient setting,113.31,70,,90.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.78,12.84,,16.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.5,80,,103.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.78,12.84,,16.62,percent of total billed charges,12.84% of total billed charges,20.78,12.84,,16.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.22,65,,84.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,100,,,Fee Schedule,100% of Custom Fee Schedule,145.68,90,,116.54,percent of total billed charges,90% of total billed charges for outpatient setting,2.24,145.68,
CEFZIL 250 MG/5ML SUSP:50ML BTL,3302617,CDM,259,RC,,,Outpatient,,,156.68,156.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.68,70,,87.74,percent of total billed charges,70% of total billed charges for outpatient setting,132.99,84.88,,106.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.34,50,,62.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.51,75,,94.01,percent of total billed charges,75% of total billed charges for outpatient setting,109.68,70,,87.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,12.84,,16.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.34,80,,100.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,12.84,,16.1,percent of total billed charges,12.84% of total billed charges,20.12,12.84,,16.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.84,65,,81.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.84,35,,43.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.01,90,,112.81,percent of total billed charges,90% of total billed charges for outpatient setting,20.12,141.01,
CEFZIL 250 MG/5ML SUSP:75ML BTL,3303066,CDM,259,RC,,,Outpatient,,,156.68,156.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.68,70,,87.74,percent of total billed charges,70% of total billed charges for outpatient setting,132.99,84.88,,106.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.34,50,,62.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.51,75,,94.01,percent of total billed charges,75% of total billed charges for outpatient setting,109.68,70,,87.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,12.84,,16.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.34,80,,100.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,12.84,,16.1,percent of total billed charges,12.84% of total billed charges,20.12,12.84,,16.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.84,65,,81.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.84,35,,43.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.01,90,,112.81,percent of total billed charges,90% of total billed charges for outpatient setting,20.12,141.01,
CEFZIL 250MG/5ML SUSP : 100 ML,3302619,CDM,259,RC,,,Outpatient,,,16.11,16.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,13.67,84.88,,10.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.06,50,,6.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.08,75,,9.66,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,80,,10.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.47,65,,8.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,35,,4.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.5,90,,11.6,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,14.5,
CELECOXIB (CELEBREX) CAP: 100 MG,3300789,CDM,259,RC,,,Outpatient,,,4.25,4.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,3.61,84.88,,2.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.13,50,,1.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.19,75,,2.55,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,80,,2.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.76,65,,2.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,35,,1.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.83,90,,3.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.83,
CELECOXIB (genCELEBREX) CAP 100 MG,3300790,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CELECOXIB (genCELEBREX) CAP 200 MG,3300791,CDM,259,RC,,,Outpatient,,,13.68,13.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,84.88,,9.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.84,50,,5.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.26,75,,8.21,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,80,,8.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.89,65,,7.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,35,,3.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.31,90,,9.85,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.31,
CELESTONE SOLUSPAN 3-3 MG/ML INJ: 5 ML,3302636,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
"CELL COUNT WITH DIFF,BODY FLUID",220507,CDM,300,RC,89051,HCPCS,Outpatient,,,25.2,22.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,70,,14.11,percent of total billed charges,70% of total billed charges for outpatient setting,21.39,84.88,,17.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.9,75,,15.12,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,70,,14.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,80,,16.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,100,,,Fee Schedule,100% of Custom Fee Schedule,22.68,90,,18.14,percent of total billed charges,90% of total billed charges for outpatient setting,5.6,22.68,
CELLERATERX 1GM SRG PWDR /WCI-01-SACRXP,69169811,CDM,272,RC,,,Outpatient,,,2079,2079,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.3,70,,1164.24,percent of total billed charges,70% of total billed charges for outpatient setting,1764.66,84.88,,1411.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,1039.5,50,,831.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1559.25,75,,1247.4,percent of total billed charges,75% of total billed charges for outpatient setting,1455.3,70,,1164.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1663.2,80,,1330.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1351.35,65,,1081.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.65,35,,582.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1871.1,90,,1496.88,percent of total billed charges,90% of total billed charges for outpatient setting,266.94,1871.1,
CELLERATERX 5GM SRG PWDR / WCI-05-SACRXP,69169812,CDM,272,RC,,,Outpatient,,,3190,3190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2233,70,,1786.4,percent of total billed charges,70% of total billed charges for outpatient setting,2707.67,84.88,,2166.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2392.5,75,,1914,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552,80,,2041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2073.5,65,,1658.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.5,35,,893.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2871,90,,2296.8,percent of total billed charges,90% of total billed charges for outpatient setting,409.6,2871,
CELLULAR MATRIX 1000CC,69161749,CDM,278,RC,,,Outpatient,,,3313.99,3313.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1988.39,60,,1590.71,percent of total billed charges,60% of total Billed charges for outpatient setting,2812.91,84.88,,2250.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,1657,50,,1325.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2485.49,75,,1988.39,percent of total billed charges,75% of total billed charges for outpatient setting,1657,50,,1325.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.52,12.84,,340.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2651.19,80,,2120.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.52,12.84,,340.42,percent of total billed charges,12.84% of total billed charges,425.52,12.84,,340.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3479.69,105,,2783.75,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.9,35,,927.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1988.39,60,,1590.71,percent of total billed charges,60% of total billed charges for outpatient setting,425.52,3479.69,
CELLULOSE (SORBSAN) TOP 3X3 DRESS :,3300792,CDM,272,RC,,,Outpatient,,,9.65,9.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.76,70,,5.41,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,84.88,,6.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.83,50,,3.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.24,75,,5.79,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,70,,5.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.72,80,,6.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.27,65,,5.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,35,,2.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.69,90,,6.95,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,8.69,
CEMENT 40G BONE RALLY / 71271580,71000697,CDM,278,RC,C1713,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,60,,124.8,percent of total billed charges,60% of total Billed charges for outpatient setting,220.69,84.88,,176.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195,75,,156,percent of total billed charges,75% of total billed charges for outpatient setting,130,50,,104,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,12.84,,26.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208,80,,166.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,12.84,,26.7,percent of total billed charges,12.84% of total billed charges,33.38,12.84,,26.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260,65,,208,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91,35,,72.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,156,60,,124.8,percent of total billed charges,60% of total billed charges for outpatient setting,33.38,260,
CEMENT 40G BONE RALLY MV AB / 71271590,69162777,CDM,278,RC,C1713,HCPCS,Outpatient,,,780,780,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,60,,374.4,percent of total billed charges,60% of total Billed charges for outpatient setting,662.06,84.88,,529.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585,75,,468,percent of total billed charges,75% of total billed charges for outpatient setting,390,50,,312,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624,80,,499.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,780,65,,624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,35,,218.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,468,60,,374.4,percent of total billed charges,60% of total billed charges for outpatient setting,100.15,780,
CEMENT 41G BONE TOBRA / 6197-9-001,602380,CDM,278,RC,C1713,HCPCS,Outpatient,,,956.8,956.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.08,60,,459.26,percent of total billed charges,60% of total Billed charges for outpatient setting,812.13,84.88,,649.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.6,75,,574.08,percent of total billed charges,75% of total billed charges for outpatient setting,478.4,50,,382.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.44,80,,612.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.8,65,,765.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.88,35,,267.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,574.08,60,,459.26,percent of total billed charges,60% of total billed charges for outpatient setting,122.85,956.8,
CEMENT 41G BONE TOBRA / 6197-9-001,71000398,CDM,278,RC,C1713,HCPCS,Outpatient,,,956.8,956.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.08,60,,459.26,percent of total billed charges,60% of total Billed charges for outpatient setting,812.13,84.88,,649.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.6,75,,574.08,percent of total billed charges,75% of total billed charges for outpatient setting,478.4,50,,382.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.44,80,,612.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,122.85,12.84,,98.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.8,65,,765.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.88,35,,267.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,574.08,60,,459.26,percent of total billed charges,60% of total billed charges for outpatient setting,122.85,956.8,
CEMENT 5CC HYDROSET / 397005,70000115,CDM,278,RC,C1713,HCPCS,Outpatient,,,3214.7,3214.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1928.82,60,,1543.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2728.64,84.88,,2182.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.03,75,,1928.82,percent of total billed charges,75% of total billed charges for outpatient setting,1607.35,50,,1285.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.77,12.84,,330.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2571.76,80,,2057.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.77,12.84,,330.22,percent of total billed charges,12.84% of total billed charges,412.77,12.84,,330.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3375.44,105,,2700.35,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.15,35,,900.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1928.82,60,,1543.06,percent of total billed charges,60% of total billed charges for outpatient setting,412.77,3375.44,
CEMENT BONE 40G FORTRESS/ 4129.4000S,69169294,CDM,278,RC,C1713,HCPCS,Outpatient,,,1008,1008,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.8,60,,483.84,percent of total billed charges,60% of total Billed charges for outpatient setting,855.59,84.88,,684.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,75,,604.8,percent of total billed charges,75% of total billed charges for outpatient setting,504,50,,403.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,80,,645.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1008,65,,806.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,35,,282.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,60,,483.84,percent of total billed charges,60% of total billed charges for outpatient setting,129.43,1008,
CEMENT BONE CONCORD 20G / 4129.2000S,69162312,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
CEMENT BONE CONCORD HP  26G  458.693S,69162311,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
CEMENT BONE FORTRESS PLUS / 4129.2020S,69162756,CDM,278,RC,C1713,HCPCS,Outpatient,,,460,460,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276,60,,220.8,percent of total billed charges,60% of total Billed charges for outpatient setting,390.45,84.88,,312.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345,75,,276,percent of total billed charges,75% of total billed charges for outpatient setting,230,50,,184,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.06,12.84,,47.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368,80,,294.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.06,12.84,,47.25,percent of total billed charges,12.84% of total billed charges,59.06,12.84,,47.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,460,65,,368,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,35,,128.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,276,60,,220.8,percent of total billed charges,60% of total billed charges for outpatient setting,59.06,460,
CEMENT BOWL STRYKER / 6201-003-410,69159683,CDM,270,RC,,,Outpatient,,,83.72,83.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,71.06,84.88,,56.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.86,50,,33.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.79,75,,50.23,percent of total billed charges,75% of total billed charges for outpatient setting,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.98,80,,53.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.42,65,,43.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,35,,23.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.35,90,,60.28,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75.35,
CEMENT CARTRIDGE PRISM II / 5401-33-500,69169643,CDM,278,RC,C1713,HCPCS,Outpatient,,,700,700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,60,,336,percent of total billed charges,60% of total Billed charges for outpatient setting,594.16,84.88,,475.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525,75,,420,percent of total billed charges,75% of total billed charges for outpatient setting,350,50,,280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.88,12.84,,71.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560,80,,448,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.88,12.84,,71.9,percent of total billed charges,12.84% of total billed charges,89.88,12.84,,71.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,700,65,,560,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245,35,,196,percent of total billed charges,35% of total Billed charges for Outpatient Setting,420,60,,336,percent of total billed charges,60% of total billed charges for outpatient setting,89.88,700,
CEMENT GENTAMICIN BONE / 5450-35-500,88790,CDM,278,RC,C1713,HCPCS,Outpatient,,,632,632,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.2,60,,303.36,percent of total billed charges,60% of total Billed charges for outpatient setting,536.44,84.88,,429.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474,75,,379.2,percent of total billed charges,75% of total billed charges for outpatient setting,316,50,,252.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.15,12.84,,64.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.6,80,,404.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.15,12.84,,64.92,percent of total billed charges,12.84% of total billed charges,81.15,12.84,,64.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,632,65,,505.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.2,35,,176.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.2,60,,303.36,percent of total billed charges,60% of total billed charges for outpatient setting,81.15,632,
CEMENT HYDROSET / 897010,2257225,CDM,278,RC,C1713,HCPCS,Outpatient,,,5504.58,5504.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3302.75,60,,2642.2,percent of total billed charges,60% of total Billed charges for outpatient setting,4672.29,84.88,,3737.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4128.44,75,,3302.75,percent of total billed charges,75% of total billed charges for outpatient setting,2752.29,50,,2201.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.79,12.84,,565.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4403.66,80,,3522.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.79,12.84,,565.43,percent of total billed charges,12.84% of total billed charges,706.79,12.84,,565.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5779.81,105,,4623.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926.6,35,,1541.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3302.75,60,,2642.2,percent of total billed charges,60% of total billed charges for outpatient setting,706.79,5779.81,
CEMENT MIXER PK / 658.919S,69162408,CDM,272,RC,,,Outpatient,,,562.38,562.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,477.35,84.88,,381.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.19,50,,224.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.79,75,,337.43,percent of total billed charges,75% of total billed charges for outpatient setting,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.9,80,,359.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,365.55,65,,292.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,35,,157.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,90,,404.91,percent of total billed charges,90% of total billed charges for outpatient setting,72.21,506.14,
CEMENT MIXER PK CONCORD   658.913S,69162310,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
CEMENT MIXER TRANSFER PK / 658.959S,69162755,CDM,272,RC,,,Outpatient,,,1020,1020,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714,70,,571.2,percent of total billed charges,70% of total billed charges for outpatient setting,865.78,84.88,,692.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,510,50,,408,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765,75,,612,percent of total billed charges,75% of total billed charges for outpatient setting,714,70,,571.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.97,12.84,,104.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,816,80,,652.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.97,12.84,,104.78,percent of total billed charges,12.84% of total billed charges,130.97,12.84,,104.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663,65,,530.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357,35,,285.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,918,90,,734.4,percent of total billed charges,90% of total billed charges for outpatient setting,130.97,918,
CEMENT PALACOS W/ GENT / 1113-140-01,69162283,CDM,278,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
CEMENT SIMPLEX BONE / 6192-1-001,768869,CDM,278,RC,C1713,HCPCS,Outpatient,,,235.25,235.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.15,60,,112.92,percent of total billed charges,60% of total Billed charges for outpatient setting,199.68,84.88,,159.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.44,75,,141.15,percent of total billed charges,75% of total billed charges for outpatient setting,117.63,50,,94.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.21,12.84,,24.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.2,80,,150.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.21,12.84,,24.17,percent of total billed charges,12.84% of total billed charges,30.21,12.84,,24.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,235.25,65,,188.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.34,35,,65.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.15,60,,112.92,percent of total billed charges,60% of total billed charges for outpatient setting,30.21,235.25,
CEMENT SIMPLEX W/ GENT / 6195-1-001,69169798,CDM,278,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.14,60,,404.91,percent of total billed charges,60% of total Billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,843.57,65,,674.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,60,,404.91,percent of total billed charges,60% of total billed charges for outpatient setting,108.31,843.57,
CENTRAL LINE 7FR 20CM 3L / CDC-45703-XP1,69162884,CDM,272,RC,C1751,HCPCS,Outpatient,,,520.6,520.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.42,70,,291.54,percent of total billed charges,70% of total billed charges for outpatient setting,441.89,84.88,,353.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.45,75,,312.36,percent of total billed charges,75% of total billed charges for outpatient setting,364.42,70,,291.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.85,12.84,,53.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.48,80,,333.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.85,12.84,,53.48,percent of total billed charges,12.84% of total billed charges,66.85,12.84,,53.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,338.39,65,,270.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.21,35,,145.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,468.54,90,,374.83,percent of total billed charges,90% of total billed charges for outpatient setting,66.85,468.54,
CENTRAL LINE 7FR 30CM 3LUMEN / AK-14703,6150962,CDM,272,RC,C1751,HCPCS,Outpatient,,,163.03,163.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.12,70,,91.3,percent of total billed charges,70% of total billed charges for outpatient setting,138.38,84.88,,110.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.27,75,,97.82,percent of total billed charges,75% of total billed charges for outpatient setting,114.12,70,,91.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,12.84,,16.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.42,80,,104.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,12.84,,16.74,percent of total billed charges,12.84% of total billed charges,20.93,12.84,,16.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.97,65,,84.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.06,35,,45.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.73,90,,117.38,percent of total billed charges,90% of total billed charges for outpatient setting,20.93,146.73,
CENTRUM SILVER TAB,3303129,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CENTURION FMS ULTRA  KIT / 8065752201,69169273,CDM,272,RC,,,Outpatient,,,354.84,354.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.39,70,,198.71,percent of total billed charges,70% of total billed charges for outpatient setting,301.19,84.88,,240.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,177.42,50,,141.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.13,75,,212.9,percent of total billed charges,75% of total billed charges for outpatient setting,248.39,70,,198.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.56,12.84,,36.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.87,80,,227.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.56,12.84,,36.45,percent of total billed charges,12.84% of total billed charges,45.56,12.84,,36.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,230.65,65,,184.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.19,35,,99.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,319.36,90,,255.49,percent of total billed charges,90% of total billed charges for outpatient setting,45.56,319.36,
CEPACOL MAXIUM STRENGTH: LOZ,3302746,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CEPACOL MOUTH WASH: 32OZ,3302871,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CEPHALEXIN (genericKEFLEX) CAP 250 MG,3300793,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CEPHALEXIN CAP  500MG,3302733,CDM,259,RC,,,Outpatient,,,12.99,12.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,11.03,84.88,,8.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.5,50,,5.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.74,75,,7.79,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.39,80,,8.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.44,65,,6.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,35,,3.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.69,90,,9.35,percent of total billed charges,90% of total billed charges for outpatient setting,1.67,11.69,
CEPHALEXIN MONOHYDRATE CAP: 250 MG,3300794,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CERAMENT 5ML 800-4000,69161863,CDM,278,RC,,,Outpatient,,,3960,3960,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2376,60,,1900.8,percent of total billed charges,60% of total Billed charges for outpatient setting,3361.25,84.88,,2689,percent of total billed charges,84.88% of total billed charges for outpatient setting,1980,50,,1584,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2970,75,,2376,percent of total billed charges,75% of total billed charges for outpatient setting,1980,50,,1584,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.46,12.84,,406.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3168,80,,2534.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.46,12.84,,406.77,percent of total billed charges,12.84% of total billed charges,508.46,12.84,,406.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4158,105,,3326.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,35,,1108.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2376,60,,1900.8,percent of total billed charges,60% of total billed charges for outpatient setting,508.46,4158,
CERCLAGE WIRE 1.25MM 291.02,6150646,CDM,278,RC,L8699,HCPCS,Outpatient,,,256.91,256.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.15,60,,123.32,percent of total billed charges,60% of total Billed charges for outpatient setting,218.07,84.88,,174.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.46,50,,102.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.68,75,,154.14,percent of total billed charges,75% of total billed charges for outpatient setting,128.46,50,,102.77,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.53,80,,164.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,256.91,65,,205.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.92,35,,71.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.15,60,,123.32,percent of total billed charges,60% of total billed charges for outpatient setting,32.99,256.91,
CERIVASTATIN SOD (BAYCOL) TAB: 0.4 MG,3300795,CDM,259,RC,,,Outpatient,,,4.39,4.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,70,,2.46,percent of total billed charges,70% of total billed charges for outpatient setting,3.73,84.88,,2.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.2,50,,1.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.29,75,,2.63,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,70,,2.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.56,12.84,,0.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,80,,2.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.56,12.84,,0.45,percent of total billed charges,12.84% of total billed charges,0.56,12.84,,0.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.85,65,,2.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,35,,1.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.95,90,,3.16,percent of total billed charges,90% of total billed charges for outpatient setting,0.56,3.95,
CERULOPLASMIN,220831,CDM,301,RC,82390,HCPCS,Outpatient,,,48.33,43.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,41.02,84.88,,32.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.25,75,,29,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,80,,30.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,100,,,Fee Schedule,100% of Custom Fee Schedule,43.5,90,,34.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,43.5,
CERVICAL COLLAR SMALL / 070103,69161773,CDM,272,RC,,,Outpatient,,,45.42,45.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,38.55,84.88,,30.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.71,50,,18.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.07,75,,27.26,percent of total billed charges,75% of total billed charges for outpatient setting,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,80,,29.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.52,65,,23.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.9,35,,12.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.88,90,,32.7,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.88,
CERVICAL COLLAR UNIVERSAL / ORT130105D,70000332,CDM,272,RC,,,Outpatient,,,25.5,25.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.85,70,,14.28,percent of total billed charges,70% of total billed charges for outpatient setting,21.64,84.88,,17.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.75,50,,10.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,75,,15.3,percent of total billed charges,75% of total billed charges for outpatient setting,17.85,70,,14.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,80,,16.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.58,65,,13.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,35,,7.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.95,90,,18.36,percent of total billed charges,90% of total billed charges for outpatient setting,3.27,22.95,
CERVICAL COLLAR XL / 102668-050,69162070,CDM,272,RC,,,Outpatient,,,44.66,44.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.26,70,,25.01,percent of total billed charges,70% of total billed charges for outpatient setting,37.91,84.88,,30.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.33,50,,17.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,75,,26.8,percent of total billed charges,75% of total billed charges for outpatient setting,31.26,70,,25.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,12.84,,4.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,80,,28.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,5.73,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.03,65,,23.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.63,35,,12.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.19,90,,32.15,percent of total billed charges,90% of total billed charges for outpatient setting,5.73,40.19,
CERVICAL COLLAR XX-LARGE / 102668-060,69162390,CDM,272,RC,,,Outpatient,,,42.78,42.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.95,70,,23.96,percent of total billed charges,70% of total billed charges for outpatient setting,36.31,84.88,,29.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.39,50,,17.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.09,75,,25.67,percent of total billed charges,75% of total billed charges for outpatient setting,29.95,70,,23.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.22,80,,27.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.81,65,,22.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.97,35,,11.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.5,90,,30.8,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,38.5,
CETAPHIL GENTLE SKIN CLEANSE  8OZ,3303116,CDM,259,RC,,,Outpatient,,,32.43,32.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.7,70,,18.16,percent of total billed charges,70% of total billed charges for outpatient setting,27.53,84.88,,22.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,50,,12.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,75,,19.46,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,70,,18.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.94,80,,20.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.08,65,,16.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.35,35,,9.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.19,90,,23.35,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,29.19,
CETAPHIL MOISTURIZING CREAM: 16OZ,3303193,CDM,259,RC,,,Outpatient,,,46.56,46.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,70,,26.07,percent of total billed charges,70% of total billed charges for outpatient setting,39.52,84.88,,31.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.28,50,,18.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.92,75,,27.94,percent of total billed charges,75% of total billed charges for outpatient setting,32.59,70,,26.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.98,12.84,,4.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.25,80,,29.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.98,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,5.98,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.26,65,,24.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,35,,13.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.9,90,,33.52,percent of total billed charges,90% of total billed charges for outpatient setting,5.98,41.9,
CETIRIZINE (genericZYRTEC) 10MG  TAB,3302854,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CETIRIZINE HCL 5 MG:GENERIC ZYRTEC,3303284,CDM,259,RC,,,Outpatient,,,14.73,14.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,70,,8.25,percent of total billed charges,70% of total billed charges for outpatient setting,12.5,84.88,,10,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.37,50,,5.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.05,75,,8.84,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,70,,8.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,12.84,,1.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.78,80,,9.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,12.84,,1.51,percent of total billed charges,12.84% of total billed charges,1.89,12.84,,1.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.57,65,,7.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,35,,4.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.26,90,,10.61,percent of total billed charges,90% of total billed charges for outpatient setting,1.89,13.26,
CETYLPYRIDINIUM (CEPACOL) LOZ CHRY:3.6MG,3300796,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
"CH50, TOTAL COMPLEMENT",220736,CDM,302,RC,86162,HCPCS,Outpatient,,,91.44,82.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.01,70,,51.21,percent of total billed charges,70% of total billed charges for outpatient setting,77.61,84.88,,62.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,68.58,75,,54.86,percent of total billed charges,75% of total billed charges for outpatient setting,64.01,70,,51.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.15,80,,58.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.67,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.15,100,,,Fee Schedule,100% of Custom Fee Schedule,82.3,90,,65.84,percent of total billed charges,90% of total billed charges for outpatient setting,20.32,82.3,
CHANTIX (VARENICLINE) 0.5 MG TAB,3303192,CDM,259,RC,,,Outpatient,,,24.19,24.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,20.53,84.88,,16.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.1,50,,9.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.14,75,,14.51,percent of total billed charges,75% of total billed charges for outpatient setting,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,80,,15.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.72,65,,12.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,35,,6.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.77,90,,17.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,21.77,
CHANTIX(VARENICLINE):STARTING MONTH PAK,3303256,CDM,259,RC,,,Outpatient,,,467.66,467.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.36,70,,261.89,percent of total billed charges,70% of total billed charges for outpatient setting,396.95,84.88,,317.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,233.83,50,,187.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350.75,75,,280.6,percent of total billed charges,75% of total billed charges for outpatient setting,327.36,70,,261.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.05,12.84,,48.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.13,80,,299.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.05,12.84,,48.04,percent of total billed charges,12.84% of total billed charges,60.05,12.84,,48.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,303.98,65,,243.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,35,,130.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,420.89,90,,336.71,percent of total billed charges,90% of total billed charges for outpatient setting,60.05,420.89,
CHARCOAL (ACTIDOSE) SOL 25GM  : 120ML,3300797,CDM,259,RC,,,Outpatient,,,23.05,23.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,70,,12.91,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.53,50,,9.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.29,75,,13.83,percent of total billed charges,75% of total billed charges for outpatient setting,16.14,70,,12.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,12.84,,2.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.44,80,,14.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,12.84,,2.37,percent of total billed charges,12.84% of total billed charges,2.96,12.84,,2.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.98,65,,11.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,35,,6.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.75,90,,16.6,percent of total billed charges,90% of total billed charges for outpatient setting,2.96,20.75,
CHARCOAL (ACTIDOSE) SOL 50GM : 240ML,3300798,CDM,259,RC,,,Outpatient,,,28.31,28.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,24.03,84.88,,19.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.16,50,,11.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.23,75,,16.98,percent of total billed charges,75% of total billed charges for outpatient setting,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.65,80,,18.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.4,65,,14.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,35,,7.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.48,90,,20.38,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,25.48,
CHARCOAL (ACTIDOSE-AQUA) SOL 25GM :120ML,3300528,CDM,259,RC,,,Outpatient,,,18.47,18.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,70,,10.34,percent of total billed charges,70% of total billed charges for outpatient setting,15.68,84.88,,12.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.24,50,,7.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.85,75,,11.08,percent of total billed charges,75% of total billed charges for outpatient setting,12.93,70,,10.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.78,80,,11.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.01,65,,9.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,35,,5.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.62,90,,13.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,16.62,
CHARCOAL (ACTIDOSE-AQUA)SOL 25GM : 120ML,3300529,CDM,259,RC,,,Outpatient,,,19.55,19.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.69,70,,10.95,percent of total billed charges,70% of total billed charges for outpatient setting,16.59,84.88,,13.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.78,50,,7.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.66,75,,11.73,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,70,,10.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.64,80,,12.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.71,65,,10.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,35,,5.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.6,90,,14.08,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,17.6,
CHARCOAL (ACTIDOSE-AQUA)SOL 50GM : 240ML,3300530,CDM,259,RC,,,Outpatient,,,22.77,22.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,19.33,84.88,,15.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.39,50,,9.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.08,75,,13.66,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,12.84,,2.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,80,,14.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,12.84,,2.34,percent of total billed charges,12.84% of total billed charges,2.92,12.84,,2.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.8,65,,11.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,35,,6.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.49,90,,16.39,percent of total billed charges,90% of total billed charges for outpatient setting,2.92,20.49,
CHARCOAL (ACTIDOSE-AQUA)SOL 50GM : 240ML,3300532,CDM,259,RC,,,Outpatient,,,24,24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,70,,13.44,percent of total billed charges,70% of total billed charges for outpatient setting,20.37,84.88,,16.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,12,50,,9.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,75,,14.4,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,70,,13.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,80,,15.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.08,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.6,65,,12.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,35,,6.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.6,90,,17.28,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,21.6,
CHARCOAL POWDER 30GM : U/D,3300531,CDM,259,RC,,,Outpatient,,,27.64,27.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,70,,15.48,percent of total billed charges,70% of total billed charges for outpatient setting,23.46,84.88,,18.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.82,50,,11.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.73,75,,16.58,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,70,,15.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,12.84,,2.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.11,80,,17.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,12.84,,2.84,percent of total billed charges,12.84% of total billed charges,3.55,12.84,,2.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.97,65,,14.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,35,,7.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.88,90,,19.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.55,24.88,
CHARGING SYSTEM - AXONIC INTERSTIM/1401,69169720,CDM,272,RC,,,Outpatient,,,3454.5,3454.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2418.15,70,,1934.52,percent of total billed charges,70% of total billed charges for outpatient setting,2932.18,84.88,,2345.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1727.25,50,,1381.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2590.88,75,,2072.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.56,12.84,,354.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2763.6,80,,2210.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.56,12.84,,354.85,percent of total billed charges,12.84% of total billed charges,443.56,12.84,,354.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2245.43,65,,1796.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.08,35,,967.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3109.05,90,,2487.24,percent of total billed charges,90% of total billed charges for outpatient setting,443.56,3109.05,
CHEMICAL CAUTERIZATION,5100169,CDM,510,RC,,,Outpatient,,,513.83,513.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.68,70,,287.74,percent of total billed charges,70% of total billed charges for outpatient setting,436.14,84.88,,348.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.92,50,,205.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.37,75,,308.3,percent of total billed charges,75% of total billed charges for outpatient setting,359.68,70,,287.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.98,12.84,,52.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.06,80,,328.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.98,12.84,,52.78,percent of total billed charges,12.84% of total billed charges,65.98,12.84,,52.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,333.99,65,,267.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.84,35,,143.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,462.45,90,,369.96,percent of total billed charges,90% of total billed charges for outpatient setting,65.98,462.45,
CHEMILUMINESCENT ASSAY,200447,CDM,300,RC,82397,HCPCS,Outpatient,,,63.54,57.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,53.93,84.88,,43.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.66,75,,38.13,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,80,,40.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,57.19,90,,45.75,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,57.19,
CHEST 1 VIEW,2400920,CDM,324,RC,71045,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,19.62,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,19.62,240.13,
CHEST 1 VIEW**,2410920,CDM,324,RC,71045,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,19.62,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,19.62,240.13,
CHEST 2 VWS W/APICAL LORD**,2410930,CDM,324,RC,71021,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHEST 2VWS W/O OBLIQUE PROJECTIONS**,2410935,CDM,324,RC,71022,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHEST 3 VIEWS,2400931,CDM,324,RC,71047,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
CHEST 4 OR MORE VIEWS,2500005,CDM,324,RC,71048,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,40.86,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,40.86,295.41,
CHEST SPEC VWS**,2410150,CDM,324,RC,71035,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHEST TUBE 28 FR STRAIGHT / 8888570549,6150881,CDM,272,RC,,,Outpatient,,,50.24,50.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.17,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,42.64,84.88,,34.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.12,50,,20.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.68,75,,30.14,percent of total billed charges,75% of total billed charges for outpatient setting,35.17,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.19,80,,32.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.66,65,,26.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.58,35,,14.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.22,90,,36.18,percent of total billed charges,90% of total billed charges for outpatient setting,6.45,45.22,
CHEST TWO VIEWS,2400925,CDM,324,RC,71046,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,29.82,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,29.82,240.13,
CHEST TWO VIEWS,2410925,CDM,324,RC,71046,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,29.82,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,29.82,240.13,
CHEST TWO VIEWS DRP,2500003,CDM,324,RC,71046,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,29.82,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,29.82,240.13,
CHIPS 30CC ALLOGRAFT CANC / 3102-1430,1669764,CDM,278,RC,C1762,HCPCS,Outpatient,,,2007.25,2007.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1204.35,60,,963.48,percent of total billed charges,60% of total Billed charges for outpatient setting,1703.75,84.88,,1363,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505.44,75,,1204.35,percent of total billed charges,75% of total billed charges for outpatient setting,1003.63,50,,802.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.73,12.84,,206.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1605.8,80,,1284.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.73,12.84,,206.18,percent of total billed charges,12.84% of total billed charges,257.73,12.84,,206.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2007.25,65,,1605.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.54,35,,562.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1204.35,60,,963.48,percent of total billed charges,60% of total billed charges for outpatient setting,257.73,2007.25,
CHLAMYDIA AB IgM,220838,CDM,302,RC,86632,HCPCS,Outpatient,,,57.06,51.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.94,70,,31.95,percent of total billed charges,70% of total billed charges for outpatient setting,48.43,84.88,,38.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.8,75,,34.24,percent of total billed charges,75% of total billed charges for outpatient setting,39.94,70,,31.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.65,80,,36.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.06,100,,,Fee Schedule,100% of Custom Fee Schedule,51.35,90,,41.08,percent of total billed charges,90% of total billed charges for outpatient setting,12.68,51.35,
CHLAMYDIA ANTIBODIES IgG,220839,CDM,302,RC,86631,HCPCS,Outpatient,,,53.19,47.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.23,70,,29.78,percent of total billed charges,70% of total billed charges for outpatient setting,45.15,84.88,,36.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.89,75,,31.91,percent of total billed charges,75% of total billed charges for outpatient setting,37.23,70,,29.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.55,80,,34.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.42,100,,,Fee Schedule,100% of Custom Fee Schedule,47.87,90,,38.3,percent of total billed charges,90% of total billed charges for outpatient setting,11.82,47.87,
CHLAMYDIA TRACHOMATIS;AMP PROBE TECHNIQU,201417,CDM,300,RC,87491,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
"CHLAYMDIA/GC, URINE",220891,CDM,300,RC,87491,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
CHLOGRAFIN MEGLUMINE : 20ML,3302245,CDM,255,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CHLORAL HYDRATE SYRP 500MG/5ML :5ML DOSE,3300799,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORAMBUCIL (LEUKERAN) TAB: 2 MG,3300800,CDM,259,RC,,,Outpatient,,,4.73,4.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,70,,2.65,percent of total billed charges,70% of total billed charges for outpatient setting,4.01,84.88,,3.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.37,50,,1.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.55,75,,2.84,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,70,,2.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,80,,3.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.07,65,,2.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,35,,1.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.26,90,,3.41,percent of total billed charges,90% of total billed charges for outpatient setting,0.61,4.26,
CHLORAMBUCIL (LEUKERAN) TAB: 2 MG,3300801,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORAPREP 10.5ML ORANGE / 930715,69169074,CDM,272,RC,,,Outpatient,,,25.92,25.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,22,84.88,,17.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.96,50,,10.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.44,75,,15.55,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.74,80,,16.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.85,65,,13.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,35,,7.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.33,90,,18.66,percent of total billed charges,90% of total billed charges for outpatient setting,3.33,23.33,
CHLORAPREP 26 ML / 930815,69161097,CDM,272,RC,,,Outpatient,,,40.67,40.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.47,70,,22.78,percent of total billed charges,70% of total billed charges for outpatient setting,34.52,84.88,,27.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.34,50,,16.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,75,,24.4,percent of total billed charges,75% of total billed charges for outpatient setting,28.47,70,,22.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,12.84,,4.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.54,80,,26.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,12.84,,4.18,percent of total billed charges,12.84% of total billed charges,5.22,12.84,,4.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.44,65,,21.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.23,35,,11.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.6,90,,29.28,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,36.6,
CHLORAPREP 3ML ORANGE / 930415,70000497,CDM,272,RC,,,Outpatient,,,8.05,8.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,70,,4.51,percent of total billed charges,70% of total billed charges for outpatient setting,6.83,84.88,,5.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.03,50,,3.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.04,75,,4.83,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,70,,4.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,80,,5.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.23,65,,4.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,35,,2.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.25,90,,5.8,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,7.25,
CHLORASEPTIC GENERIC THROAT SPRAY  6 OZ,3302718,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CHLORASEPTIC LOZ:,3302598,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CHLORDIAZ/CLINDIN 5-2.5 (LIBRAX)CAP,3302852,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORDIAZEPOXIDE (genLIBRIUM) CAP 10 MG,3300802,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORDIAZEPOXIDE (LIBRIUM) AMP: 100MG,3300804,CDM,250,RC,,,Outpatient,,,78.07,78.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.65,70,,43.72,percent of total billed charges,70% of total billed charges for outpatient setting,66.27,84.88,,53.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.04,50,,31.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.55,75,,46.84,percent of total billed charges,75% of total billed charges for outpatient setting,54.65,70,,43.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,12.84,,8.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.46,80,,49.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,12.84,,8.02,percent of total billed charges,12.84% of total billed charges,10.02,12.84,,8.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.75,65,,40.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.32,35,,21.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.26,90,,56.21,percent of total billed charges,90% of total billed charges for outpatient setting,10.02,70.26,
CHLORDIAZEPOXIDE (LIBRIUM) CAP  25 MG,3300803,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CHLORHEX (BETASEPT) SOL 4-4% W/PMP :,3300806,CDM,259,RC,,,Outpatient,,,31.13,31.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.79,70,,17.43,percent of total billed charges,70% of total billed charges for outpatient setting,26.42,84.88,,21.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.57,50,,12.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.35,75,,18.68,percent of total billed charges,75% of total billed charges for outpatient setting,21.79,70,,17.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,12.84,,3.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.9,80,,19.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,12.84,,3.2,percent of total billed charges,12.84% of total billed charges,4,12.84,,3.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.23,65,,16.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,35,,8.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.02,90,,22.42,percent of total billed charges,90% of total billed charges for outpatient setting,4,28.02,
CHLORHEX (HIBICLENS) 4-4% SKIN CL : 4 OZ,3300805,CDM,259,RC,,,Outpatient,,,55.94,55.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.16,70,,31.33,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,84.88,,37.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.97,50,,22.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.96,75,,33.57,percent of total billed charges,75% of total billed charges for outpatient setting,39.16,70,,31.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,12.84,,5.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,80,,35.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,7.18,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.36,65,,29.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,35,,15.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.35,90,,40.28,percent of total billed charges,90% of total billed charges for outpatient setting,7.18,50.35,
CHLORHEXIDINE GLUC ORAL(PERIDEX):0.12%,3307290,CDM,259,RC,,,Outpatient,,,12.71,12.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,70,,7.12,percent of total billed charges,70% of total billed charges for outpatient setting,10.79,84.88,,8.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.36,50,,5.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.53,75,,7.62,percent of total billed charges,75% of total billed charges for outpatient setting,8.9,70,,7.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,80,,8.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.26,65,,6.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.45,35,,3.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.44,90,,9.15,percent of total billed charges,90% of total billed charges for outpatient setting,1.63,11.44,
CHLORHEXIDINE(GEN HIBICLENS)4% TOP 237ML,3300807,CDM,259,RC,,,Outpatient,,,63.65,63.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,70,,35.65,percent of total billed charges,70% of total billed charges for outpatient setting,54.03,84.88,,43.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.83,50,,25.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.74,75,,38.19,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,70,,35.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,12.84,,6.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.92,80,,40.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,12.84,,6.54,percent of total billed charges,12.84% of total billed charges,8.17,12.84,,6.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.37,65,,33.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,35,,17.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.29,90,,45.83,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,57.29,
CHLORIDE - BLOOD,200445,CDM,300,RC,82435,HCPCS,Outpatient,,,20.7,18.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,17.57,84.88,,14.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.53,75,,12.42,percent of total billed charges,75% of total billed charges for outpatient setting,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.56,80,,13.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,18.63,90,,14.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.6,18.63,
CHLORIDE - URINE,200446,CDM,300,RC,82436,HCPCS,Outpatient,,,25.88,23.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.12,70,,14.5,percent of total billed charges,70% of total billed charges for outpatient setting,21.97,84.88,,17.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.41,75,,15.53,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,70,,14.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,80,,16.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,100,,,Fee Schedule,100% of Custom Fee Schedule,23.29,90,,18.63,percent of total billed charges,90% of total billed charges for outpatient setting,5.75,23.29,
CHLOROTHIAZIDE (DIURIL):250 MG TAB,3302862,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CHLOROTHIAZIDE (DIURIL)500MG: INJ,3302944,CDM,636,RC,J1205,HCPCS,Outpatient,,,484.77,484.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.34,70,,271.47,percent of total billed charges,70% of total billed charges for outpatient setting,411.47,84.88,,329.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,363.58,75,,290.86,percent of total billed charges,75% of total billed charges for outpatient setting,339.34,70,,271.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,12.84,,49.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.82,80,,310.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,12.84,,49.79,percent of total billed charges,12.84% of total billed charges,62.24,12.84,,49.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.1,65,,252.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,100,,,Fee Schedule,100% of Custom Fee Schedule,436.29,90,,349.03,percent of total billed charges,90% of total billed charges for outpatient setting,46.54,436.29,
CHLORPHENIRAMINE (TELDRIN) TAB: 4 MG,3300808,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORPROMAZINE (THORAZINE) TAB : 10 MG,3300810,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CHLORPROMAZINE (THORAZINE) TAB : 25 MG,3300809,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHLORPROMAZNE (THORAZINE)25MG/ML AMP:2ML,3300811,CDM,250,RC,,,Outpatient,,,161.25,161.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.88,70,,90.3,percent of total billed charges,70% of total billed charges for outpatient setting,136.87,84.88,,109.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.63,50,,64.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.94,75,,96.75,percent of total billed charges,75% of total billed charges for outpatient setting,112.88,70,,90.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,12.84,,16.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129,80,,103.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,12.84,,16.56,percent of total billed charges,12.84% of total billed charges,20.7,12.84,,16.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.81,65,,83.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.44,35,,45.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.13,90,,116.1,percent of total billed charges,90% of total billed charges for outpatient setting,20.7,145.13,
CHLORTHALIDONE 25MG TABLET,3303328,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CHOL AND/OR PANCR ADDITIONAL SET INTRAOP,2400675,CDM,320,RC,74301,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHOLANGIO INTRAOPERATIVE,2400670,CDM,320,RC,74300,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHOLANGIOGRAM CATH LAPAROSCOPIC,6150676,CDM,272,RC,,,Outpatient,,,510.47,510.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.33,70,,285.86,percent of total billed charges,70% of total billed charges for outpatient setting,433.29,84.88,,346.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,255.24,50,,204.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.85,75,,306.28,percent of total billed charges,75% of total billed charges for outpatient setting,357.33,70,,285.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,12.84,,52.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.38,80,,326.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,12.84,,52.43,percent of total billed charges,12.84% of total billed charges,65.54,12.84,,52.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,331.81,65,,265.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.66,35,,142.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,459.42,90,,367.54,percent of total billed charges,90% of total billed charges for outpatient setting,65.54,459.42,
CHOLANGIOGRAPHY PERCUTANEOUS TRANSHEPAT,2400685,CDM,320,RC,74320,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.73,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,878.73,
CHOLANGIOGRAPHY/PANCREATOGRAPHY INTRAOP,2400880,CDM,320,RC,74300,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHOLEC ADDITIONAL OR RPT EXAM,2400665,CDM,320,RC,74291,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CHOLECYSTOGRAPHY ORAL CONTRAST,2400660,CDM,320,RC,74290,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
CHOLESTEROL,200450,CDM,300,RC,82465,HCPCS,Outpatient,,,19.58,17.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,70,,10.97,percent of total billed charges,70% of total billed charges for outpatient setting,16.62,84.88,,13.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.69,75,,11.75,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,70,,10.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.66,80,,12.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,100,,,Fee Schedule,100% of Custom Fee Schedule,17.62,90,,14.1,percent of total billed charges,90% of total billed charges for outpatient setting,4.26,17.62,
CHOLESTEROL SERUM OR BLD TOTAL,201456,CDM,301,RC,82465,HCPCS,Outpatient,,,19.58,17.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,70,,10.97,percent of total billed charges,70% of total billed charges for outpatient setting,16.62,84.88,,13.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.69,75,,11.75,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,70,,10.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.66,80,,12.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,100,,,Fee Schedule,100% of Custom Fee Schedule,17.62,90,,14.1,percent of total billed charges,90% of total billed charges for outpatient setting,4.26,17.62,
CHOLEST-OFF CAPLETS,3304459,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
CHOLESTYRAMINE (PREVALITE) 4GM TAB :,3300812,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHOLESTYRAMINE (PREVALITE) POWDER : 4GM,3300814,CDM,259,RC,,,Outpatient,,,116.46,116.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.52,70,,65.22,percent of total billed charges,70% of total billed charges for outpatient setting,98.85,84.88,,79.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.23,50,,46.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.35,75,,69.88,percent of total billed charges,75% of total billed charges for outpatient setting,81.52,70,,65.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.95,12.84,,11.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.17,80,,74.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.95,12.84,,11.96,percent of total billed charges,12.84% of total billed charges,14.95,12.84,,11.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.7,65,,60.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.76,35,,32.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.81,90,,83.85,percent of total billed charges,90% of total billed charges for outpatient setting,14.95,104.81,
CHOLESTYRAMINE (PREVALITE) TAB 4GM :,3300813,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CHOLESTYRAMINE (QUESTRAN) 4 GM PWD,3300815,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
CHOLINE (TRILISATE) TAB : 500 MG,3300816,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CHOLINE (TRILISATE) TAB : 750 MG,3300817,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CHONDROITIN VISCOAT (DUOVISC) KT :,3300819,CDM,259,RC,,,Outpatient,,,521.84,521.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.29,70,,292.23,percent of total billed charges,70% of total billed charges for outpatient setting,442.94,84.88,,354.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,260.92,50,,208.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.38,75,,313.1,percent of total billed charges,75% of total billed charges for outpatient setting,365.29,70,,292.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.47,80,,333.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,339.2,65,,271.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.64,35,,146.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,469.66,90,,375.73,percent of total billed charges,90% of total billed charges for outpatient setting,67,469.66,
CHONDROITIN(VISCOAT)SYRINGE 0.5MG/ML:,3300818,CDM,259,RC,,,Outpatient,,,396.98,396.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.89,70,,222.31,percent of total billed charges,70% of total billed charges for outpatient setting,336.96,84.88,,269.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,198.49,50,,158.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.74,75,,238.19,percent of total billed charges,75% of total billed charges for outpatient setting,277.89,70,,222.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,12.84,,40.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.58,80,,254.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,12.84,,40.78,percent of total billed charges,12.84% of total billed charges,50.97,12.84,,40.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,258.04,65,,206.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.94,35,,111.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,357.28,90,,285.82,percent of total billed charges,90% of total billed charges for outpatient setting,50.97,357.28,
CHROMAGEN CAPSULE,3302753,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CHROMAGEN FORTE: CAPSULE,3303064,CDM,250,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CHROMATOGRPHY QNT COLUMN,201491,CDM,305,RC,82542,HCPCS,Outpatient,,,108.41,97.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.89,70,,60.71,percent of total billed charges,70% of total billed charges for outpatient setting,92.02,84.88,,73.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,81.31,75,,65.05,percent of total billed charges,75% of total billed charges for outpatient setting,75.89,70,,60.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,80,,69.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,97.57,90,,78.06,percent of total billed charges,90% of total billed charges for outpatient setting,24.09,97.57,
CHROMIUM PLASMA,220201,CDM,300,RC,82495,HCPCS,Outpatient,,,91.26,82.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,70,,51.1,percent of total billed charges,70% of total billed charges for outpatient setting,77.46,84.88,,61.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,68.45,75,,54.76,percent of total billed charges,75% of total billed charges for outpatient setting,63.88,70,,51.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.01,80,,58.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.61,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,100% of Custom Fee Schedule,82.13,90,,65.7,percent of total billed charges,90% of total billed charges for outpatient setting,20.28,82.13,
CHROMOGRANIN A,220389,CDM,302,RC,86316,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,84.29,
CHROMOSOME ANAL 20TO25CELLS 2KARYOTYPES,201057,CDM,300,RC,88264,HCPCS,Outpatient,,,650.75,585.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.53,70,,364.42,percent of total billed charges,70% of total billed charges for outpatient setting,552.36,84.88,,441.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,214.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,488.06,75,,390.45,percent of total billed charges,75% of total billed charges for outpatient setting,455.53,70,,364.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.6,80,,416.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,181.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.36,100,,,Fee Schedule,100% of Custom Fee Schedule,585.68,90,,468.54,percent of total billed charges,90% of total billed charges for outpatient setting,144.61,585.68,
"CHROMOSOME ANAL., 15-20CELLS,2KARYOTYPES",201037,CDM,300,RC,88262,HCPCS,Outpatient,,,564.71,508.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.3,70,,316.24,percent of total billed charges,70% of total billed charges for outpatient setting,479.33,84.88,,383.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,214.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,423.53,75,,338.82,percent of total billed charges,75% of total billed charges for outpatient setting,395.3,70,,316.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.77,80,,361.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,181.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.36,100,,,Fee Schedule,100% of Custom Fee Schedule,508.24,90,,406.59,percent of total billed charges,90% of total billed charges for outpatient setting,125.49,508.24,
CILOSTAZOL (PLETAL) TAB: 100 MG,3300820,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CIMETIDINE 400MG  TAB,3303097,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CIMETIDINE(TAGAMET)300MG TAB:UD,3302604,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CIPRO (CIPROFLOXIN) 400MG INJ: 20ML,3302685,CDM,250,RC,,,Outpatient,,,152.49,152.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.74,70,,85.39,percent of total billed charges,70% of total billed charges for outpatient setting,129.43,84.88,,103.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.25,50,,61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.37,75,,91.5,percent of total billed charges,75% of total billed charges for outpatient setting,106.74,70,,85.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,12.84,,15.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.99,80,,97.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,12.84,,15.66,percent of total billed charges,12.84% of total billed charges,19.58,12.84,,15.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.12,65,,79.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.37,35,,42.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.24,90,,109.79,percent of total billed charges,90% of total billed charges for outpatient setting,19.58,137.24,
CIPROFLOX (CILOXAN) OPTH SOL 0.3% 5ML,3300821,CDM,259,RC,,,Outpatient,,,86,86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.2,70,,48.16,percent of total billed charges,70% of total billed charges for outpatient setting,73,84.88,,58.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,43,50,,34.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.5,75,,51.6,percent of total billed charges,75% of total billed charges for outpatient setting,60.2,70,,48.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,12.84,,8.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.8,80,,55.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,12.84,,8.83,percent of total billed charges,12.84% of total billed charges,11.04,12.84,,8.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.9,65,,44.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,35,,24.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,77.4,90,,61.92,percent of total billed charges,90% of total billed charges for outpatient setting,11.04,77.4,
CIPROFLOX (CIPRO) 400MG/200ML PREMIX :,3300826,CDM,250,RC,J0744,HCPCS,Outpatient,,,90.84,90.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.59,70,,50.87,percent of total billed charges,70% of total billed charges for outpatient setting,77.1,84.88,,61.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,68.13,75,,54.5,percent of total billed charges,75% of total billed charges for outpatient setting,63.59,70,,50.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.66,12.84,,9.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.67,80,,58.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.66,12.84,,9.33,percent of total billed charges,12.84% of total billed charges,11.66,12.84,,9.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.05,65,,47.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,100,,,Fee Schedule,100% of Custom Fee Schedule,81.76,90,,65.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,81.76,
CIPROFLOX /DEXAMETHASONE(CIPRODEX):7.5ML,3306436,CDM,259,RC,,,Outpatient,,,529.13,529.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.39,70,,296.31,percent of total billed charges,70% of total billed charges for outpatient setting,449.13,84.88,,359.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,264.57,50,,211.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.85,75,,317.48,percent of total billed charges,75% of total billed charges for outpatient setting,370.39,70,,296.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.94,12.84,,54.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.3,80,,338.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.94,12.84,,54.35,percent of total billed charges,12.84% of total billed charges,67.94,12.84,,54.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.93,65,,275.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.2,35,,148.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,476.22,90,,380.98,percent of total billed charges,90% of total billed charges for outpatient setting,67.94,476.22,
CIPROFLOXACIN (CIPRO) TAB: 250 MG,3300822,CDM,259,RC,,,Outpatient,,,10.17,10.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,70,,5.7,percent of total billed charges,70% of total billed charges for outpatient setting,8.63,84.88,,6.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.09,50,,4.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.63,75,,6.1,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,70,,5.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.31,12.84,,1.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.14,80,,6.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.31,12.84,,1.05,percent of total billed charges,12.84% of total billed charges,1.31,12.84,,1.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.61,65,,5.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,35,,2.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.15,90,,7.32,percent of total billed charges,90% of total billed charges for outpatient setting,1.31,9.15,
CIPROFLOXACIN (CIPRO) TAB: 250 MG,3300823,CDM,259,RC,,,Outpatient,,,11.18,11.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,70,,6.26,percent of total billed charges,70% of total billed charges for outpatient setting,9.49,84.88,,7.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.59,50,,4.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.39,75,,6.71,percent of total billed charges,75% of total billed charges for outpatient setting,7.83,70,,6.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.94,80,,7.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.27,65,,5.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,35,,3.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.06,90,,8.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.44,10.06,
CIPROFLOXACIN (CIPRO) TAB: 500MG,3300824,CDM,259,RC,,,Outpatient,,,11.87,11.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.9,75,,7.12,percent of total billed charges,75% of total billed charges for outpatient setting,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,35,,3.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.68,90,,8.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,10.68,
CIPROFLOXACIN (CIPRO) TAB: 500MG,3300825,CDM,259,RC,,,Outpatient,,,12.26,12.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.41,84.88,,8.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.13,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.2,75,,7.36,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,80,,7.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,65,,6.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,35,,3.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.03,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.03,
CIPROFLOXACIN 500MG TAB,3302884,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CIPROFLOXACIN OPHTH SOL 0.3% 2.5ML,3313023,CDM,259,RC,,,Outpatient,,,47.46,47.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,70,,26.58,percent of total billed charges,70% of total billed charges for outpatient setting,40.28,84.88,,32.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.73,50,,18.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.6,75,,28.48,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,70,,26.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.97,80,,30.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.85,65,,24.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,35,,13.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.71,90,,34.17,percent of total billed charges,90% of total billed charges for outpatient setting,6.09,42.71,
CIRCUIT VENTILATOR ADULT / 1609,69162379,CDM,271,RC,,,Outpatient,,,90.85,90.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,70,,50.88,percent of total billed charges,70% of total billed charges for outpatient setting,77.11,84.88,,61.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.43,50,,36.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.14,75,,54.51,percent of total billed charges,75% of total billed charges for outpatient setting,63.6,70,,50.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,80,,58.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.05,65,,47.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.8,35,,25.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.77,90,,65.42,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,81.77,
CISATRACURIUM (NIMBEX) 2MG/ML 5ML,3314152,CDM,250,RC,,,Outpatient,,,104.37,104.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.06,70,,58.45,percent of total billed charges,70% of total billed charges for outpatient setting,88.59,84.88,,70.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.19,50,,41.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.28,75,,62.62,percent of total billed charges,75% of total billed charges for outpatient setting,73.06,70,,58.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,12.84,,10.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.5,80,,66.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,12.84,,10.72,percent of total billed charges,12.84% of total billed charges,13.4,12.84,,10.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.84,65,,54.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.53,35,,29.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.93,90,,75.14,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,93.93,
CISATRACURIUM (NIMBEX) 2MG/ML 5ML,3314153,CDM,250,RC,,,Outpatient,,,104.58,104.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.21,70,,58.57,percent of total billed charges,70% of total billed charges for outpatient setting,88.77,84.88,,71.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.29,50,,41.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.44,75,,62.75,percent of total billed charges,75% of total billed charges for outpatient setting,73.21,70,,58.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.66,80,,66.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.98,65,,54.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.6,35,,29.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.12,90,,75.3,percent of total billed charges,90% of total billed charges for outpatient setting,13.43,94.12,
CITALOPRAM (CELEXA) TAB : 20 MG,3300828,CDM,259,RC,,,Outpatient,,,5.66,5.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,84.88,,3.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.83,50,,2.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.25,75,,3.4,percent of total billed charges,75% of total billed charges for outpatient setting,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,80,,3.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.68,65,,2.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,35,,1.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.09,90,,4.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,5.09,
CITALOPRAM (CELEXA) TAB : 20 MG,3300829,CDM,259,RC,,,Outpatient,,,6.21,6.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,84.88,,4.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,50,,2.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.66,75,,3.73,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,80,,3.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.04,65,,3.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.59,90,,4.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.59,
CITALOPRAM(genericCELEXA)TAB 20MG,3302941,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CITRIC ACID  24HR URINE,202163,CDM,301,RC,82507,HCPCS,Outpatient,,,125.1,112.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.57,70,,70.06,percent of total billed charges,70% of total billed charges for outpatient setting,106.18,84.88,,84.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,93.83,75,,75.06,percent of total billed charges,75% of total billed charges for outpatient setting,87.57,70,,70.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.08,80,,80.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,40.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.72,100,,,Fee Schedule,100% of Custom Fee Schedule,112.59,90,,90.07,percent of total billed charges,90% of total billed charges for outpatient setting,27.8,112.59,
CITRIC ACID (CYTRA 3) VANIL SYRP : 480ML,3300830,CDM,259,RC,,,Outpatient,,,45.7,45.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.99,70,,25.59,percent of total billed charges,70% of total billed charges for outpatient setting,38.79,84.88,,31.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.85,50,,18.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.28,75,,27.42,percent of total billed charges,75% of total billed charges for outpatient setting,31.99,70,,25.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.87,12.84,,4.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,80,,29.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.87,12.84,,4.7,percent of total billed charges,12.84% of total billed charges,5.87,12.84,,4.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.71,65,,23.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16,35,,12.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.13,90,,32.9,percent of total billed charges,90% of total billed charges for outpatient setting,5.87,41.13,
CITRIC ACID (SOD CITRAT) 300MG SOL :30ML,3300832,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CITRIC ACID (SODIUM CITRATE) SOL : 5ML,3300831,CDM,259,RC,,,Outpatient,,,22.59,22.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.3,50,,9.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.68,65,,11.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,35,,6.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,20.33,
CK-ISOENZYMES,220067,CDM,300,RC,82552,HCPCS,Outpatient,,,60.26,54.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,84.88,,40.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.2,75,,36.16,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.21,80,,38.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,100,,,Fee Schedule,100% of Custom Fee Schedule,54.23,90,,43.38,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,54.23,
CKMB,222007,CDM,301,RC,82553,HCPCS,Outpatient,,,51.98,46.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.39,70,,29.11,percent of total billed charges,70% of total billed charges for outpatient setting,44.12,84.88,,35.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.99,75,,31.19,percent of total billed charges,75% of total billed charges for outpatient setting,36.39,70,,29.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.58,80,,33.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.86,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,100% of Custom Fee Schedule,46.78,90,,37.42,percent of total billed charges,90% of total billed charges for outpatient setting,11.55,46.78,
CLAFORAN INJ : 1GM,3302514,CDM,250,RC,,,Outpatient,,,71.83,71.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.28,70,,40.22,percent of total billed charges,70% of total billed charges for outpatient setting,60.97,84.88,,48.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.92,50,,28.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.87,75,,43.1,percent of total billed charges,75% of total billed charges for outpatient setting,50.28,70,,40.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,12.84,,7.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.46,80,,45.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,12.84,,7.38,percent of total billed charges,12.84% of total billed charges,9.22,12.84,,7.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.69,65,,37.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,35,,20.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.65,90,,51.72,percent of total billed charges,90% of total billed charges for outpatient setting,9.22,64.65,
CLAFORAN INJ : 500MG,3302613,CDM,250,RC,,,Outpatient,,,26.09,26.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,70,,14.61,percent of total billed charges,70% of total billed charges for outpatient setting,22.15,84.88,,17.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.05,50,,10.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,75,,15.66,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,70,,14.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.35,12.84,,2.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.87,80,,16.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.35,12.84,,2.68,percent of total billed charges,12.84% of total billed charges,3.35,12.84,,2.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.96,65,,13.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.13,35,,7.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.48,90,,18.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.35,23.48,
CLAFORAN INJ: 2GM,3302515,CDM,250,RC,,,Outpatient,,,80.54,80.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.38,70,,45.1,percent of total billed charges,70% of total billed charges for outpatient setting,68.36,84.88,,54.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.27,50,,32.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.41,75,,48.33,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,70,,45.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,12.84,,8.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.43,80,,51.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,12.84,,8.27,percent of total billed charges,12.84% of total billed charges,10.34,12.84,,8.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.35,65,,41.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.19,35,,22.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.49,90,,57.99,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,72.49,
CLAFORAN/NS IVPB 1GM /50 ML,3302729,CDM,250,RC,,,Outpatient,,,113.43,113.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,96.28,84.88,,77.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.72,50,,45.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.07,75,,68.06,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,80,,72.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.73,65,,58.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,35,,31.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.09,90,,81.67,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.09,
CLAMP 4MM DIST. RAD FIXATION,69162093,CDM,272,RC,,,Outpatient,,,2126.32,2126.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488.42,70,,1190.74,percent of total billed charges,70% of total billed charges for outpatient setting,1804.82,84.88,,1443.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,1063.16,50,,850.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1594.74,75,,1275.79,percent of total billed charges,75% of total billed charges for outpatient setting,1488.42,70,,1190.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.02,12.84,,218.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701.06,80,,1360.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.02,12.84,,218.42,percent of total billed charges,12.84% of total billed charges,273.02,12.84,,218.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1382.11,65,,1105.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.21,35,,595.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1913.69,90,,1530.95,percent of total billed charges,90% of total billed charges for outpatient setting,273.02,1913.69,
CLAMP FOLEY CATHETER / 39132,69169344,CDM,270,RC,,,Outpatient,,,3.08,3.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.31,75,,1.85,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.77,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.77,
CLAMP PENILE CUNNINGHAM LARGE/ 004054,69169604,CDM,272,RC,,,Outpatient,,,147.05,147.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.94,70,,82.35,percent of total billed charges,70% of total billed charges for outpatient setting,124.82,84.88,,99.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.53,50,,58.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.29,75,,88.23,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,70,,82.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,12.84,,15.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.64,80,,94.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,12.84,,15.1,percent of total billed charges,12.84% of total billed charges,18.88,12.84,,15.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.58,65,,76.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.47,35,,41.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.35,90,,105.88,percent of total billed charges,90% of total billed charges for outpatient setting,18.88,132.35,
CLAMP PENILE CUNNINGHAM MED / 004053,69169603,CDM,272,RC,,,Outpatient,,,122.4,122.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.68,70,,68.54,percent of total billed charges,70% of total billed charges for outpatient setting,103.89,84.88,,83.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.2,50,,48.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,75,,73.44,percent of total billed charges,75% of total billed charges for outpatient setting,85.68,70,,68.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.72,12.84,,12.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,80,,78.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.72,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.72,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.56,65,,63.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,35,,34.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.16,90,,88.13,percent of total billed charges,90% of total billed charges for outpatient setting,15.72,110.16,
CLARITHROMY (BIAXIN)SUSP 250MG/5Ml  50ML,3300833,CDM,259,RC,,,Outpatient,,,106.56,106.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.59,70,,59.67,percent of total billed charges,70% of total billed charges for outpatient setting,90.45,84.88,,72.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.28,50,,42.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.92,75,,63.94,percent of total billed charges,75% of total billed charges for outpatient setting,74.59,70,,59.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,12.84,,10.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.25,80,,68.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,12.84,,10.94,percent of total billed charges,12.84% of total billed charges,13.68,12.84,,10.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.26,65,,55.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.3,35,,29.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.9,90,,76.72,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,95.9,
CLARITHROMYCIN (BIAXIN) TAB  250 MG,3300834,CDM,259,RC,,,Outpatient,,,13.24,13.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,70,,7.42,percent of total billed charges,70% of total billed charges for outpatient setting,11.24,84.88,,8.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.62,50,,5.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.93,75,,7.94,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,70,,7.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.59,80,,8.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.61,65,,6.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,35,,3.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.92,90,,9.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.7,11.92,
CLARITHROMYCIN (BIAXIN) TAB: 500 MG,3300835,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLARITHROMYCIN(BIAXIN)SUSP 250/5ML:100ML,3302786,CDM,259,RC,,,Outpatient,,,196.59,196.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.61,70,,110.09,percent of total billed charges,70% of total billed charges for outpatient setting,166.87,84.88,,133.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.3,50,,78.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.44,75,,117.95,percent of total billed charges,75% of total billed charges for outpatient setting,137.61,70,,110.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.24,12.84,,20.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.27,80,,125.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.24,12.84,,20.19,percent of total billed charges,12.84% of total billed charges,25.24,12.84,,20.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.78,65,,102.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.81,35,,55.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,176.93,90,,141.54,percent of total billed charges,90% of total billed charges for outpatient setting,25.24,176.93,
CLAVICLE BILATERAL,2400472,CDM,320,RC,73000,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
CLAVICLE COMPLETE LEFT,2400471,CDM,320,RC,73000,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
CLAVICLE COMPLETE RIGHT,2400470,CDM,320,RC,73000,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
CLEARIFY VIS SYSTEM / 21-345,69161331,CDM,272,RC,,,Outpatient,,,153,153,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.1,70,,85.68,percent of total billed charges,70% of total billed charges for outpatient setting,129.87,84.88,,103.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.5,50,,61.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,75,,91.8,percent of total billed charges,75% of total billed charges for outpatient setting,107.1,70,,85.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.65,12.84,,15.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,80,,97.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.65,12.84,,15.72,percent of total billed charges,12.84% of total billed charges,19.65,12.84,,15.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.45,65,,79.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,35,,42.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.7,90,,110.16,percent of total billed charges,90% of total billed charges for outpatient setting,19.65,137.7,
CLEARVISIONS II TUBING SET  031229-10,69160930,CDM,272,RC,,,Outpatient,,,143.97,143.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.78,70,,80.62,percent of total billed charges,70% of total billed charges for outpatient setting,122.2,84.88,,97.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.99,50,,57.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.98,75,,86.38,percent of total billed charges,75% of total billed charges for outpatient setting,100.78,70,,80.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,12.84,,14.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.18,80,,92.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,12.84,,14.79,percent of total billed charges,12.84% of total billed charges,18.49,12.84,,14.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.58,65,,74.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.39,35,,40.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.57,90,,103.66,percent of total billed charges,90% of total billed charges for outpatient setting,18.49,129.57,
CLEOCIN 600/50ML PREMIX:,3302562,CDM,250,RC,,,Outpatient,,,28.17,28.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,70,,15.78,percent of total billed charges,70% of total billed charges for outpatient setting,23.91,84.88,,19.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.09,50,,11.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.13,75,,16.9,percent of total billed charges,75% of total billed charges for outpatient setting,19.72,70,,15.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.54,80,,18.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.31,65,,14.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.35,90,,20.28,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.35,
CLEOCIN CAP 150MG,3302563,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLINDAMYCIN  CLEOCIN 600MG 4ML,3300840,CDM,250,RC,J3490,HCPCS,Outpatient,,,104.45,104.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,70,,58.5,percent of total billed charges,70% of total billed charges for outpatient setting,88.66,84.88,,70.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.34,75,,62.67,percent of total billed charges,75% of total billed charges for outpatient setting,73.12,70,,58.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.41,12.84,,10.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.56,80,,66.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.41,12.84,,10.73,percent of total billed charges,12.84% of total billed charges,13.41,12.84,,10.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.89,65,,54.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,35,,29.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.01,90,,75.21,percent of total billed charges,90% of total billed charges for outpatient setting,13.41,94.01,
CLINDAMYCIN (CLEOCIN) : 900 MG/6 ML,3302564,CDM,250,RC,,,Outpatient,,,118.2,118.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.74,70,,66.19,percent of total billed charges,70% of total billed charges for outpatient setting,100.33,84.88,,80.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.1,50,,47.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.65,75,,70.92,percent of total billed charges,75% of total billed charges for outpatient setting,82.74,70,,66.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.18,12.84,,12.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.56,80,,75.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.18,12.84,,12.14,percent of total billed charges,12.84% of total billed charges,15.18,12.84,,12.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.83,65,,61.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.37,35,,33.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.38,90,,85.1,percent of total billed charges,90% of total billed charges for outpatient setting,15.18,106.38,
CLINDAMYCIN (CLEOCIN) 600/50ML PREMIX:,3300839,CDM,250,RC,,,Outpatient,,,30.99,30.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.69,70,,17.35,percent of total billed charges,70% of total billed charges for outpatient setting,26.3,84.88,,21.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.5,50,,12.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.24,75,,18.59,percent of total billed charges,75% of total billed charges for outpatient setting,21.69,70,,17.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,12.84,,3.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,80,,19.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,3.98,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.14,65,,16.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,35,,8.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.89,90,,22.31,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,27.89,
CLINDAMYCIN (CLEOCIN) CAP : 150 MG,3300836,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CLINDAMYCIN (CLEOCIN) CAP : 150 MG,3300837,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CLINDAMYCIN (CLEOCIN) CAP : 150 MG,3300838,CDM,259,RC,,,Outpatient,,,27.85,27.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,70,,15.6,percent of total billed charges,70% of total billed charges for outpatient setting,23.64,84.88,,18.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.93,50,,11.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.89,75,,16.71,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,70,,15.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,80,,17.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.1,65,,14.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.75,35,,7.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.07,90,,20.06,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,25.07,
CLINDAMYCIN /D5W 600MG/50ML IVPB,3303353,CDM,250,RC,,,Outpatient,,,40.29,40.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.2,70,,22.56,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,84.88,,27.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.15,50,,16.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.22,75,,24.18,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,70,,22.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,12.84,,4.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.23,80,,25.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,5.17,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.19,65,,20.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,35,,11.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.26,90,,29.01,percent of total billed charges,90% of total billed charges for outpatient setting,5.17,36.26,
CLINDAMYCIN /D5W 900MG/50ML IVPB,3303351,CDM,250,RC,,,Outpatient,,,33.94,33.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,70,,19.01,percent of total billed charges,70% of total billed charges for outpatient setting,28.81,84.88,,23.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.97,50,,13.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,75,,20.37,percent of total billed charges,75% of total billed charges for outpatient setting,23.76,70,,19.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,80,,21.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.06,65,,17.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.88,35,,9.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.55,90,,24.44,percent of total billed charges,90% of total billed charges for outpatient setting,4.36,30.55,
CLINDAMYCIN /NS IVPB 300MG/50ML,3303352,CDM,250,RC,,,Outpatient,,,74.51,74.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.16,70,,41.73,percent of total billed charges,70% of total billed charges for outpatient setting,63.24,84.88,,50.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.26,50,,29.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.88,75,,44.7,percent of total billed charges,75% of total billed charges for outpatient setting,52.16,70,,41.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.61,80,,47.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.43,65,,38.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.08,35,,20.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.06,90,,53.65,percent of total billed charges,90% of total billed charges for outpatient setting,9.57,67.06,
CLINDAMYCIN genCLEOCIN 150MG/ML INJ 4ML,3302565,CDM,250,RC,,,Outpatient,,,321.37,321.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.96,70,,179.97,percent of total billed charges,70% of total billed charges for outpatient setting,272.78,84.88,,218.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.69,50,,128.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.03,75,,192.82,percent of total billed charges,75% of total billed charges for outpatient setting,224.96,70,,179.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.26,12.84,,33.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.1,80,,205.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.26,12.84,,33.01,percent of total billed charges,12.84% of total billed charges,41.26,12.84,,33.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208.89,65,,167.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,35,,89.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.23,90,,231.38,percent of total billed charges,90% of total billed charges for outpatient setting,41.26,289.23,
CLINDAMYCIN/CLEOCIN INJ 300MG/2ML 2ML,3300841,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLINIC LEVEL I,5100155,CDM,510,RC,99201,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.05,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,28.05,302.15,
CLINIC LEVEL I,6154000,CDM,510,RC,99201,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.05,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,28.05,302.15,
CLINIC LEVEL II,2200960,CDM,510,RC,99202,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.71,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,302.15,
CLINIC LEVEL II,5100160,CDM,510,RC,99202,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.71,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,302.15,
CLINIC LEVEL III,5100165,CDM,510,RC,99203,HCPCS,Outpatient,,,342.55,342.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.79,70,,191.83,percent of total billed charges,70% of total billed charges for outpatient setting,290.76,84.88,,232.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,171.28,50,,137.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.91,75,,205.53,percent of total billed charges,75% of total billed charges for outpatient setting,239.79,70,,191.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.04,80,,219.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,222.66,65,,178.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.36,100,,,Fee Schedule,100% of Custom Fee Schedule,308.3,90,,246.64,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,308.3,
CLINIC LEVEL IV,5100170,CDM,510,RC,99204,HCPCS,Outpatient,,,568.63,568.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.04,70,,318.43,percent of total billed charges,70% of total billed charges for outpatient setting,482.65,84.88,,386.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.32,50,,227.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.47,75,,341.18,percent of total billed charges,75% of total billed charges for outpatient setting,398.04,70,,318.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.9,80,,363.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,369.61,65,,295.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.63,100,,,Fee Schedule,100% of Custom Fee Schedule,511.77,90,,409.42,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,511.77,
CLINIC LEVEL V,5100175,CDM,510,RC,99205,HCPCS,Outpatient,,,568.63,568.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.04,70,,318.43,percent of total billed charges,70% of total billed charges for outpatient setting,482.65,84.88,,386.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.32,50,,227.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.47,75,,341.18,percent of total billed charges,75% of total billed charges for outpatient setting,398.04,70,,318.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.9,80,,363.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,369.61,65,,295.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.72,100,,,Fee Schedule,100% of Custom Fee Schedule,511.77,90,,409.42,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,511.77,
CLINIMIX  / D15W  5% AMINO ACID: 1 LITER,3303332,CDM,250,RC,,,Outpatient,,,486.8,486.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,413.2,84.88,,330.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.4,50,,194.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.1,75,,292.08,percent of total billed charges,75% of total billed charges for outpatient setting,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.44,80,,311.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.42,65,,253.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.38,35,,136.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.12,90,,350.5,percent of total billed charges,90% of total billed charges for outpatient setting,62.51,438.12,
CLINIMIX  / D20W /5% 2  LITER,3304509,CDM,250,RC,,,Outpatient,,,486.8,486.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,413.2,84.88,,330.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.4,50,,194.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.1,75,,292.08,percent of total billed charges,75% of total billed charges for outpatient setting,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.44,80,,311.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.42,65,,253.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.38,35,,136.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.12,90,,350.5,percent of total billed charges,90% of total billed charges for outpatient setting,62.51,438.12,
CLINIMIX  / D25W /5% 2  LITER,3303318,CDM,250,RC,,,Outpatient,,,486.8,486.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,413.2,84.88,,330.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.4,50,,194.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.1,75,,292.08,percent of total billed charges,75% of total billed charges for outpatient setting,340.76,70,,272.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.44,80,,311.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.42,65,,253.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.38,35,,136.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.12,90,,350.5,percent of total billed charges,90% of total billed charges for outpatient setting,62.51,438.12,
CLINIMIX E / D10W  4.25%: 1 LITER,3303269,CDM,250,RC,,,Outpatient,,,714.05,714.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.84,70,,399.87,percent of total billed charges,70% of total billed charges for outpatient setting,606.09,84.88,,484.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,357.03,50,,285.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.54,75,,428.43,percent of total billed charges,75% of total billed charges for outpatient setting,499.84,70,,399.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.24,80,,456.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,464.13,65,,371.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.92,35,,199.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642.65,90,,514.12,percent of total billed charges,90% of total billed charges for outpatient setting,91.68,642.65,
CLINIMIX E 4.25%/D10% 2000MLS,3303201,CDM,250,RC,,,Outpatient,,,714.05,714.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.84,70,,399.87,percent of total billed charges,70% of total billed charges for outpatient setting,606.09,84.88,,484.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,357.03,50,,285.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.54,75,,428.43,percent of total billed charges,75% of total billed charges for outpatient setting,499.84,70,,399.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.24,80,,456.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,464.13,65,,371.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.92,35,,199.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642.65,90,,514.12,percent of total billed charges,90% of total billed charges for outpatient setting,91.68,642.65,
CLINIMIX E 5%/D15% 1000MLS,3303781,CDM,250,RC,,,Outpatient,,,486.87,486.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.81,70,,272.65,percent of total billed charges,70% of total billed charges for outpatient setting,413.26,84.88,,330.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.44,50,,194.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.15,75,,292.12,percent of total billed charges,75% of total billed charges for outpatient setting,340.81,70,,272.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.5,80,,311.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.47,65,,253.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,35,,136.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.18,90,,350.54,percent of total billed charges,90% of total billed charges for outpatient setting,62.51,438.18,
CLINIMIX E 5/15   2  LITER,3303321,CDM,250,RC,,,Outpatient,,,262.37,262.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.66,70,,146.93,percent of total billed charges,70% of total billed charges for outpatient setting,222.7,84.88,,178.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.19,50,,104.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.78,75,,157.42,percent of total billed charges,75% of total billed charges for outpatient setting,183.66,70,,146.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.69,12.84,,26.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.9,80,,167.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.69,12.84,,26.95,percent of total billed charges,12.84% of total billed charges,33.69,12.84,,26.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,170.54,65,,136.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.83,35,,73.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,236.13,90,,188.9,percent of total billed charges,90% of total billed charges for outpatient setting,33.69,236.13,
CLINIMIX E 5/20:  2 LITER,3304536,CDM,250,RC,,,Outpatient,,,486.87,486.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.81,70,,272.65,percent of total billed charges,70% of total billed charges for outpatient setting,413.26,84.88,,330.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.44,50,,194.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.15,75,,292.12,percent of total billed charges,75% of total billed charges for outpatient setting,340.81,70,,272.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.5,80,,311.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,62.51,12.84,,50.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.47,65,,253.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,35,,136.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.18,90,,350.54,percent of total billed charges,90% of total billed charges for outpatient setting,62.51,438.18,
CLINISOL(AMINO ACIDS) 15%,3303079,CDM,250,RC,,,Outpatient,,,145.94,145.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.16,70,,81.73,percent of total billed charges,70% of total billed charges for outpatient setting,123.87,84.88,,99.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.97,50,,58.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.46,75,,87.57,percent of total billed charges,75% of total billed charges for outpatient setting,102.16,70,,81.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.74,12.84,,14.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.75,80,,93.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.74,12.84,,14.99,percent of total billed charges,12.84% of total billed charges,18.74,12.84,,14.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.86,65,,75.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.08,35,,40.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.35,90,,105.08,percent of total billed charges,90% of total billed charges for outpatient setting,18.74,131.35,
CLIP 2.8MM 235CM RESOLUTION / M00521230,2081892,CDM,272,RC,,,Outpatient,,,1060.8,1060.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.56,70,,594.05,percent of total billed charges,70% of total billed charges for outpatient setting,900.41,84.88,,720.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,530.4,50,,424.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,75,,636.48,percent of total billed charges,75% of total billed charges for outpatient setting,742.56,70,,594.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.21,12.84,,108.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.64,80,,678.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.21,12.84,,108.97,percent of total billed charges,12.84% of total billed charges,136.21,12.84,,108.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,689.52,65,,551.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.28,35,,297.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,954.72,90,,763.78,percent of total billed charges,90% of total billed charges for outpatient setting,136.21,954.72,
CLIP 2.8X235CM RESOLUTION  / M00522610,70000099,CDM,272,RC,,,Outpatient,,,1060.8,1060.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.56,70,,594.05,percent of total billed charges,70% of total billed charges for outpatient setting,900.41,84.88,,720.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,530.4,50,,424.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,75,,636.48,percent of total billed charges,75% of total billed charges for outpatient setting,742.56,70,,594.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.21,12.84,,108.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.64,80,,678.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.21,12.84,,108.97,percent of total billed charges,12.84% of total billed charges,136.21,12.84,,108.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,689.52,65,,551.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.28,35,,297.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,954.72,90,,763.78,percent of total billed charges,90% of total billed charges for outpatient setting,136.21,954.72,
CLIP 235CM RESOLUTION 360 / M00521231,736098,CDM,272,RC,,,Outpatient,,,1024.92,1024.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.44,70,,573.95,percent of total billed charges,70% of total billed charges for outpatient setting,869.95,84.88,,695.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,512.46,50,,409.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,768.69,75,,614.95,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,70,,573.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.6,12.84,,105.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.94,80,,655.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.6,12.84,,105.28,percent of total billed charges,12.84% of total billed charges,131.6,12.84,,105.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,666.2,65,,532.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.72,35,,286.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,922.43,90,,737.94,percent of total billed charges,90% of total billed charges for outpatient setting,131.6,922.43,
CLIP 235CM RESOLUTION 360 / M00521400,7420189,CDM,272,RC,,,Outpatient,,,1427.68,1427.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,999.38,70,,799.5,percent of total billed charges,70% of total billed charges for outpatient setting,1211.81,84.88,,969.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,713.84,50,,571.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1070.76,75,,856.61,percent of total billed charges,75% of total billed charges for outpatient setting,999.38,70,,799.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.31,12.84,,146.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.14,80,,913.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.31,12.84,,146.65,percent of total billed charges,12.84% of total billed charges,183.31,12.84,,146.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,927.99,65,,742.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.69,35,,399.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1284.91,90,,1027.93,percent of total billed charges,90% of total billed charges for outpatient setting,183.31,1284.91,
CLIP 360 ULTRA RESOLUTION  / M00521401,7381297,CDM,272,RC,,,Outpatient,,,1104.92,1104.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.44,70,,618.75,percent of total billed charges,70% of total billed charges for outpatient setting,937.86,84.88,,750.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,552.46,50,,441.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,828.69,75,,662.95,percent of total billed charges,75% of total billed charges for outpatient setting,773.44,70,,618.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.87,12.84,,113.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.94,80,,707.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.87,12.84,,113.5,percent of total billed charges,12.84% of total billed charges,141.87,12.84,,113.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,718.2,65,,574.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.72,35,,309.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,994.43,90,,795.54,percent of total billed charges,90% of total billed charges for outpatient setting,141.87,994.43,
CLIP APPLIER MED / MCM20,6150424,CDM,272,RC,,,Outpatient,,,180.95,180.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.67,70,,101.34,percent of total billed charges,70% of total billed charges for outpatient setting,153.59,84.88,,122.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.48,50,,72.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.71,75,,108.57,percent of total billed charges,75% of total billed charges for outpatient setting,126.67,70,,101.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.23,12.84,,18.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.76,80,,115.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.23,12.84,,18.58,percent of total billed charges,12.84% of total billed charges,23.23,12.84,,18.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.62,65,,94.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.33,35,,50.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.86,90,,130.29,percent of total billed charges,90% of total billed charges for outpatient setting,23.23,162.86,
CLIP APPLIER SMALL / MCS20,6150425,CDM,272,RC,,,Outpatient,,,181.05,181.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.74,70,,101.39,percent of total billed charges,70% of total billed charges for outpatient setting,153.68,84.88,,122.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.53,50,,72.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.79,75,,108.63,percent of total billed charges,75% of total billed charges for outpatient setting,126.74,70,,101.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.84,80,,115.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.68,65,,94.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.37,35,,50.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.95,90,,130.36,percent of total billed charges,90% of total billed charges for outpatient setting,23.25,162.95,
CLIP LG LIGATING HORIZON / 004200,69161543,CDM,272,RC,,,Outpatient,,,36.16,36.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,70,,20.25,percent of total billed charges,70% of total billed charges for outpatient setting,30.69,84.88,,24.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.08,50,,14.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.12,75,,21.7,percent of total billed charges,75% of total billed charges for outpatient setting,25.31,70,,20.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,80,,23.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.5,65,,18.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,35,,10.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.54,90,,26.03,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,32.54,
CLIP SPRING REVERE CANN / 675.705S,69159386,CDM,272,RC,,,Outpatient,,,1592,1592,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.4,70,,891.52,percent of total billed charges,70% of total billed charges for outpatient setting,1351.29,84.88,,1081.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,796,50,,636.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1194,75,,955.2,percent of total billed charges,75% of total billed charges for outpatient setting,1114.4,70,,891.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.6,80,,1018.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1034.8,65,,827.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.2,35,,445.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1432.8,90,,1146.24,percent of total billed charges,90% of total billed charges for outpatient setting,204.41,1432.8,
CLIP VAC DISP FILTER / 5575,69162161,CDM,270,RC,,,Outpatient,,,89.18,89.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.43,70,,49.94,percent of total billed charges,70% of total billed charges for outpatient setting,75.7,84.88,,60.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.59,50,,35.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.89,75,,53.51,percent of total billed charges,75% of total billed charges for outpatient setting,62.43,70,,49.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,12.84,,9.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.34,80,,57.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,12.84,,9.16,percent of total billed charges,12.84% of total billed charges,11.45,12.84,,9.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.97,65,,46.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.21,35,,24.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.26,90,,64.21,percent of total billed charges,90% of total billed charges for outpatient setting,11.45,80.26,
CLIPPER BLADE / CAH4406D,70000019,CDM,270,RC,,,Outpatient,,,21.42,21.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,18.18,84.88,,14.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.71,50,,8.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.92,65,,11.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,35,,6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.28,90,,15.42,percent of total billed charges,90% of total billed charges for outpatient setting,2.75,19.28,
CLIPPER BLADE SENSICLIP PINK / 4403A,69160831,CDM,270,RC,,,Outpatient,,,44.38,44.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.07,70,,24.86,percent of total billed charges,70% of total billed charges for outpatient setting,37.67,84.88,,30.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.19,50,,17.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.29,75,,26.63,percent of total billed charges,75% of total billed charges for outpatient setting,31.07,70,,24.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,12.84,,4.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,80,,28.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,12.84,,4.56,percent of total billed charges,12.84% of total billed charges,5.7,12.84,,4.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.85,65,,23.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,35,,12.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.94,90,,31.95,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,39.94,
CLONAZEPAM (genericKLONOPIN) TAB 0.5 MG,3300845,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLONAZEPAM (genericKLONOPIN) TAB 1 MG,3300844,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLONAZEPAM (KLONOPIN) TAB : 0.5 MG,3300842,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CLONAZEPAM (KLONOPIN) TAB : 0.5 MG,3300843,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CLONAZEPAM DISINTEGRATING :0.5 MG TAB,3303149,CDM,259,RC,,,Outpatient,,,35.07,35.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,70,,19.64,percent of total billed charges,70% of total billed charges for outpatient setting,29.77,84.88,,23.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.54,50,,14.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.3,75,,21.04,percent of total billed charges,75% of total billed charges for outpatient setting,24.55,70,,19.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.06,80,,22.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,4.5,12.84,,3.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.8,65,,18.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,35,,9.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.56,90,,25.25,percent of total billed charges,90% of total billed charges for outpatient setting,4.5,31.56,
CLONIDINE (CATAPRES TTS 1) PATCH,3300848,CDM,259,RC,,,Outpatient,,,74.82,74.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.37,70,,41.9,percent of total billed charges,70% of total billed charges for outpatient setting,63.51,84.88,,50.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.41,50,,29.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.12,75,,44.9,percent of total billed charges,75% of total billed charges for outpatient setting,52.37,70,,41.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.61,12.84,,7.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.86,80,,47.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.61,12.84,,7.69,percent of total billed charges,12.84% of total billed charges,9.61,12.84,,7.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.63,65,,38.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.19,35,,20.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.34,90,,53.87,percent of total billed charges,90% of total billed charges for outpatient setting,9.61,67.34,
CLONIDINE (CATAPRES TTS 2) PATCH,3300849,CDM,259,RC,,,Outpatient,,,142.79,142.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.95,70,,79.96,percent of total billed charges,70% of total billed charges for outpatient setting,121.2,84.88,,96.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.4,50,,57.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.09,75,,85.67,percent of total billed charges,75% of total billed charges for outpatient setting,99.95,70,,79.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.23,80,,91.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.81,65,,74.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.98,35,,39.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.51,90,,102.81,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,128.51,
CLONIDINE (CATAPRES TTS 3) PATCH,3302976,CDM,259,RC,,,Outpatient,,,167.19,167.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.03,70,,93.62,percent of total billed charges,70% of total billed charges for outpatient setting,141.91,84.88,,113.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,83.6,50,,66.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.39,75,,100.31,percent of total billed charges,75% of total billed charges for outpatient setting,117.03,70,,93.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,12.84,,17.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.75,80,,107,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,12.84,,17.18,percent of total billed charges,12.84% of total billed charges,21.47,12.84,,17.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,108.67,65,,86.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.52,35,,46.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.47,90,,120.38,percent of total billed charges,90% of total billed charges for outpatient setting,21.47,150.47,
CLONIDINE (genericCATAPRES) 0.1MG TAB,3300846,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLOPIDOGREL (PLAVIX) TAB  75 MG,3300850,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLOPIDOGREL (PLAVIX) TAB : 75 MG,3300851,CDM,259,RC,,,Outpatient,,,10.25,10.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,8.7,84.88,,6.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,50,,4.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.69,75,,6.15,percent of total billed charges,75% of total billed charges for outpatient setting,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.2,80,,6.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.66,65,,5.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,35,,2.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.23,90,,7.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.32,9.23,
CLORAZEPATE (TRANXENE ) TAB : 7.5 MG,3300853,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLORAZEPATE (TRANXENE DIPOT) TAB : 7.5MG,3300854,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLORAZEPATE (TRANXENE) TAB : 3.75 MG,3300852,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLORPACTIN(OXYCHLOROSENE 2GM),3305192,CDM,259,RC,,,Outpatient,,,19.55,19.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.69,70,,10.95,percent of total billed charges,70% of total billed charges for outpatient setting,16.59,84.88,,13.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.78,50,,7.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.66,75,,11.73,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,70,,10.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.64,80,,12.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.71,65,,10.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,35,,5.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.6,90,,14.08,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,17.6,
CLOS DIFF TOXINS A+B,222005,CDM,302,RC,87449,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
CLOS SYS-C THMPSN / CTI-SP,69161743,CDM,272,RC,,,Outpatient,,,340,340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,190.4,percent of total billed charges,70% of total billed charges for outpatient setting,288.59,84.88,,230.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255,75,,204,percent of total billed charges,75% of total billed charges for outpatient setting,238,70,,190.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272,80,,217.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,221,65,,176.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,35,,95.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306,90,,244.8,percent of total billed charges,90% of total billed charges for outpatient setting,43.66,306,
CLOSURE SKIN STERI-STRIP 1/4X3,6150430,CDM,272,RC,,,Outpatient,,,5.66,5.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,84.88,,3.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.83,50,,2.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.25,75,,3.4,percent of total billed charges,75% of total billed charges for outpatient setting,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,80,,3.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.68,65,,2.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,35,,1.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.09,90,,4.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,5.09,
CLOTRIMAZOLE (MYCELEX) CRM : 30 GM,3300855,CDM,259,RC,,,Outpatient,,,40.52,40.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.36,70,,22.69,percent of total billed charges,70% of total billed charges for outpatient setting,34.39,84.88,,27.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.26,50,,16.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.39,75,,24.31,percent of total billed charges,75% of total billed charges for outpatient setting,28.36,70,,22.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.2,12.84,,4.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,80,,25.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.2,12.84,,4.16,percent of total billed charges,12.84% of total billed charges,5.2,12.84,,4.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.34,65,,21.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,35,,11.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.47,90,,29.18,percent of total billed charges,90% of total billed charges for outpatient setting,5.2,36.47,
CLOTRIMAZOLE (MYCELEX) LOZ: 10 MG,3300858,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CLOTRIMAZOLE 1% CREAM  30 GM,3300857,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CLOTRIMAZOLE CREAM : 15 GM,3300856,CDM,259,RC,,,Outpatient,,,16.02,16.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.21,70,,8.97,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,84.88,,10.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.01,50,,6.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.02,75,,9.62,percent of total billed charges,75% of total billed charges for outpatient setting,11.21,70,,8.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,12.84,,1.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.82,80,,10.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,12.84,,1.65,percent of total billed charges,12.84% of total billed charges,2.06,12.84,,1.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.41,65,,8.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,35,,4.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.42,90,,11.54,percent of total billed charges,90% of total billed charges for outpatient setting,2.06,14.42,
CLOTRIMAZOLE/BETAMETH CR 15GM,3302849,CDM,259,RC,,,Outpatient,,,94.86,94.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.4,70,,53.12,percent of total billed charges,70% of total billed charges for outpatient setting,80.52,84.88,,64.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.43,50,,37.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.15,75,,56.92,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,70,,53.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.18,12.84,,9.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.89,80,,60.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.18,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,12.18,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.66,65,,49.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.2,35,,26.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.37,90,,68.3,percent of total billed charges,90% of total billed charges for outpatient setting,12.18,85.37,
CLOTTING FACTOR XIII FIBRIN STAB SCRN,201313,CDM,300,RC,85291,HCPCS,Outpatient,,,41,36.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.7,70,,22.96,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,84.88,,27.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.75,75,,24.6,percent of total billed charges,75% of total billed charges for outpatient setting,28.7,70,,22.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.8,80,,26.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,100,,,Fee Schedule,100% of Custom Fee Schedule,36.9,90,,29.52,percent of total billed charges,90% of total billed charges for outpatient setting,9.11,36.9,
CMV BY PCR,220081,CDM,306,RC,87496,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
CMV IGG,220068,CDM,302,RC,86644,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,58.28,
CMV IGM,220069,CDM,302,RC,86645,HCPCS,Outpatient,,,75.83,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,70,,42.46,percent of total billed charges,70% of total billed charges for outpatient setting,64.36,84.88,,51.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.87,75,,45.5,percent of total billed charges,75% of total billed charges for outpatient setting,53.08,70,,42.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.66,80,,48.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.94,100,,,Fee Schedule,100% of Custom Fee Schedule,68.25,90,,54.6,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,68.25,
CMV RAPID CULTURE,200152,CDM,302,RC,87254,HCPCS,Outpatient,,,88.02,79.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.61,70,,49.29,percent of total billed charges,70% of total billed charges for outpatient setting,74.71,84.88,,59.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.02,75,,52.82,percent of total billed charges,75% of total billed charges for outpatient setting,61.61,70,,49.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.42,80,,56.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.09,100,,,Fee Schedule,100% of Custom Fee Schedule,79.22,90,,63.38,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,79.22,
CMV RAPID CULTURE,220079,CDM,302,RC,87254,HCPCS,Outpatient,,,88.02,79.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.61,70,,49.29,percent of total billed charges,70% of total billed charges for outpatient setting,74.71,84.88,,59.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.02,75,,52.82,percent of total billed charges,75% of total billed charges for outpatient setting,61.61,70,,49.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.42,80,,56.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.09,100,,,Fee Schedule,100% of Custom Fee Schedule,79.22,90,,63.38,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,79.22,
COALITION 6MM LARGE / 384.106,69162065,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
COALITION 7MM LARGE  384.107,69162186,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
COALITION 8MM LARGE  384.108,69162064,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
COALITION 9MM LARGE  384.109,69162189,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
COBALT  PLASMA,200427,CDM,300,RC,83018,HCPCS,Outpatient,,,98.82,88.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.17,70,,55.34,percent of total billed charges,70% of total billed charges for outpatient setting,83.88,84.88,,67.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,74.12,75,,59.3,percent of total billed charges,75% of total billed charges for outpatient setting,69.17,70,,55.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.06,80,,63.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.11,100,,,Fee Schedule,100% of Custom Fee Schedule,88.94,90,,71.15,percent of total billed charges,90% of total billed charges for outpatient setting,10.36,88.94,
COBAN 4X5YD STER LF / CAH45S,6150467,CDM,270,RC,,,Outpatient,,,12.69,12.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,10.77,84.88,,8.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.35,50,,5.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.52,75,,7.62,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.15,80,,8.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.25,65,,6.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,35,,3.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.42,90,,9.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.63,11.42,
COBAN NEON LTX FREE NS 1X5 / MDS089001CP,70000425,CDM,270,RC,,,Outpatient,,,9.26,9.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,7.86,84.88,,6.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.63,50,,3.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.95,75,,5.56,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,80,,5.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.02,65,,4.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,35,,2.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.33,90,,6.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.33,
COBAN WRAP NEON 3IN / CAH35LFCP,6150466,CDM,270,RC,,,Outpatient,,,10.35,10.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,70,,5.8,percent of total billed charges,70% of total billed charges for outpatient setting,8.79,84.88,,7.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.18,50,,4.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.76,75,,6.21,percent of total billed charges,75% of total billed charges for outpatient setting,7.25,70,,5.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,80,,6.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.73,65,,5.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,35,,2.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.32,90,,7.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,9.32,
COBAN WRAP TAN 2IN NS LF / 1582,70000575,CDM,270,RC,,,Outpatient,,,6.75,6.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.73,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.38,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,80,,4.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.39,65,,3.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.08,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.08,
COBAN WRAP TAN 2IN NS LF CS / 1582,70000590,CDM,270,RC,,,Outpatient,,,6.75,6.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.73,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.38,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,80,,4.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.39,65,,3.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.08,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.08,
COCAINE HCL 4% SOL : 4 ML,3300859,CDM,259,RC,,,Outpatient,,,42.74,42.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.92,70,,23.94,percent of total billed charges,70% of total billed charges for outpatient setting,36.28,84.88,,29.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.37,50,,17.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.06,75,,25.65,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,70,,23.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.19,80,,27.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.78,65,,22.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.96,35,,11.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.47,90,,30.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,38.47,
COCAINE HCL 4% SOL : 4 ML,3300860,CDM,259,RC,,,Outpatient,,,54.93,54.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.45,70,,30.76,percent of total billed charges,70% of total billed charges for outpatient setting,46.62,84.88,,37.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.47,50,,21.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.2,75,,32.96,percent of total billed charges,75% of total billed charges for outpatient setting,38.45,70,,30.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,12.84,,5.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.94,80,,35.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,12.84,,5.64,percent of total billed charges,12.84% of total billed charges,7.05,12.84,,5.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.7,65,,28.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.23,35,,15.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.44,90,,39.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,49.44,
COCAINE HCL 4% TOPICAL SOLN 4ML,3313363,CDM,250,RC,,,Outpatient,,,1003.63,1003.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.54,70,,562.03,percent of total billed charges,70% of total billed charges for outpatient setting,851.88,84.88,,681.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,501.82,50,,401.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,752.72,75,,602.18,percent of total billed charges,75% of total billed charges for outpatient setting,702.54,70,,562.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.87,12.84,,103.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.9,80,,642.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.87,12.84,,103.1,percent of total billed charges,12.84% of total billed charges,128.87,12.84,,103.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,652.36,65,,521.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.27,35,,281.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,903.27,90,,722.62,percent of total billed charges,90% of total billed charges for outpatient setting,128.87,903.27,
COCAINE HCL POWDER : 5GM,3300861,CDM,259,RC,,,Outpatient,,,922.48,922.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.74,70,,516.59,percent of total billed charges,70% of total billed charges for outpatient setting,783,84.88,,626.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,461.24,50,,368.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,691.86,75,,553.49,percent of total billed charges,75% of total billed charges for outpatient setting,645.74,70,,516.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.45,12.84,,94.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,737.98,80,,590.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.45,12.84,,94.76,percent of total billed charges,12.84% of total billed charges,118.45,12.84,,94.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,599.61,65,,479.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.87,35,,258.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,830.23,90,,664.18,percent of total billed charges,90% of total billed charges for outpatient setting,118.45,830.23,
COCCIDIOIDES ANTIBODY,220849,CDM,302,RC,86635,HCPCS,Outpatient,,,79.7,71.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.79,70,,44.63,percent of total billed charges,70% of total billed charges for outpatient setting,67.65,84.88,,54.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.78,75,,47.82,percent of total billed charges,75% of total billed charges for outpatient setting,55.79,70,,44.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.76,80,,51.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.75,100,,,Fee Schedule,100% of Custom Fee Schedule,71.73,90,,57.38,percent of total billed charges,90% of total billed charges for outpatient setting,11.47,71.73,
COCCIDIOIDES PANEL,220930,CDM,302,RC,86635,HCPCS,Outpatient,,,79.7,71.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.79,70,,44.63,percent of total billed charges,70% of total billed charges for outpatient setting,67.65,84.88,,54.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.78,75,,47.82,percent of total billed charges,75% of total billed charges for outpatient setting,55.79,70,,44.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.76,80,,51.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.75,100,,,Fee Schedule,100% of Custom Fee Schedule,71.73,90,,57.38,percent of total billed charges,90% of total billed charges for outpatient setting,11.47,71.73,
CODE BLUE,6000015,CDM,480,RC,92950,HCPCS,Outpatient,,,1540.91,1540.91,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1078.64,70,,862.91,percent of total billed charges,70% of total billed charges for outpatient setting,1307.92,84.88,,1046.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,50,,276.86,percent of total billed charges,50% of total Billed charges for outpatient setting,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1155.68,75,,924.54,percent of total billed charges,75% of total billed charges for outpatient setting,1078.64,70,,862.91,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,197.85,12.84,,158.28,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1232.73,80,,986.18,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,197.85,12.84,,158.28,percent of total billed charges,12.84% of total billed charges,197.85,12.84,,158.28,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,189.92,100,,,Fee Schedule,100% of Custom Fee Schedule,1386.82,90,,1109.46,percent of total billed charges,90% of total billed charges for outpatient setting,189.92,1386.82,
CODE BLUE,5100145,CDM,480,RC,92950,HCPCS,Outpatient,,,1544.95,1544.95,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1081.47,70,,865.18,percent of total billed charges,70% of total billed charges for outpatient setting,1311.35,84.88,,1049.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,50,,276.86,percent of total billed charges,50% of total Billed charges for outpatient setting,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1158.71,75,,926.97,percent of total billed charges,75% of total billed charges for outpatient setting,1081.47,70,,865.18,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,198.37,12.84,,158.696,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1235.96,80,,988.77,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,198.37,12.84,,158.7,percent of total billed charges,12.84% of total billed charges,198.37,12.84,,158.7,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,189.92,100,,,Fee Schedule,100% of Custom Fee Schedule,1390.46,90,,1112.37,percent of total billed charges,90% of total billed charges for outpatient setting,189.92,1390.46,
CODEINE (TYLENOL W/COD) TAB 300/30MG:,3300866,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CODEINE ACEP (TYLENOL #3) TAB :300/30MG,3300863,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CODEINE SULF TAB: 15 MG,3300862,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CODICLEAR DH SYRUP:100MG/5ML,3303158,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
COGENTIN INJ 1MG/ML: 2ML,3302539,CDM,250,RC,,,Outpatient,,,24.89,24.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.42,70,,13.94,percent of total billed charges,70% of total billed charges for outpatient setting,21.13,84.88,,16.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.45,50,,9.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.67,75,,14.94,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,70,,13.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.91,80,,15.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.18,65,,12.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.71,35,,6.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.4,90,,17.92,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,22.4,
COLCHICINE SF SOL 0.5MG/ML : 2ML,3300869,CDM,250,RC,,,Outpatient,,,20.09,20.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.06,70,,11.25,percent of total billed charges,70% of total billed charges for outpatient setting,17.05,84.88,,13.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.05,50,,8.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.07,75,,12.06,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,70,,11.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,80,,12.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.06,65,,10.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.03,35,,5.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.08,90,,14.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.58,18.08,
COLCHICINE TAB: 0.6 MG,3300867,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COLCRYS 0.6MG TABLET(COLCHICINE),3300868,CDM,259,RC,,,Outpatient,,,16.58,16.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,70,,9.29,percent of total billed charges,70% of total billed charges for outpatient setting,14.07,84.88,,11.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.29,50,,6.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.44,75,,9.95,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,70,,9.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.26,80,,10.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.78,65,,8.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,35,,4.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.92,90,,11.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.92,
COLD AGGLUTININ,220521,CDM,302,RC,86157,HCPCS,Outpatient,,,36.27,32.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,70,,20.31,percent of total billed charges,70% of total billed charges for outpatient setting,30.79,84.88,,24.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.2,75,,21.76,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,70,,20.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.02,80,,23.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of Custom Fee Schedule,32.64,90,,26.11,percent of total billed charges,90% of total billed charges for outpatient setting,8.06,32.64,
COLD KNIFE STRAIGHT BLADE / K-SB,6152114,CDM,270,RC,,,Outpatient,,,434.24,434.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.97,70,,243.18,percent of total billed charges,70% of total billed charges for outpatient setting,368.58,84.88,,294.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,217.12,50,,173.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.68,75,,260.54,percent of total billed charges,75% of total billed charges for outpatient setting,303.97,70,,243.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.76,12.84,,44.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.39,80,,277.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.76,12.84,,44.61,percent of total billed charges,12.84% of total billed charges,55.76,12.84,,44.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,282.26,65,,225.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.98,35,,121.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,390.82,90,,312.66,percent of total billed charges,90% of total billed charges for outpatient setting,55.76,390.82,
COLESTIPOL 1 GM TABS (COLESTID),3306058,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
COLLAGENASE (SANTYL) OINT 30 GM,3300871,CDM,259,RC,,,Outpatient,,,929.24,929.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.47,70,,520.38,percent of total billed charges,70% of total billed charges for outpatient setting,788.74,84.88,,630.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,464.62,50,,371.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,696.93,75,,557.54,percent of total billed charges,75% of total billed charges for outpatient setting,650.47,70,,520.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.31,12.84,,95.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.39,80,,594.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.31,12.84,,95.45,percent of total billed charges,12.84% of total billed charges,119.31,12.84,,95.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,604.01,65,,483.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.23,35,,260.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,836.32,90,,669.06,percent of total billed charges,90% of total billed charges for outpatient setting,119.31,836.32,
COLLAGENASE (SANTYL) OINT: 15 GM,3300870,CDM,259,RC,,,Outpatient,,,90.58,90.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.41,70,,50.73,percent of total billed charges,70% of total billed charges for outpatient setting,76.88,84.88,,61.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.29,50,,36.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.94,75,,54.35,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,70,,50.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.63,12.84,,9.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.46,80,,57.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.63,12.84,,9.3,percent of total billed charges,12.84% of total billed charges,11.63,12.84,,9.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.88,65,,47.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,35,,25.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.52,90,,65.22,percent of total billed charges,90% of total billed charges for outpatient setting,11.63,81.52,
COLLAR ADLT CERVICAL VISTA / 984000,70000478,CDM,272,RC,,,Outpatient,,,229.6,229.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.72,70,,128.58,percent of total billed charges,70% of total billed charges for outpatient setting,194.88,84.88,,155.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.8,50,,91.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.2,75,,137.76,percent of total billed charges,75% of total billed charges for outpatient setting,160.72,70,,128.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.48,12.84,,23.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.68,80,,146.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.48,12.84,,23.58,percent of total billed charges,12.84% of total billed charges,29.48,12.84,,23.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.24,65,,119.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.36,35,,64.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.64,90,,165.31,percent of total billed charges,90% of total billed charges for outpatient setting,29.48,206.64,
COLLAR BUTTON VT 1.27 BLUE DBL / 525-012,69160905,CDM,360,RC,,,Outpatient,,,96.06,96.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.24,70,,53.79,percent of total billed charges,70% of total billed charges for outpatient setting,81.54,84.88,,65.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.03,50,,38.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.05,75,,57.64,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,70,,53.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.85,80,,61.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.62,35,,26.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.45,90,,69.16,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.45,
COLLAR LG CERVICAL / 79-83017,69161775,CDM,272,RC,,,Outpatient,,,23.94,23.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,84.88,,16.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,50,,9.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.96,75,,14.37,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.15,80,,15.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.56,65,,12.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,35,,6.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.55,90,,17.24,percent of total billed charges,90% of total billed charges for outpatient setting,3.07,21.55,
COLLAR MED CERVICAL / 79-83014,69161774,CDM,272,RC,,,Outpatient,,,23.94,23.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,84.88,,16.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,50,,9.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.96,75,,14.37,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.15,80,,15.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.56,65,,12.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,35,,6.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.55,90,,17.24,percent of total billed charges,90% of total billed charges for outpatient setting,3.07,21.55,
COLLAR UNIVERSAL CERVICAL / 79-83500,370701,CDM,271,RC,,,Outpatient,,,21.51,21.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.06,70,,12.05,percent of total billed charges,70% of total billed charges for outpatient setting,18.26,84.88,,14.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.76,50,,8.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.13,75,,12.9,percent of total billed charges,75% of total billed charges for outpatient setting,15.06,70,,12.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,12.84,,2.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.21,80,,13.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,12.84,,2.21,percent of total billed charges,12.84% of total billed charges,2.76,12.84,,2.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.98,65,,11.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.53,35,,6.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.36,90,,15.49,percent of total billed charges,90% of total billed charges for outpatient setting,2.76,19.36,
COLLODION FLEX LIQ : 120ML,3300872,CDM,259,RC,,,Outpatient,,,33.95,33.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,70,,19.02,percent of total billed charges,70% of total billed charges for outpatient setting,28.82,84.88,,23.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.98,50,,13.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,75,,20.37,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,70,,19.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,80,,21.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.07,65,,17.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.88,35,,9.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.56,90,,24.45,percent of total billed charges,90% of total billed charges for outpatient setting,4.36,30.56,
COLON RECTAL RETRACTOR LONESTAR / 3307G,69162700,CDM,270,RC,,,Outpatient,,,263.93,263.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,224.02,84.88,,179.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.97,50,,105.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.95,75,,158.36,percent of total billed charges,75% of total billed charges for outpatient setting,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.14,80,,168.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.55,65,,137.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,35,,73.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,237.54,90,,190.03,percent of total billed charges,90% of total billed charges for outpatient setting,33.89,237.54,
COLOR FLOW,2600030,CDM,480,RC,93325,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
COLPO PNEUMO OCCLUDER RUMI / CPO-6,69161666,CDM,272,RC,,,Outpatient,,,219.8,219.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.86,70,,123.09,percent of total billed charges,70% of total billed charges for outpatient setting,186.57,84.88,,149.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.9,50,,87.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.85,75,,131.88,percent of total billed charges,75% of total billed charges for outpatient setting,153.86,70,,123.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.22,12.84,,22.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.84,80,,140.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.22,12.84,,22.58,percent of total billed charges,12.84% of total billed charges,28.22,12.84,,22.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.87,65,,114.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.93,35,,61.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,197.82,90,,158.26,percent of total billed charges,90% of total billed charges for outpatient setting,28.22,197.82,
COMBINED ENDOSCOPIC CATHETERIZATION OF T,2400705,CDM,320,RC,74330,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
COMBIVENT INHALER,3302742,CDM,259,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
COMBUNOX:OXYCODONE/IBUPROFEN 5MG/400MG,3303134,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
COMP 26MM PATELLAR / 71420580,69169535,CDM,278,RC,C1776,HCPCS,Outpatient,,,2359.86,2359.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.92,60,,1132.74,percent of total billed charges,60% of total Billed charges for outpatient setting,2003.05,84.88,,1602.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1769.9,75,,1415.92,percent of total billed charges,75% of total billed charges for outpatient setting,1179.93,50,,943.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.01,12.84,,242.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1887.89,80,,1510.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.01,12.84,,242.41,percent of total billed charges,12.84% of total billed charges,303.01,12.84,,242.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2477.85,105,,1982.28,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.95,35,,660.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1415.92,60,,1132.74,percent of total billed charges,60% of total billed charges for outpatient setting,303.01,2477.85,
COMP 35MM PATELLAR / 71420578,69161102,CDM,278,RC,C1776,HCPCS,Outpatient,,,2247.49,2247.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1348.49,60,,1078.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1907.67,84.88,,1526.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.62,75,,1348.5,percent of total billed charges,75% of total billed charges for outpatient setting,1123.75,50,,899,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.58,12.84,,230.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.99,80,,1438.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.58,12.84,,230.86,percent of total billed charges,12.84% of total billed charges,288.58,12.84,,230.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2359.86,105,,1887.89,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.62,35,,629.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1348.49,60,,1078.79,percent of total billed charges,60% of total billed charges for outpatient setting,288.58,2359.86,
COMP METABOLIC PANEL,200015,CDM,301,RC,80053,HCPCS,Outpatient,,,47.52,42.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,40.33,84.88,,32.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.64,75,,28.51,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,80,,30.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of Custom Fee Schedule,42.77,90,,34.22,percent of total billed charges,90% of total billed charges for outpatient setting,10.56,42.77,
COMP SZ 1 FEMORAL LT / 00-5926-011-01,71000295,CDM,278,RC,C1776,HCPCS,Outpatient,,,6500,6500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3900,60,,3120,percent of total billed charges,60% of total Billed charges for outpatient setting,5517.2,84.88,,4413.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4875,75,,3900,percent of total billed charges,75% of total billed charges for outpatient setting,3250,50,,2600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5200,80,,4160,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6825,105,,5460,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,35,,1820,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3900,60,,3120,percent of total billed charges,60% of total billed charges for outpatient setting,834.6,6825,
COMP SZ 2 FEM LT CR / 5517-F-201,71000602,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 2 LT FEM TRTHLN / 5512-F-201,71000516,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 2 TIBIAL TRIATHLON / 5536-B-200,69169880,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
COMP SZ 3 FEMORAL LT CR / 5517-F-301,69169879,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 3 FEMORAL LT TRIAT / 5510-F-301,71000553,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 3 FEMORAL RT CR / 5517-F-302,69169890,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 3 FEMORAL RT TRIAT / 5510-F-302,71000122,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 3 LT FEM TRTHLN / 5512-F-301,71000921,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 3 RT FEM TRTHLN / 5512-F-302,71000804,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 3 TIBIAL TRIATHLON / 5536-B-300,71000117,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
COMP SZ 4 ATTUNE FEM CRUC / 1504-00-224,71000438,CDM,278,RC,C1776,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
COMP SZ 4 FEMORAL LT CR / 5517-F-401,71000175,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 4 FEMORAL LT TRIAT / 5510-F-401,71000481,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 4 FEMORAL RT CR / 5517-F-402,71000382,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 4 FEMORAL RT TRIAT / 5510-F-402,71000124,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 4 LT FEM TRTHLN / 5512-F-401,71000437,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 4 RT FEM TRTHLN / 5512-F-402,71000368,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 4 TIB POL TRIATHLON / 5534-A-411,71000706,CDM,278,RC,C1776,HCPCS,Outpatient,,,2988,2988,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792.8,60,,1434.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2536.21,84.88,,2028.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241,75,,1792.8,percent of total billed charges,75% of total billed charges for outpatient setting,1494,50,,1195.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2390.4,80,,1912.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3137.4,105,,2509.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.8,35,,836.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1792.8,60,,1434.24,percent of total billed charges,60% of total billed charges for outpatient setting,383.66,3137.4,
COMP SZ 4 TIBIAL / 5536-B-400,71000203,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
COMP SZ 5 FEMORAL LT CR / 5517-F-501,71000451,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 5 FEMORAL LT TRIAT / 5510-F-501,71000539,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 5 FEMORAL RT CR / 5517-F-502,71000363,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 5 FEMORAL RT TRIAT / 5510-F-502,71000461,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 5 LT FEM TRTHLN / 5512-F-501,71000647,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 5 RT FEM TRTHLN / 5512-F-502,71000811,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 5 TIB POL TRIATHLON / 5534-A-509,71000928,CDM,278,RC,C1776,HCPCS,Outpatient,,,2988,2988,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792.8,60,,1434.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2536.21,84.88,,2028.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241,75,,1792.8,percent of total billed charges,75% of total billed charges for outpatient setting,1494,50,,1195.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2390.4,80,,1912.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3137.4,105,,2509.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.8,35,,836.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1792.8,60,,1434.24,percent of total billed charges,60% of total billed charges for outpatient setting,383.66,3137.4,
COMP SZ 5 TIB TRIATHLON / 5536-B-500,71000558,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
COMP SZ 6 FEMORAL LT CR / 5517-F-601,71000383,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 6 FEMORAL LT TRIAT / 5510-F-601,71000405,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 6 FEMORAL RT CR / 5517-F-602,69169739,CDM,278,RC,C1776,HCPCS,Outpatient,,,4244,4244,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2546.4,60,,2037.12,percent of total billed charges,60% of total Billed charges for outpatient setting,3602.31,84.88,,2881.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3183,75,,2546.4,percent of total billed charges,75% of total billed charges for outpatient setting,2122,50,,1697.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.93,12.84,,435.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3395.2,80,,2716.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.93,12.84,,435.94,percent of total billed charges,12.84% of total billed charges,544.93,12.84,,435.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4456.2,105,,3564.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1485.4,35,,1188.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2546.4,60,,2037.12,percent of total billed charges,60% of total billed charges for outpatient setting,544.93,4456.2,
COMP SZ 6 FEMORAL RT TRIAT / 5510-F-602,71000402,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 6 RT FEM TRTHLN / 5512-F-601,71000877,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 6 TIB POL TRIATHLON / 5534-A-616,71000909,CDM,278,RC,C1776,HCPCS,Outpatient,,,2988,2988,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792.8,60,,1434.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2536.21,84.88,,2028.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241,75,,1792.8,percent of total billed charges,75% of total billed charges for outpatient setting,1494,50,,1195.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2390.4,80,,1912.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3137.4,105,,2509.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.8,35,,836.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1792.8,60,,1434.24,percent of total billed charges,60% of total billed charges for outpatient setting,383.66,3137.4,
COMP SZ 7 FEM ATTUNE RT / 1504-01-207,71000931,CDM,278,RC,C1776,HCPCS,Outpatient,,,3916,3916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2349.6,60,,1879.68,percent of total billed charges,60% of total Billed charges for outpatient setting,3323.9,84.88,,2659.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2937,75,,2349.6,percent of total billed charges,75% of total billed charges for outpatient setting,1958,50,,1566.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.81,12.84,,402.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3132.8,80,,2506.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.81,12.84,,402.25,percent of total billed charges,12.84% of total billed charges,502.81,12.84,,402.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4111.8,105,,3289.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1370.6,35,,1096.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2349.6,60,,1879.68,percent of total billed charges,60% of total billed charges for outpatient setting,502.81,4111.8,
COMP SZ 7 FEM STAB RT TRTLN / 5512-F-702,71000478,CDM,278,RC,C1776,HCPCS,Outpatient,,,12746.08,12746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.65,60,,6118.12,percent of total billed charges,60% of total Billed charges for outpatient setting,10818.87,84.88,,8655.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9559.56,75,,7647.65,percent of total billed charges,75% of total billed charges for outpatient setting,6373.04,50,,5098.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10196.86,80,,8157.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,1636.6,12.84,,1309.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13383.38,105,,10706.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4461.13,35,,3568.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7647.65,60,,6118.12,percent of total billed charges,60% of total billed charges for outpatient setting,1636.6,13383.38,
COMP SZ 7 FEMORAL LFT TRIAT / 5510-F-701,69169764,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 7 FEMORAL RT CR / 5517-F-702,71000529,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 7 FEMORAL RT TRIAT / 5510-F-702,71000597,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMP SZ 7 TIB POL TRIATHLON / 5534-A-713,71000598,CDM,278,RC,C1776,HCPCS,Outpatient,,,2988,2988,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792.8,60,,1434.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2536.21,84.88,,2028.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241,75,,1792.8,percent of total billed charges,75% of total billed charges for outpatient setting,1494,50,,1195.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2390.4,80,,1912.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,383.66,12.84,,306.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3137.4,105,,2509.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.8,35,,836.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1792.8,60,,1434.24,percent of total billed charges,60% of total billed charges for outpatient setting,383.66,3137.4,
COMP SZ 7 TIBIAL / 5536-B-700,69169762,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
COMP SZ 8 FEMORAL LT CR / 5517-F-801,71000617,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMP SZ 8 FEMORAL RT CR / 5517-F-802,71000132,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
COMPLEMENT C1Q,220700,CDM,302,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLEMENT C2,220701,CDM,302,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLEMENT C3,220441,CDM,300,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLEMENT C4,220442,CDM,300,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLEMENT C5,220455,CDM,300,RC,86160,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLEMENT COMPONENT 1 FUNCTIONAL,201721,CDM,302,RC,86161,HCPCS,Outpatient,,,54,48.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,45.84,84.88,,36.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.5,75,,32.4,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,70,,30.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,80,,34.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,100% of Custom Fee Schedule,48.6,90,,38.88,percent of total billed charges,90% of total billed charges for outpatient setting,12,48.6,
COMPLETE INHALANT PROFILE SEROLAB,201087,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
COMPLEX CYSTOMETROGRAM,5100065,CDM,360,RC,,,Outpatient,,,1332.47,1332.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.73,70,,746.18,percent of total billed charges,70% of total billed charges for outpatient setting,1131,84.88,,904.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,666.24,50,,532.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,999.35,75,,799.48,percent of total billed charges,75% of total billed charges for outpatient setting,932.73,70,,746.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.09,12.84,,136.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.98,80,,852.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.09,12.84,,136.87,percent of total billed charges,12.84% of total billed charges,171.09,12.84,,136.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.36,35,,373.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1199.22,90,,959.38,percent of total billed charges,90% of total billed charges for outpatient setting,171.09,1199.22,
COMPLEX MOTION BILATERAL,2400830,CDM,320,RC,76102,HCPCS,Outpatient,,,193.06,144.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,163.87,84.88,,131.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,96.53,50,,77.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.8,75,,115.84,percent of total billed charges,75% of total billed charges for outpatient setting,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,12.84,,19.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.45,80,,123.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,173.75,90,,139,percent of total billed charges,90% of total billed charges for outpatient setting,24.79,378.18,
COMPLEX MOTION BODY SECTION,2400825,CDM,320,RC,76101,HCPCS,Outpatient,,,193.06,144.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,163.87,84.88,,131.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,96.53,50,,77.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.8,75,,115.84,percent of total billed charges,75% of total billed charges for outpatient setting,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,12.84,,19.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.45,80,,123.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,173.75,90,,139,percent of total billed charges,90% of total billed charges for outpatient setting,24.79,378.18,
COMPLEX UROFLOWMETRY,5100075,CDM,360,RC,,,Outpatient,,,743.44,743.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.41,70,,416.33,percent of total billed charges,70% of total billed charges for outpatient setting,631.03,84.88,,504.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,371.72,50,,297.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,557.58,75,,446.06,percent of total billed charges,75% of total billed charges for outpatient setting,520.41,70,,416.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.46,12.84,,76.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.75,80,,475.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.46,12.84,,76.37,percent of total billed charges,12.84% of total billed charges,95.46,12.84,,76.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.2,35,,208.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.1,90,,535.28,percent of total billed charges,90% of total billed charges for outpatient setting,95.46,669.1,
COMPONENT 12X24MM RADL / 00-8700-001-24,2132725,CDM,278,RC,C1776,HCPCS,Outpatient,,,3360,3360,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2016,60,,1612.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2851.97,84.88,,2281.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,75,,2016,percent of total billed charges,75% of total billed charges for outpatient setting,1680,50,,1344,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.42,12.84,,345.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2688,80,,2150.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.42,12.84,,345.14,percent of total billed charges,12.84% of total billed charges,431.42,12.84,,345.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3528,105,,2822.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,35,,940.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2016,60,,1612.8,percent of total billed charges,60% of total billed charges for outpatient setting,431.42,3528,
COMPONENT 27MM GLENOSPHERE / 1307-60-000,848377,CDM,278,RC,C1776,HCPCS,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
COMPONENT 38MM GLENOSPHERE / 1307-60-138,848378,CDM,278,RC,C1776,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
COMPONENT DISTAL RT OPTIROM / 09610,70000390,CDM,278,RC,C1776,HCPCS,Outpatient,,,5332,5332,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3199.2,60,,2559.36,percent of total billed charges,60% of total Billed charges for outpatient setting,4525.8,84.88,,3620.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3999,75,,3199.2,percent of total billed charges,75% of total billed charges for outpatient setting,2666,50,,2132.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.63,12.84,,547.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4265.6,80,,3412.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.63,12.84,,547.7,percent of total billed charges,12.84% of total billed charges,684.63,12.84,,547.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5598.6,105,,4478.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1866.2,35,,1492.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3199.2,60,,2559.36,percent of total billed charges,60% of total billed charges for outpatient setting,684.63,5598.6,
COMPONENT SZ 3 FEM CONSTR RT / 71421173,69169196,CDM,278,RC,C1776,HCPCS,Outpatient,,,11810.72,11810.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7086.43,60,,5669.14,percent of total billed charges,60% of total Billed charges for outpatient setting,10024.94,84.88,,8019.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8858.04,75,,7086.43,percent of total billed charges,75% of total billed charges for outpatient setting,5905.36,50,,4724.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9448.58,80,,7558.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12401.26,105,,9921.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4133.75,35,,3307,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7086.43,60,,5669.14,percent of total billed charges,60% of total billed charges for outpatient setting,1516.5,12401.26,
COMPONENT SZ 3 FEM PT ST RT / 71421203,69169533,CDM,278,RC,C1776,HCPCS,Outpatient,,,6339.92,6339.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.95,60,,3043.16,percent of total billed charges,60% of total Billed charges for outpatient setting,5381.32,84.88,,4305.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4754.94,75,,3803.95,percent of total billed charges,75% of total billed charges for outpatient setting,3169.96,50,,2535.97,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.05,12.84,,651.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5071.94,80,,4057.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.05,12.84,,651.24,percent of total billed charges,12.84% of total billed charges,814.05,12.84,,651.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6656.92,105,,5325.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2218.97,35,,1775.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3803.95,60,,3043.16,percent of total billed charges,60% of total billed charges for outpatient setting,814.05,6656.92,
COMPONENT SZ 3 RT FEM / 5515-F-302,71000589,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 4 FEM CONSTR LT / 71421164,69161870,CDM,278,RC,C1776,HCPCS,Outpatient,,,11810.72,11810.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7086.43,60,,5669.14,percent of total billed charges,60% of total Billed charges for outpatient setting,10024.94,84.88,,8019.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8858.04,75,,7086.43,percent of total billed charges,75% of total billed charges for outpatient setting,5905.36,50,,4724.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9448.58,80,,7558.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12401.26,105,,9921.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4133.75,35,,3307,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7086.43,60,,5669.14,percent of total billed charges,60% of total billed charges for outpatient setting,1516.5,12401.26,
COMPONENT SZ 4 FEM POST RT / 71421204,69161111,CDM,278,RC,C1776,HCPCS,Outpatient,,,3281.02,3281.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968.61,60,,1574.89,percent of total billed charges,60% of total Billed charges for outpatient setting,2784.93,84.88,,2227.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460.77,75,,1968.62,percent of total billed charges,75% of total billed charges for outpatient setting,1640.51,50,,1312.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.28,12.84,,337.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2624.82,80,,2099.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.28,12.84,,337.02,percent of total billed charges,12.84% of total billed charges,421.28,12.84,,337.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3445.07,105,,2756.06,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1148.36,35,,918.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1968.61,60,,1574.89,percent of total billed charges,60% of total billed charges for outpatient setting,421.28,3445.07,
COMPONENT SZ 4 LT FEM / 5515-F-401,71000859,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 5 CONSTR RT / 71421175,69161366,CDM,278,RC,C1776,HCPCS,Outpatient,,,13027.5,13027.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7816.5,60,,6253.2,percent of total billed charges,60% of total Billed charges for outpatient setting,11057.74,84.88,,8846.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9770.63,75,,7816.5,percent of total billed charges,75% of total billed charges for outpatient setting,6513.75,50,,5211,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1672.73,12.84,,1338.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10422,80,,8337.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1672.73,12.84,,1338.18,percent of total billed charges,12.84% of total billed charges,1672.73,12.84,,1338.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13678.88,105,,10943.1,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.63,35,,3647.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7816.5,60,,6253.2,percent of total billed charges,60% of total billed charges for outpatient setting,1672.73,13678.88,
COMPONENT SZ 5 FEM CONSTR LT / 71421165,71000594,CDM,278,RC,C1776,HCPCS,Outpatient,,,11810.72,11810.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7086.43,60,,5669.14,percent of total billed charges,60% of total Billed charges for outpatient setting,10024.94,84.88,,8019.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8858.04,75,,7086.43,percent of total billed charges,75% of total billed charges for outpatient setting,5905.36,50,,4724.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9448.58,80,,7558.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,1516.5,12.84,,1213.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12401.26,105,,9921.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4133.75,35,,3307,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7086.43,60,,5669.14,percent of total billed charges,60% of total billed charges for outpatient setting,1516.5,12401.26,
COMPONENT SZ 5 FEM POST RT / 71421205,69161115,CDM,278,RC,C1776,HCPCS,Outpatient,,,5699.4,5699.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.64,60,,2735.71,percent of total billed charges,60% of total Billed charges for outpatient setting,4837.65,84.88,,3870.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4274.55,75,,3419.64,percent of total billed charges,75% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.52,80,,3647.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5984.37,105,,4787.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.79,35,,1595.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3419.64,60,,2735.71,percent of total billed charges,60% of total billed charges for outpatient setting,731.8,5984.37,
COMPONENT SZ 5 LT FEM / 5515-F-501,71000880,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 5 RT FEM / 5515-F-502,71000571,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 6 FEM CRUC LT / 71421236,69162476,CDM,278,RC,C1776,HCPCS,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
COMPONENT SZ 7 FEM CONSTR LT / 71421167,69161480,CDM,278,RC,C1776,HCPCS,Outpatient,,,13678.88,13678.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8207.33,60,,6565.86,percent of total billed charges,60% of total Billed charges for outpatient setting,11610.63,84.88,,9288.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10259.16,75,,8207.33,percent of total billed charges,75% of total billed charges for outpatient setting,6839.44,50,,5471.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1756.37,12.84,,1405.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10943.1,80,,8754.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1756.37,12.84,,1405.1,percent of total billed charges,12.84% of total billed charges,1756.37,12.84,,1405.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14362.82,105,,11490.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4787.61,35,,3830.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8207.33,60,,6565.86,percent of total billed charges,60% of total billed charges for outpatient setting,1756.37,14362.82,
COMPONENT SZ 7 FEM CRUC LT / 71421237,69161128,CDM,278,RC,C1776,HCPCS,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
COMPONENT SZ 7 RT FEM / 5515-F-702,71000419,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 8 FEM CR RET LT / 7141238,69162529,CDM,278,RC,C1776,HCPCS,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
COMPONENT SZ 8 LT FEM / 5515-F-801,69169799,CDM,278,RC,C1776,HCPCS,Outpatient,,,2990.4,2990.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.24,60,,1435.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2538.25,84.88,,2030.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.8,75,,1794.24,percent of total billed charges,75% of total billed charges for outpatient setting,1495.2,50,,1196.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.32,80,,1913.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,383.97,12.84,,307.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.92,105,,2511.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.64,35,,837.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794.24,60,,1435.39,percent of total billed charges,60% of total billed charges for outpatient setting,383.97,3139.92,
COMPONENT SZ 8 TIB TRTHLN / 5536-B-800,71000653,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
CONCENTRATIONS FOR INFECTIOUS AGENTS,201537,CDM,300,RC,87015,HCPCS,Outpatient,,,30.06,27.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,25.51,84.88,,20.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.55,75,,18.04,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,80,,19.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of Custom Fee Schedule,27.05,90,,21.64,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,27.05,
CONCORDE TI 9X10X27 / 1969-27-010,70000452,CDM,278,RC,C1821,HCPCS,Outpatient,,,12768,12768,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7660.8,60,,6128.64,percent of total billed charges,60% of total Billed charges for outpatient setting,10837.48,84.88,,8669.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9576,75,,7660.8,percent of total billed charges,75% of total billed charges for outpatient setting,6384,50,,5107.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.41,12.84,,1311.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10214.4,80,,8171.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.41,12.84,,1311.53,percent of total billed charges,12.84% of total billed charges,1639.41,12.84,,1311.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13406.4,105,,10725.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4468.8,35,,3575.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7660.8,60,,6128.64,percent of total billed charges,60% of total billed charges for outpatient setting,1639.41,13406.4,
CONCORDE TI 9X9X23 / 1969-23-509,69162949,CDM,278,RC,C1821,HCPCS,Outpatient,,,8420,8420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5052,60,,4041.6,percent of total billed charges,60% of total Billed charges for outpatient setting,7146.9,84.88,,5717.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6315,75,,5052,percent of total billed charges,75% of total billed charges for outpatient setting,4210,50,,3368,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.13,12.84,,864.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6736,80,,5388.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.13,12.84,,864.9,percent of total billed charges,12.84% of total billed charges,1081.13,12.84,,864.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8841,105,,7072.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2947,35,,2357.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5052,60,,4041.6,percent of total billed charges,60% of total billed charges for outpatient setting,1081.13,8841,
CONCTR MOD HEAD OPEN 5.5-6.35 /1175.6355,69169467,CDM,278,RC,C1713,HCPCS,Outpatient,,,5984,5984,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3590.4,60,,2872.32,percent of total billed charges,60% of total Billed charges for outpatient setting,5079.22,84.88,,4063.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4488,75,,3590.4,percent of total billed charges,75% of total billed charges for outpatient setting,2992,50,,2393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4787.2,80,,3829.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6283.2,105,,5026.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2094.4,35,,1675.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3590.4,60,,2872.32,percent of total billed charges,60% of total billed charges for outpatient setting,768.35,6283.2,
CONCTR SNGL HEAD 5.5-6.0 12MM/1175.9214,69169465,CDM,278,RC,C1713,HCPCS,Outpatient,,,3324,3324,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.4,60,,1595.52,percent of total billed charges,60% of total Billed charges for outpatient setting,2821.41,84.88,,2257.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493,75,,1994.4,percent of total billed charges,75% of total billed charges for outpatient setting,1662,50,,1329.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.8,12.84,,341.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2659.2,80,,2127.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.8,12.84,,341.44,percent of total billed charges,12.84% of total billed charges,426.8,12.84,,341.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3490.2,105,,2792.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.4,35,,930.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1994.4,60,,1595.52,percent of total billed charges,60% of total billed charges for outpatient setting,426.8,3490.2,
CONE 15MM 135D WAGNER / 01.00561.315,71000228,CDM,278,RC,C1776,HCPCS,Outpatient,,,5434,5434,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3260.4,60,,2608.32,percent of total billed charges,60% of total Billed charges for outpatient setting,4612.38,84.88,,3689.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4075.5,75,,3260.4,percent of total billed charges,75% of total billed charges for outpatient setting,2717,50,,2173.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.73,12.84,,558.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4347.2,80,,3477.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.73,12.84,,558.18,percent of total billed charges,12.84% of total billed charges,697.73,12.84,,558.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5705.7,105,,4564.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1901.9,35,,1521.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3260.4,60,,2608.32,percent of total billed charges,60% of total billed charges for outpatient setting,697.73,5705.7,
CONE SZ B TIT TRTHLN / 5549-A-222,71000825,CDM,278,RC,C1776,HCPCS,Outpatient,,,8698.84,8698.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5219.3,60,,4175.44,percent of total billed charges,60% of total Billed charges for outpatient setting,7383.58,84.88,,5906.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6524.13,75,,5219.3,percent of total billed charges,75% of total billed charges for outpatient setting,4349.42,50,,3479.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.93,12.84,,893.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6959.07,80,,5567.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.93,12.84,,893.54,percent of total billed charges,12.84% of total billed charges,1116.93,12.84,,893.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9133.78,105,,7307.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3044.59,35,,2435.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5219.3,60,,4175.44,percent of total billed charges,60% of total billed charges for outpatient setting,1116.93,9133.78,
CONE SZ C TRTHLN / 5549-A-130,71000580,CDM,278,RC,C1776,HCPCS,Outpatient,,,8133.92,8133.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4880.35,60,,3904.28,percent of total billed charges,60% of total Billed charges for outpatient setting,6904.07,84.88,,5523.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6100.44,75,,4880.35,percent of total billed charges,75% of total billed charges for outpatient setting,4066.96,50,,3253.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6507.14,80,,5205.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8540.62,105,,6832.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2846.87,35,,2277.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4880.35,60,,3904.28,percent of total billed charges,60% of total billed charges for outpatient setting,1044.4,8540.62,
CONE SZ D TIT TRTHLN / 5549-A-241,71000954,CDM,278,RC,C1776,HCPCS,Outpatient,,,8698.84,8698.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5219.3,60,,4175.44,percent of total billed charges,60% of total Billed charges for outpatient setting,7383.58,84.88,,5906.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6524.13,75,,5219.3,percent of total billed charges,75% of total billed charges for outpatient setting,4349.42,50,,3479.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.93,12.84,,893.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6959.07,80,,5567.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.93,12.84,,893.54,percent of total billed charges,12.84% of total billed charges,1116.93,12.84,,893.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9133.78,105,,7307.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3044.59,35,,2435.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5219.3,60,,4175.44,percent of total billed charges,60% of total billed charges for outpatient setting,1116.93,9133.78,
CONE SZ D TRTHLN / 5549-A-140,71000467,CDM,278,RC,C1776,HCPCS,Outpatient,,,8133.92,8133.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4880.35,60,,3904.28,percent of total billed charges,60% of total Billed charges for outpatient setting,6904.07,84.88,,5523.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6100.44,75,,4880.35,percent of total billed charges,75% of total billed charges for outpatient setting,4066.96,50,,3253.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6507.14,80,,5205.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8540.62,105,,6832.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2846.87,35,,2277.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4880.35,60,,3904.28,percent of total billed charges,60% of total billed charges for outpatient setting,1044.4,8540.62,
CONE SZ E TRTHLN / 5549-A-150,71000374,CDM,278,RC,C1776,HCPCS,Outpatient,,,8133.92,8133.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4880.35,60,,3904.28,percent of total billed charges,60% of total Billed charges for outpatient setting,6904.07,84.88,,5523.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6100.44,75,,4880.35,percent of total billed charges,75% of total billed charges for outpatient setting,4066.96,50,,3253.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6507.14,80,,5205.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,1044.4,12.84,,835.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8540.62,105,,6832.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2846.87,35,,2277.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4880.35,60,,3904.28,percent of total billed charges,60% of total billed charges for outpatient setting,1044.4,8540.62,
CONFIRM RX CARDIAC MNTR/ DM3500,69169121,CDM,278,RC,C1764,HCPCS,Outpatient,,,7200,7200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,60,,3456,percent of total billed charges,60% of total Billed charges for outpatient setting,6111.36,84.88,,4889.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400,75,,4320,percent of total billed charges,75% of total billed charges for outpatient setting,3600,50,,2880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.48,12.84,,739.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5760,80,,4608,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.48,12.84,,739.58,percent of total billed charges,12.84% of total billed charges,924.48,12.84,,739.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7560,105,,6048,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,35,,2016,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4320,60,,3456,percent of total billed charges,60% of total billed charges for outpatient setting,924.48,7560,
CONNCTR 5.5 ROD 400MM / 1175.1554,69169482,CDM,278,RC,C1713,HCPCS,Outpatient,,,2616,2616,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1569.6,60,,1255.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2220.46,84.88,,1776.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1962,75,,1569.6,percent of total billed charges,75% of total billed charges for outpatient setting,1308,50,,1046.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.89,12.84,,268.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2092.8,80,,1674.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.89,12.84,,268.71,percent of total billed charges,12.84% of total billed charges,335.89,12.84,,268.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2746.8,105,,2197.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.6,35,,732.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1569.6,60,,1255.68,percent of total billed charges,60% of total billed charges for outpatient setting,335.89,2746.8,
CONNECTOR 5-IN-1 STERILE // DYND50510,6150120,CDM,272,RC,,,Outpatient,,,7.8,7.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,70,,4.37,percent of total billed charges,70% of total billed charges for outpatient setting,6.62,84.88,,5.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.9,50,,3.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,75,,4.68,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,70,,4.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,80,,4.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.07,65,,4.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.73,35,,2.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.02,90,,5.62,percent of total billed charges,90% of total billed charges for outpatient setting,1,7.02,
CONNECTOR 7/8 - 1/4IN / RF10112,69162839,CDM,272,RC,,,Outpatient,,,13.89,13.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,70,,7.78,percent of total billed charges,70% of total billed charges for outpatient setting,11.79,84.88,,9.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.95,50,,5.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.42,75,,8.34,percent of total billed charges,75% of total billed charges for outpatient setting,9.72,70,,7.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.11,80,,8.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.03,65,,7.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,35,,3.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.5,90,,10,percent of total billed charges,90% of total billed charges for outpatient setting,1.78,12.5,
CONNECTOR DBL HEAD 5.5-6.0 / 1175.9933,69169379,CDM,278,RC,C1713,HCPCS,Outpatient,,,4986,4986,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2991.6,60,,2393.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4232.12,84.88,,3385.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3739.5,75,,2991.6,percent of total billed charges,75% of total billed charges for outpatient setting,2493,50,,1994.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.2,12.84,,512.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3988.8,80,,3191.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.2,12.84,,512.16,percent of total billed charges,12.84% of total billed charges,640.2,12.84,,512.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5235.3,105,,4188.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.1,35,,1396.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2991.6,60,,2393.28,percent of total billed charges,60% of total billed charges for outpatient setting,640.2,5235.3,
CONNECTOR IV ONE LINK BAXTER / 7N8399,1156682,CDM,270,RC,,,Outpatient,,,10.26,10.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,8.71,84.88,,6.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,50,,4.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.7,75,,6.16,percent of total billed charges,75% of total billed charges for outpatient setting,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.21,80,,6.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.67,65,,5.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,35,,2.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.23,90,,7.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.32,9.23,
CONNECTOR MICROCLAVE CLEAR / 12512-01,69162104,CDM,272,RC,,,Outpatient,,,9.53,9.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.67,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,8.09,84.88,,6.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.77,50,,3.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.15,75,,5.72,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,80,,6.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.19,65,,4.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,35,,2.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.58,90,,6.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.58,
CONNECTOR MOD HEAD 5.5-6.35 / 1175.6255,69169172,CDM,278,RC,C1713,HCPCS,Outpatient,,,5984,5984,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3590.4,60,,2872.32,percent of total billed charges,60% of total Billed charges for outpatient setting,5079.22,84.88,,4063.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4488,75,,3590.4,percent of total billed charges,75% of total billed charges for outpatient setting,2992,50,,2393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4787.2,80,,3829.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6283.2,105,,5026.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2094.4,35,,1675.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3590.4,60,,2872.32,percent of total billed charges,60% of total billed charges for outpatient setting,768.35,6283.2,
CONNECTOR MOD HEAD 5.5-6.35 /1175.6255,69169772,CDM,278,RC,C1713,HCPCS,Outpatient,,,5984,5984,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3590.4,60,,2872.32,percent of total billed charges,60% of total Billed charges for outpatient setting,5079.22,84.88,,4063.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4488,75,,3590.4,percent of total billed charges,75% of total billed charges for outpatient setting,2992,50,,2393.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4787.2,80,,3829.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,768.35,12.84,,614.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6283.2,105,,5026.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2094.4,35,,1675.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3590.4,60,,2872.32,percent of total billed charges,60% of total billed charges for outpatient setting,768.35,6283.2,
CONNECTOR PORT ERBEFLO / 20325-211,71000071,CDM,272,RC,,,Outpatient,,,41.65,41.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,70,,23.33,percent of total billed charges,70% of total billed charges for outpatient setting,35.35,84.88,,28.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.83,50,,16.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.24,75,,24.99,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,70,,23.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.32,80,,26.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.07,65,,21.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.58,35,,11.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.49,90,,29.99,percent of total billed charges,90% of total billed charges for outpatient setting,5.35,37.49,
CONSULT OUTSIDE FILMS,2400845,CDM,320,RC,76140,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,35,,52.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
CONSULTATION AND REPORT,200396,CDM,314,RC,88323,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,178.52,
CONTAINER EMPTY EVAC : 1000ML,3300873,CDM,272,RC,,,Outpatient,,,58.43,58.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.9,70,,32.72,percent of total billed charges,70% of total billed charges for outpatient setting,49.6,84.88,,39.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.22,50,,23.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.82,75,,35.06,percent of total billed charges,75% of total billed charges for outpatient setting,40.9,70,,32.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.74,80,,37.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.98,65,,30.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.45,35,,16.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.59,90,,42.07,percent of total billed charges,90% of total billed charges for outpatient setting,7.5,52.59,
CONTRAST INJECTION LINE 30 /91031302,8370115,CDM,272,RC,,,Outpatient,,,58.49,58.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.94,70,,32.75,percent of total billed charges,70% of total billed charges for outpatient setting,49.65,84.88,,39.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.25,50,,23.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.87,75,,35.1,percent of total billed charges,75% of total billed charges for outpatient setting,40.94,70,,32.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.51,12.84,,6.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,80,,37.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.51,12.84,,6.01,percent of total billed charges,12.84% of total billed charges,7.51,12.84,,6.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.02,65,,30.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,35,,16.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.64,90,,42.11,percent of total billed charges,90% of total billed charges for outpatient setting,7.51,52.64,
CONVEX 0 DEG 10X22MM /3110-2210,69169394,CDM,278,RC,C1821,HCPCS,Outpatient,,,9200,9200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5520,60,,4416,percent of total billed charges,60% of total Billed charges for outpatient setting,7808.96,84.88,,6247.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6900,75,,5520,percent of total billed charges,75% of total billed charges for outpatient setting,4600,50,,3680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7360,80,,5888,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9660,105,,7728,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3220,35,,2576,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5520,60,,4416,percent of total billed charges,60% of total billed charges for outpatient setting,1181.28,9660,
CONVEX 0 DEG 11X22MM /3110-2211,69169277,CDM,278,RC,C1821,HCPCS,Outpatient,,,9200,9200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5520,60,,4416,percent of total billed charges,60% of total Billed charges for outpatient setting,7808.96,84.88,,6247.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6900,75,,5520,percent of total billed charges,75% of total billed charges for outpatient setting,4600,50,,3680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7360,80,,5888,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9660,105,,7728,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3220,35,,2576,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5520,60,,4416,percent of total billed charges,60% of total billed charges for outpatient setting,1181.28,9660,
CONVEX 0 DEG 12X22MM /3110-2212,69169332,CDM,278,RC,C1821,HCPCS,Outpatient,,,9200,9200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5520,60,,4416,percent of total billed charges,60% of total Billed charges for outpatient setting,7808.96,84.88,,6247.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6900,75,,5520,percent of total billed charges,75% of total billed charges for outpatient setting,4600,50,,3680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7360,80,,5888,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,1181.28,12.84,,945.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9660,105,,7728,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3220,35,,2576,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5520,60,,4416,percent of total billed charges,60% of total billed charges for outpatient setting,1181.28,9660,
COPPER SERUM,220060,CDM,301,RC,82525,HCPCS,Outpatient,,,55.85,50.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,47.41,84.88,,37.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.89,75,,33.51,percent of total billed charges,75% of total billed charges for outpatient setting,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,80,,35.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,100% of Custom Fee Schedule,50.27,90,,40.22,percent of total billed charges,90% of total billed charges for outpatient setting,12.41,50.27,
COPPER URINE,220062,CDM,301,RC,82525,HCPCS,Outpatient,,,55.85,50.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,47.41,84.88,,37.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.89,75,,33.51,percent of total billed charges,75% of total billed charges for outpatient setting,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,80,,35.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,100% of Custom Fee Schedule,50.27,90,,40.22,percent of total billed charges,90% of total billed charges for outpatient setting,12.41,50.27,
CORE 11X12 7MM / 414.107S,69162489,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
CORE 14MM 24-32MM / 351.050,69162630,CDM,278,RC,C1821,HCPCS,Outpatient,,,14880,14880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8928,60,,7142.4,percent of total billed charges,60% of total Billed charges for outpatient setting,12630.14,84.88,,10104.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11160,75,,8928,percent of total billed charges,75% of total billed charges for outpatient setting,7440,50,,5952,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1910.59,12.84,,1528.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11904,80,,9523.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1910.59,12.84,,1528.47,percent of total billed charges,12.84% of total billed charges,1910.59,12.84,,1528.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15624,105,,12499.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5208,35,,4166.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8928,60,,7142.4,percent of total billed charges,60% of total billed charges for outpatient setting,1910.59,15624,
CORE 14MM/25-30MM / 337.001,69169592,CDM,278,RC,C1821,HCPCS,Outpatient,,,17600,17600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10560,60,,8448,percent of total billed charges,60% of total Billed charges for outpatient setting,14938.88,84.88,,11951.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13200,75,,10560,percent of total billed charges,75% of total billed charges for outpatient setting,8800,50,,7040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.84,12.84,,1807.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14080,80,,11264,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.84,12.84,,1807.87,percent of total billed charges,12.84% of total billed charges,2259.84,12.84,,1807.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18480,105,,14784,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6160,35,,4928,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10560,60,,8448,percent of total billed charges,60% of total billed charges for outpatient setting,2259.84,18480,
CORTICAL CANCELLOUS MATCHSTICK .5x5 CM,69159033,CDM,278,RC,,,Outpatient,,,1616.96,1616.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.18,60,,776.14,percent of total billed charges,60% of total Billed charges for outpatient setting,1372.48,84.88,,1097.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,808.48,50,,646.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1212.72,75,,970.18,percent of total billed charges,75% of total billed charges for outpatient setting,808.48,50,,646.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.62,12.84,,166.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.57,80,,1034.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.62,12.84,,166.1,percent of total billed charges,12.84% of total billed charges,207.62,12.84,,166.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1616.96,65,,1293.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.94,35,,452.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,970.18,60,,776.14,percent of total billed charges,60% of total billed charges for outpatient setting,207.62,1616.96,
CORTISOL,220276,CDM,301,RC,82533,HCPCS,Outpatient,,,73.35,66.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,62.26,84.88,,49.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.01,75,,44.01,percent of total billed charges,75% of total billed charges for outpatient setting,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.68,80,,46.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.91,100,,,Fee Schedule,100% of Custom Fee Schedule,66.02,90,,52.82,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,66.02,
CORTISOL DEXAMETHASONE SUPPRESSION TEST,220500,CDM,301,RC,82533,HCPCS,Outpatient,,,73.35,66.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,62.26,84.88,,49.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.01,75,,44.01,percent of total billed charges,75% of total billed charges for outpatient setting,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.68,80,,46.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.91,100,,,Fee Schedule,100% of Custom Fee Schedule,66.02,90,,52.82,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,66.02,
CORTISOL FREE SERUM,220054,CDM,301,RC,82530,HCPCS,Outpatient,,,75.2,67.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.64,70,,42.11,percent of total billed charges,70% of total billed charges for outpatient setting,63.83,84.88,,51.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.4,75,,45.12,percent of total billed charges,75% of total billed charges for outpatient setting,52.64,70,,42.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.16,80,,48.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.69,100,,,Fee Schedule,100% of Custom Fee Schedule,67.68,90,,54.14,percent of total billed charges,90% of total billed charges for outpatient setting,16.71,67.68,
CORTISOL SALIVARY,201088,CDM,300,RC,82533,HCPCS,Outpatient,,,73.35,66.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,62.26,84.88,,49.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.01,75,,44.01,percent of total billed charges,75% of total billed charges for outpatient setting,51.35,70,,41.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.68,80,,46.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.91,100,,,Fee Schedule,100% of Custom Fee Schedule,66.02,90,,52.82,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,66.02,
CORTISOL URINARY FREE,220053,CDM,301,RC,82530,HCPCS,Outpatient,,,75.2,67.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.64,70,,42.11,percent of total billed charges,70% of total billed charges for outpatient setting,63.83,84.88,,51.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.4,75,,45.12,percent of total billed charges,75% of total billed charges for outpatient setting,52.64,70,,42.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.16,80,,48.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.69,100,,,Fee Schedule,100% of Custom Fee Schedule,67.68,90,,54.14,percent of total billed charges,90% of total billed charges for outpatient setting,16.71,67.68,
CORTISPORIN OPTH. DROPS: 7.5 ML,3302908,CDM,259,RC,,,Outpatient,,,133.76,133.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.63,70,,74.9,percent of total billed charges,70% of total billed charges for outpatient setting,113.54,84.88,,90.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.88,50,,53.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.32,75,,80.26,percent of total billed charges,75% of total billed charges for outpatient setting,93.63,70,,74.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.17,12.84,,13.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.01,80,,85.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.17,12.84,,13.74,percent of total billed charges,12.84% of total billed charges,17.17,12.84,,13.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.94,65,,69.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.82,35,,37.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.38,90,,96.3,percent of total billed charges,90% of total billed charges for outpatient setting,17.17,120.38,
CORTISPORIN OTIC SUSP:10 ML,3301650,CDM,259,RC,,,Outpatient,,,296.42,296.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.49,70,,165.99,percent of total billed charges,70% of total billed charges for outpatient setting,251.6,84.88,,201.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,148.21,50,,118.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.32,75,,177.86,percent of total billed charges,75% of total billed charges for outpatient setting,207.49,70,,165.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.06,12.84,,30.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.14,80,,189.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.06,12.84,,30.45,percent of total billed charges,12.84% of total billed charges,38.06,12.84,,30.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,192.67,65,,154.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.75,35,,83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,266.78,90,,213.42,percent of total billed charges,90% of total billed charges for outpatient setting,38.06,266.78,
COSOPT OPTH DROPS: 5 ML,3302968,CDM,259,RC,,,Outpatient,,,189.69,189.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.78,70,,106.22,percent of total billed charges,70% of total billed charges for outpatient setting,161.01,84.88,,128.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.85,50,,75.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.27,75,,113.82,percent of total billed charges,75% of total billed charges for outpatient setting,132.78,70,,106.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.36,12.84,,19.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.75,80,,121.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.36,12.84,,19.49,percent of total billed charges,12.84% of total billed charges,24.36,12.84,,19.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.3,65,,98.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.39,35,,53.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.72,90,,136.58,percent of total billed charges,90% of total billed charges for outpatient setting,24.36,170.72,
COTTONOIDS 0.5X0.5IN NEURO / 30-054,69161676,CDM,270,RC,,,Outpatient,,,32.58,32.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.81,70,,18.25,percent of total billed charges,70% of total billed charges for outpatient setting,27.65,84.88,,22.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.29,50,,13.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.44,75,,19.55,percent of total billed charges,75% of total billed charges for outpatient setting,22.81,70,,18.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.18,12.84,,3.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.06,80,,20.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.18,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,4.18,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.18,65,,16.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,35,,9.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.32,90,,23.46,percent of total billed charges,90% of total billed charges for outpatient setting,4.18,29.32,
COTTONOIDS 0.5X3IN / 30-057,69159663,CDM,270,RC,,,Outpatient,,,35.92,35.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,70,,20.11,percent of total billed charges,70% of total billed charges for outpatient setting,30.49,84.88,,24.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.96,50,,14.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.94,75,,21.55,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,70,,20.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.61,12.84,,3.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,80,,22.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.61,12.84,,3.69,percent of total billed charges,12.84% of total billed charges,4.61,12.84,,3.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.35,65,,18.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.57,35,,10.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.33,90,,25.86,percent of total billed charges,90% of total billed charges for outpatient setting,4.61,32.33,
COTTONOIDS 1  X 1    30-059,69161736,CDM,270,RC,,,Outpatient,,,39.39,39.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.57,70,,22.06,percent of total billed charges,70% of total billed charges for outpatient setting,33.43,84.88,,26.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.7,50,,15.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.54,75,,23.63,percent of total billed charges,75% of total billed charges for outpatient setting,27.57,70,,22.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.51,80,,25.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.6,65,,20.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,35,,11.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.45,90,,28.36,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,35.45,
COTTONOIDS 1/4  X 1/4    30-154,69161751,CDM,270,RC,,,Outpatient,,,47.72,47.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.4,70,,26.72,percent of total billed charges,70% of total billed charges for outpatient setting,40.5,84.88,,32.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.86,50,,19.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.79,75,,28.63,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,70,,26.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.18,80,,30.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.02,65,,24.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,35,,13.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.95,90,,34.36,percent of total billed charges,90% of total billed charges for outpatient setting,6.13,42.95,
COUMADIN TAB: 10MG,3302501,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COUMADIN TAB: 1MG,3302511,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
COUMADIN TAB: 2.5MG,3302510,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COUMADIN TAB: 2MG,3302509,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COUMADIN TAB: 3MG,3302512,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
COUMADIN TAB: 4MG,3302508,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COUMADIN TAB: 5MG,3302507,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
COUMADIN TAB: 7.5MG,3302506,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
COUNTER SINK / 907-1003,69169357,CDM,272,RC,,,Outpatient,,,588.42,588.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.89,70,,329.51,percent of total billed charges,70% of total billed charges for outpatient setting,499.45,84.88,,399.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,294.21,50,,235.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.32,75,,353.06,percent of total billed charges,75% of total billed charges for outpatient setting,411.89,70,,329.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.55,12.84,,60.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.74,80,,376.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.55,12.84,,60.44,percent of total billed charges,12.84% of total billed charges,75.55,12.84,,60.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.47,65,,305.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.95,35,,164.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.58,90,,423.66,percent of total billed charges,90% of total billed charges for outpatient setting,75.55,529.58,
COUPLER 2MM OFFSET / 71424223,71000693,CDM,278,RC,C1713,HCPCS,Outpatient,,,2242.64,2242.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.58,60,,1076.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1903.55,84.88,,1522.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1681.98,75,,1345.58,percent of total billed charges,75% of total billed charges for outpatient setting,1121.32,50,,897.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.11,80,,1435.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2354.77,105,,1883.82,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.92,35,,627.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1345.58,60,,1076.46,percent of total billed charges,60% of total billed charges for outpatient setting,287.95,2354.77,
COUPLER 4MM OFFSET / 71424225,69161875,CDM,278,RC,C1713,HCPCS,Outpatient,,,2242.64,2242.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.58,60,,1076.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1903.55,84.88,,1522.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1681.98,75,,1345.58,percent of total billed charges,75% of total billed charges for outpatient setting,1121.32,50,,897.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.11,80,,1435.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,287.95,12.84,,230.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2354.77,105,,1883.82,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.92,35,,627.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1345.58,60,,1076.46,percent of total billed charges,60% of total billed charges for outpatient setting,287.95,2354.77,
COUPLING HINGE / 4933-0-800,70000780,CDM,278,RC,C1713,HCPCS,Outpatient,,,1687.79,1687.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.67,60,,810.14,percent of total billed charges,60% of total Billed charges for outpatient setting,1432.6,84.88,,1146.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.84,75,,1012.67,percent of total billed charges,75% of total billed charges for outpatient setting,843.9,50,,675.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.71,12.84,,173.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350.23,80,,1080.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.71,12.84,,173.37,percent of total billed charges,12.84% of total billed charges,216.71,12.84,,173.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1687.79,65,,1350.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.73,35,,472.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1012.67,60,,810.14,percent of total billed charges,60% of total billed charges for outpatient setting,216.71,1687.79,
COUPLING ROD TO ROD / 4922-1-010,70000782,CDM,278,RC,C1713,HCPCS,Outpatient,,,1938.24,1938.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.94,60,,930.35,percent of total billed charges,60% of total Billed charges for outpatient setting,1645.18,84.88,,1316.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1453.68,75,,1162.94,percent of total billed charges,75% of total billed charges for outpatient setting,969.12,50,,775.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.87,12.84,,199.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1550.59,80,,1240.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.87,12.84,,199.1,percent of total billed charges,12.84% of total billed charges,248.87,12.84,,199.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1938.24,65,,1550.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.38,35,,542.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1162.94,60,,930.35,percent of total billed charges,60% of total billed charges for outpatient setting,248.87,1938.24,
COVID-19 Ag CARD PROFICIENCY,201914,CDM,306,RC,87811,HCPCS,Outpatient,,,62.07,55.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,52.69,84.88,,42.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.55,75,,37.24,percent of total billed charges,75% of total billed charges for outpatient setting,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.66,80,,39.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of Custom Fee Schedule,55.86,90,,44.69,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,55.86,
COVID-19 Ag CARD TEST (BINAXNOW),220173,CDM,306,RC,87811,HCPCS,Outpatient,,,62.07,55.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,52.69,84.88,,42.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.55,75,,37.24,percent of total billed charges,75% of total billed charges for outpatient setting,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.66,80,,39.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of Custom Fee Schedule,55.86,90,,44.69,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,55.86,
COVID-19 RAPID TEST,22172,CDM,310,RC,87635,HCPCS,Outpatient,,,110.25,99.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,93.58,84.88,,74.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.69,75,,66.15,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,80,,70.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,100% of Custom Fee Schedule,99.23,90,,79.38,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,99.23,
COVID-19 RAPID TEST (ID NOW MOLECULAR),220172,CDM,310,RC,87635,HCPCS,Outpatient,,,110.25,99.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,93.58,84.88,,74.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.69,75,,66.15,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,80,,70.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,100% of Custom Fee Schedule,99.23,90,,79.38,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,99.23,
COVID-19 TEST 7305 (PCR TO CPL),220170,CDM,310,RC,87635,HCPCS,Outpatient,,,110.25,99.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,93.58,84.88,,74.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.69,75,,66.15,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,80,,70.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,100% of Custom Fee Schedule,99.23,90,,79.38,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,99.23,
COXSACKIE A VIRUS AB PROFILE,202169,CDM,302,RC,86658,HCPCS,Outpatient,,,58.64,52.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,49.77,84.88,,39.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.98,75,,35.18,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.91,80,,37.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,100,,,Fee Schedule,100% of Custom Fee Schedule,52.78,90,,42.22,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,52.78,
COXSACKIE B VIRUS AB PROFILE,202170,CDM,302,RC,86658,HCPCS,Outpatient,,,58.64,52.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,49.77,84.88,,39.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.98,75,,35.18,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.91,80,,37.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,100,,,Fee Schedule,100% of Custom Fee Schedule,52.78,90,,42.22,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,52.78,
CPAP,1300042,CDM,410,RC,94660,HCPCS,Outpatient,,,332.86,332.86,,269.5,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,282.53,84.88,,226.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,249.65,75,,199.72,percent of total billed charges,75% of total billed charges for outpatient setting,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,286.34,170,,,Fee Schedule,170% of Medicare OPPS rate,362.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.74,12.84,,34.192,percent of total billed charges,12.84% of total billed charges,294.76,175,,,Fee Schedule,175% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.29,80,,213.03,percent of total billed charges,80% of total billed charges for outpatient setting,235.81,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,210.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181,100,,,Case rate,pays based on fixed rate ,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.01,100,,,Fee Schedule,100% of Custom Fee Schedule,299.57,90,,239.66,percent of total billed charges,90% of total billed charges for outpatient setting,42.74,362.14,
CPAP FULL FACE MASK,69169063,CDM,270,RC,,,Outpatient,,,334.18,334.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,283.65,84.88,,226.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.09,50,,133.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.64,75,,200.51,percent of total billed charges,75% of total billed charges for outpatient setting,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.34,80,,213.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.22,65,,173.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.96,35,,93.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.76,90,,240.61,percent of total billed charges,90% of total billed charges for outpatient setting,42.91,300.76,
CPAP HEADGEAR,69169064,CDM,270,RC,,,Outpatient,,,133.68,133.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,113.47,84.88,,90.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.84,50,,53.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.26,75,,80.21,percent of total billed charges,75% of total billed charges for outpatient setting,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.94,80,,85.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.89,65,,69.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,35,,37.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.31,90,,96.25,percent of total billed charges,90% of total billed charges for outpatient setting,17.16,120.31,
CPAP TUBING,69169062,CDM,270,RC,,,Outpatient,,,133.68,133.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,113.47,84.88,,90.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.84,50,,53.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.26,75,,80.21,percent of total billed charges,75% of total billed charges for outpatient setting,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.94,80,,85.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.89,65,,69.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,35,,37.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.31,90,,96.25,percent of total billed charges,90% of total billed charges for outpatient setting,17.16,120.31,
C-PEPTIDE,220802,CDM,305,RC,84681,HCPCS,Outpatient,,,93.65,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,79.49,84.88,,63.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.24,75,,56.19,percent of total billed charges,75% of total billed charges for outpatient setting,65.56,70,,52.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.92,80,,59.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,100,,,Fee Schedule,100% of Custom Fee Schedule,84.29,90,,67.43,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,84.29,
CPK,200700,CDM,301,RC,82550,HCPCS,Outpatient,,,29.3,26.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,24.87,84.88,,19.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.98,75,,17.58,percent of total billed charges,75% of total billed charges for outpatient setting,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.44,80,,18.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,100,,,Fee Schedule,100% of Custom Fee Schedule,26.37,90,,21.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,26.37,
CPK (TO CPL),222700,CDM,301,RC,82550,HCPCS,Outpatient,,,29.3,26.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,24.87,84.88,,19.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.98,75,,17.58,percent of total billed charges,75% of total billed charges for outpatient setting,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.44,80,,18.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,100,,,Fee Schedule,100% of Custom Fee Schedule,26.37,90,,21.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,26.37,
CPL-AFB SMEAR,222021,CDM,300,RC,87206,HCPCS,Outpatient,,,24.26,21.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.59,84.88,,16.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.2,75,,14.56,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,80,,15.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.2,100,,,Fee Schedule,100% of Custom Fee Schedule,21.83,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,21.83,
"CPL-CULTURE URINE,ROUTINE",222030,CDM,300,RC,87088,HCPCS,Outpatient,,,36.41,32.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.49,70,,20.39,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,84.88,,24.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.31,75,,21.85,percent of total billed charges,75% of total billed charges for outpatient setting,25.49,70,,20.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.13,80,,23.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.82,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,100,,,Fee Schedule,100% of Custom Fee Schedule,32.77,90,,26.22,percent of total billed charges,90% of total billed charges for outpatient setting,8.09,32.77,
CPL-VANCOMYCIN PEAK,222019,CDM,300,RC,80202,HCPCS,Outpatient,,,60.93,54.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,51.72,84.88,,41.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.7,75,,36.56,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,80,,38.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.84,90,,43.87,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,54.84,
CPM KNEE DAILY USE,5100030,CDM,270,RC,E0935,HCPCS,Outpatient,,,54.08,54.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.86,70,,30.29,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,84.88,,36.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.04,50,,21.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.56,75,,32.45,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,70,,30.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.94,12.84,,5.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.26,80,,34.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.94,12.84,,5.55,percent of total billed charges,12.84% of total billed charges,6.94,12.84,,5.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.15,65,,28.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,35,,15.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.67,90,,38.94,percent of total billed charges,90% of total billed charges for outpatient setting,6.94,48.67,
CPM SOFTGOODS KIT,5150279,CDM,270,RC,,,Outpatient,,,147.04,147.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.93,70,,82.34,percent of total billed charges,70% of total billed charges for outpatient setting,124.81,84.88,,99.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.52,50,,58.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.28,75,,88.22,percent of total billed charges,75% of total billed charges for outpatient setting,102.93,70,,82.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,12.84,,15.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.63,80,,94.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,12.84,,15.1,percent of total billed charges,12.84% of total billed charges,18.88,12.84,,15.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.58,65,,76.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.46,35,,41.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.34,90,,105.87,percent of total billed charges,90% of total billed charges for outpatient setting,18.88,132.34,
CPT,1300055,CDM,410,RC,94667,HCPCS,Outpatient,,,198.34,198.34,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.84,70,,111.07,percent of total billed charges,70% of total billed charges for outpatient setting,168.35,84.88,,134.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.84,70,,111.07,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,25.47,12.84,,20.376,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.67,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,25.47,12.84,,20.38,percent of total billed charges,12.84% of total billed charges,25.47,12.84,,20.38,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.01,100,,,Fee Schedule,100% of Custom Fee Schedule,178.51,90,,142.81,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,217.24,
CREATININE,200155,CDM,300,RC,82565,HCPCS,Outpatient,,,23.04,20.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.28,75,,13.82,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,80,,14.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of Custom Fee Schedule,20.74,90,,16.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,20.74,
CREATININE,201120,CDM,300,RC,82565,HCPCS,Outpatient,,,23.04,20.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.28,75,,13.82,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,80,,14.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of Custom Fee Schedule,20.74,90,,16.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,20.74,
CREATININE CLEARANCE,220583,CDM,300,RC,82575,HCPCS,Outpatient,,,42.57,38.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.8,70,,23.84,percent of total billed charges,70% of total billed charges for outpatient setting,36.13,84.88,,28.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.93,75,,25.54,percent of total billed charges,75% of total billed charges for outpatient setting,29.8,70,,23.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.06,80,,27.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.92,100,,,Fee Schedule,100% of Custom Fee Schedule,38.31,90,,30.65,percent of total billed charges,90% of total billed charges for outpatient setting,9.46,38.31,
"CREATININE eGFR, NOVA STATSENSOR",201736,CDM,300,RC,82565,HCPCS,Outpatient,,,23.04,20.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.28,75,,13.82,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,80,,14.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of Custom Fee Schedule,20.74,90,,16.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,20.74,
CREATININE URINE  STAT TO CPL,222041,CDM,301,RC,82570,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
"CREATININE,RANDOM URINE,INCLUDE PROTEIN",220086,CDM,300,RC,82570,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
CREATININE;OTHER SOURCE,202564,CDM,301,RC,82570,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
CREO 6.5X35MM SCREW / 5119.1635,69161729,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
CREO CROSSLINK 38-50 / 1119.0039,69161885,CDM,278,RC,,,Outpatient,,,2450,2450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470,60,,1176,percent of total billed charges,60% of total Billed charges for outpatient setting,2079.56,84.88,,1663.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1837.5,75,,1470,percent of total billed charges,75% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,80,,1568,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2572.5,105,,2058,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.5,35,,686,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1470,60,,1176,percent of total billed charges,60% of total billed charges for outpatient setting,314.58,2572.5,
CREO CROSSLINK 48-60  1119.0046,69160839,CDM,278,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
CREO CROSSLINK 48-61  / 1119.0046,69161839,CDM,278,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
CREO ROD 100MM / 1119.7100,69161951,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 125MM /  1119.7125,69161884,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 35MM / 1119.7035,69161778,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 35MM / 1119.7150,70000031,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 40MM / 1119.7040,69161731,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 50MM / 1119.7050,69162062,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 55MM / 1119.7055,69162611,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 60MM / 1119.7060,69162184,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 65MM / 1119.7065,69161894,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 70MM / 1119.7070,69162342,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 75MM  1119.7075,69161838,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 80MM / 1119.7080,69161837,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO ROD 95MM  1119.7095,69162447,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
CREO SCREW 5.0X40MM / 5119.1440,69162032,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 5.0X45MM / 5119.1445,69162525,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 5.5  9.5X40MM / 5119.1940,69169477,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 5.5X45MM / 5119.1545,69161882,CDM,278,RC,,,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
CREO SCREW 5.5X50MM / 5119.1550,69162343,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 6.5X30MM / 5119.1630,69162583,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 6.5X40MM / 5119.1642,1567830,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
CREO SCREW 6.5X50MM / 5119.1650,69161836,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 6.5X50MM / 5119.1652,69162801,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 6.5X55MM / 5119.1655,69161893,CDM,278,RC,,,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
CREO SCREW 6.5X55MM / 5119.1657,69162802,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 6.5X60mm   5119.1660,69162740,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 7.5X30mm / 5119.1730,70000010,CDM,278,RC,,,Outpatient,,,2550,2550,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530,60,,1224,percent of total billed charges,60% of total Billed charges for outpatient setting,2164.44,84.88,,1731.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1912.5,75,,1530,percent of total billed charges,75% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,80,,1632,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2677.5,105,,2142,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.5,35,,714,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1530,60,,1224,percent of total billed charges,60% of total billed charges for outpatient setting,327.42,2677.5,
CREO SCREW 7.5X35mm   5119.1735,69161891,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 7.5X40mm   5119.1670,69161968,CDM,278,RC,,,Outpatient,,,2550,2550,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530,60,,1224,percent of total billed charges,60% of total Billed charges for outpatient setting,2164.44,84.88,,1731.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1912.5,75,,1530,percent of total billed charges,75% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,80,,1632,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2677.5,105,,2142,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.5,35,,714,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1530,60,,1224,percent of total billed charges,60% of total billed charges for outpatient setting,327.42,2677.5,
CREO SCREW 7.5X40mm   5119.1740,69161908,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 7.5X45MM / 5119.1745,69161883,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
CREO SCREW 7.5X50MM / 5119.1750,69161892,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
CREO SCREW 7.5X55mm   5119.1755,69162042,CDM,278,RC,,,Outpatient,,,2550,2550,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530,60,,1224,percent of total billed charges,60% of total Billed charges for outpatient setting,2164.44,84.88,,1731.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1912.5,75,,1530,percent of total billed charges,75% of total billed charges for outpatient setting,1275,50,,1020,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,80,,1632,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,327.42,12.84,,261.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2677.5,105,,2142,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.5,35,,714,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1530,60,,1224,percent of total billed charges,60% of total billed charges for outpatient setting,327.42,2677.5,
CREO SET SCREW / 1119.0010,69162246,CDM,278,RC,,,Outpatient,,,300,300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,60,,144,percent of total billed charges,60% of total Billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,300,65,,240,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,60,,144,percent of total billed charges,60% of total billed charges for outpatient setting,38.52,300,
CREON-10: CAP,3303022,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CRESCENT QUICKPASS LASSO / AR-6068C,71000527,CDM,272,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,570.39,84.88,,456.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,336,50,,268.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504,75,,403.2,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,80,,430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.8,65,,349.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,35,,188.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,90,,483.84,percent of total billed charges,90% of total billed charges for outpatient setting,86.28,604.8,
CRESCENT SUTURELASSO SD / AR-4068C,71000628,CDM,272,RC,,,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.2,65,,305.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.2,90,,423.36,percent of total billed charges,90% of total billed charges for outpatient setting,75.5,529.2,
CROMOLYN SOD (INTAL) INH : 8.1GM,3300875,CDM,259,RC,,,Outpatient,,,145.3,145.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.71,70,,81.37,percent of total billed charges,70% of total billed charges for outpatient setting,123.33,84.88,,98.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.65,50,,58.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.98,75,,87.18,percent of total billed charges,75% of total billed charges for outpatient setting,101.71,70,,81.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.66,12.84,,14.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.24,80,,92.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.66,12.84,,14.93,percent of total billed charges,12.84% of total billed charges,18.66,12.84,,14.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.45,65,,75.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.86,35,,40.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.77,90,,104.62,percent of total billed charges,90% of total billed charges for outpatient setting,18.66,130.77,
CROMOLYN SOD (INTAL) INH SOLN:2 ML,3302699,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
CROSSMATCH IGG,1000205,CDM,302,RC,86922,HCPCS,Outpatient,,,132.14,118.93,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,92.5,70,,74,percent of total billed charges,70% of total billed charges for outpatient setting,112.16,84.88,,89.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.11,75,,79.29,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,70,,74,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,105.71,80,,84.57,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.56,100,,,Fee Schedule,100% of Custom Fee Schedule,118.93,90,,95.14,percent of total billed charges,90% of total billed charges for outpatient setting,37.56,287.34,
CRP (TO LABCORP),201055,CDM,300,RC,86140,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
"CRP, CARDIAC HIGH SENSITIVITY",220387,CDM,300,RC,86141,HCPCS,Outpatient,,,58.28,52.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,70,,32.64,percent of total billed charges,70% of total billed charges for outpatient setting,49.47,84.88,,39.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.71,75,,34.97,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,70,,32.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.62,80,,37.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,52.45,90,,41.96,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,52.45,
CRUTCHES ADULT ALUM TALL / CA901TL,5050197,CDM,270,RC,,,Outpatient,,,102.2,102.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.54,70,,57.23,percent of total billed charges,70% of total billed charges for outpatient setting,86.75,84.88,,69.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.1,50,,40.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.65,75,,61.32,percent of total billed charges,75% of total billed charges for outpatient setting,71.54,70,,57.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,12.84,,10.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.76,80,,65.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,13.12,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.43,65,,53.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.77,35,,28.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.98,90,,73.58,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,91.98,
CRUTCHES ADULT ALUMINUM / CA901AD,5050196,CDM,270,RC,,,Outpatient,,,93.45,93.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.42,70,,52.34,percent of total billed charges,70% of total billed charges for outpatient setting,79.32,84.88,,63.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.73,50,,37.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.09,75,,56.07,percent of total billed charges,75% of total billed charges for outpatient setting,65.42,70,,52.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.76,80,,59.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,12,12.84,,9.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.74,65,,48.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.71,35,,26.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.11,90,,67.29,percent of total billed charges,90% of total billed charges for outpatient setting,12,84.11,
CRYOABLATION PROBE,69160891,CDM,278,RC,C2618,HCPCS,Outpatient,,,170.44,170.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.26,60,,81.81,percent of total billed charges,60% of total Billed charges for outpatient setting,144.67,84.88,,115.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.83,75,,102.26,percent of total billed charges,75% of total billed charges for outpatient setting,85.22,50,,68.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,12.84,,17.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.35,80,,109.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,21.88,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,170.44,65,,136.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,35,,47.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.26,60,,81.81,percent of total billed charges,60% of total billed charges for outpatient setting,21.88,170.44,
CRYOFIBRINOGEN,200911,CDM,300,RC,82585,HCPCS,Outpatient,,,63.63,57.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,54.01,84.88,,43.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.67,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.72,75,,38.18,percent of total billed charges,75% of total billed charges for outpatient setting,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.9,80,,40.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.28,100,,,Fee Schedule,100% of Custom Fee Schedule,57.27,90,,45.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.04,57.27,
CRYOGLOBULIN,220139,CDM,301,RC,82595,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,26.21,
CRYOTHERAPY PROSTATE PROCEDURE,69160871,CDM,360,RC,,,Outpatient,,,11930.35,11930.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8351.25,70,,6681,percent of total billed charges,70% of total billed charges for outpatient setting,10126.48,84.88,,8101.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,5965.18,50,,4772.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8947.76,75,,7158.21,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.86,12.84,,1225.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9544.28,80,,7635.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.86,12.84,,1225.49,percent of total billed charges,12.84% of total billed charges,1531.86,12.84,,1225.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4175.62,35,,3340.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10737.32,90,,8589.86,percent of total billed charges,90% of total billed charges for outpatient setting,1531.86,10737.32,
"CRYPTOCOCCAL AG, SERUM",220848,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
"CRYPTOCOCCAL ANTIGEN, CSF",202374,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
"CRYPTOSPORIDIUM, STOOL",201535,CDM,300,RC,87328,HCPCS,Outpatient,,,62.19,55.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,52.79,84.88,,42.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.64,75,,37.31,percent of total billed charges,75% of total billed charges for outpatient setting,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.75,80,,39.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,55.97,90,,44.78,percent of total billed charges,90% of total billed charges for outpatient setting,13.82,55.97,
CRYSTAL ANALYSIS,220866,CDM,300,RC,89060,HCPCS,Outpatient,,,32.99,29.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.09,70,,18.47,percent of total billed charges,70% of total billed charges for outpatient setting,28,84.88,,22.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.74,75,,19.79,percent of total billed charges,75% of total billed charges for outpatient setting,23.09,70,,18.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.39,80,,21.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,100,,,Fee Schedule,100% of Custom Fee Schedule,29.69,90,,23.75,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,29.69,
CSF GLUCOSE,201135,CDM,300,RC,82945,HCPCS,Outpatient,,,17.69,15.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,84.88,,12.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.27,75,,10.62,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,80,,11.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of Custom Fee Schedule,15.92,90,,12.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,15.92,
CSF PROTEIN,200720,CDM,300,RC,84155,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
CSF VDRL,200950,CDM,300,RC,86592,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
C-SPINE 2 OR 3 VWS,2400210,CDM,320,RC,72040,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
C-SPINE 4 OR 5 VWS,2400215,CDM,320,RC,72050,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
C-SPINE 6 OR MORE VIEWS,2400216,CDM,320,RC,72052,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
C-SPINE W/OBL/F/E (4 OR 5 VWS),2400220,CDM,320,RC,72050,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
CT 3D RENDERING/INDEP WORKSTA,2300209,CDM,350,RC,76377,HCPCS,Outpatient,,,374.96,281.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.47,70,,209.98,percent of total billed charges,70% of total billed charges for outpatient setting,318.27,84.88,,254.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.22,75,,224.98,percent of total billed charges,75% of total billed charges for outpatient setting,262.47,70,,209.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.14,12.84,,38.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.97,80,,239.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.14,12.84,,38.51,percent of total billed charges,12.84% of total billed charges,48.14,12.84,,38.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.46,90,,269.97,percent of total billed charges,90% of total billed charges for outpatient setting,48.14,1550,
CT ABD EXACT SCIENCES PROTOCOL,2300330,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ABD PELV  TRIPLE PHASE W/WO CONTRAST,2300319,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ABD PELV  W/3D UROGRAM W/WO CONTRAST,2300318,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ABD PELVIS W/ CONTRAST,2300174,CDM,352,RC,74177,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ABD PELVIS W/O CONTRAST,2300173,CDM,352,RC,74176,HCPCS,Outpatient,,,2290.05,1717.54,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,287.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2061.05,
CT ABD PELVIS W/WO CONTRAST,2300172,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ABD TRIPLE PHASE W/ WO CONTRAST,2300320,CDM,352,RC,74170,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ABD W/CONTRAST,2300165,CDM,352,RC,74160,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ABD W/O CONTRAST,2300160,CDM,352,RC,74150,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT ABD W/WO CONTRAST,2300170,CDM,352,RC,74170,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ANKLE LT W/CONTRAST,2300113,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ANKLE LT W/O CONTRAST,2300104,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ANKLE LT W/WO CONTRAST,2300114,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ANKLE RT W/CONTRAST,2300111,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ANKLE RT W/O CONTRAST,2300103,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ANKLE RT W/WO CONTRAST,2300112,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT BILAT LOW EXT W/O CONTRAST,2300121,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT CALCIUM SCORING,2300163,CDM,350,RC,75571,HCPCS,Outpatient,,,2290.05,1717.54,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.3,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,26.3,2061.05,
CT CHEST W/CONTRAST,2300060,CDM,352,RC,71260,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT CHEST W/CONTRAST**,2310060,CDM,352,RC,71260,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT CHEST W/O CONTRAST,2300055,CDM,352,RC,71250,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT CHEST W/O LOW DOSE SCREENING W/O CONT,2300316,CDM,352,RC,71271,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT CHEST W/OUT CONTRAST**,2310055,CDM,352,RC,71250,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT CHEST W/WO CONTRAST,2300065,CDM,352,RC,71270,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT CHEST W/WO CONTRAST**,2310065,CDM,352,RC,71270,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT C-SPINE W/CONTRAST,2300080,CDM,352,RC,72126,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT C-SPINE W/O CONTRAST,2300075,CDM,352,RC,72125,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT C-SPINE W/WO CONTRAST,2300076,CDM,352,RC,72127,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT CYSTROGRAM  PELVIS W/ CONTRAST,2300321,CDM,352,RC,72193,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ELBOW LT  W/CONTRAST,2300186,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ELBOW LT W/O CONTRAST,2300187,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ELBOW LT W/WO CONTRAST,2300188,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ELBOW RT  W/CONTRAST,2300183,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ELBOW RT W/O CONTRAST,2300184,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT ELBOW RT W/WO CONTRAST,2300185,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT FEMUR LT W/CONTRAST,2300145,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FEMUR LT W/O CONTRAST,2300189,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FEMUR LT W/WO CONTRAST,2300146,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FEMUR RT  W/WO CONTRAST,2300144,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FEMUR RT W/CONTRAST,2300143,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FEMUR RT W/O CONTRAST,2300147,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT LT  W/WO CONTRAST,2300118,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT LT W/CONTRAST,2300117,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT LT W/O CONTRAST,2300151,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT RT  W/WO CONTRAST,2300116,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT RT W/CONTRAST,2300115,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOOT RT W/O CONTRAST,2300149,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOREARM LT W/CONTRAST,2300227,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOREARM LT W/O CONTRAST,2300228,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOREARM LT W/WO CONTRAST,2300229,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT FOREARM RT W/CONTRAST,2300224,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOREARM RT W/O CONTRAST,2300225,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT FOREARM RT W/WO CONTRAST,2300226,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT GUIDED NEEDLE PLACEMENT,2300011,CDM,350,RC,77012,HCPCS,Outpatient,,,2290.05,1717.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HAND LT W/CONTRAST,2300199,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HAND LT W/O CONTRAST,2300201,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HAND LT W/WO CONTRAST,2300202,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT HAND RT W/CONTRAST,2300196,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HAND RT W/O CONTRAST,2300203,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HAND RT W/WO CONTRAST,2300198,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HEAD W/ CONTRAST,2300010,CDM,351,RC,70460,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT HEAD W/O CONTRAST,2300005,CDM,351,RC,70450,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT HEAD W/O MRgFUS PROTOCOL W/O CONTRAST,2300311,CDM,351,RC,70450,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT HEAD W/O STRYKER CMF IMP W/O CONTRAST,2300310,CDM,351,RC,70450,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT HEAD W/WO CONTRAST,2300015,CDM,351,RC,70470,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT HEMATURIA PROTOCOL,2300175,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP LT  W/ CONTRAST,2300128,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP LT  W/WO CONTRAST,2300129,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP LT MAKO PROTOCOL W/O CONTRAST,2300322,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP LT W/O CONTRAST,2300123,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP RT  W/WO CONTRAST,2300127,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP RT MAKO PROTOCOL  W/O CONTRAST,2300323,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP RT W/CONTRAST,2300126,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HIP RT W/O CONTRAST,2300122,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HUMERUS LT  W/CONTRAST,2300180,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HUMERUS LT W/O CONTRAST,2300181,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HUMERUS LT W/WO CONTRAST,2300182,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT HUMERUS RT  W/CONTRAST,2300177,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HUMERUS RT W/O CONTRAST,2300178,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT HUMERUS RT W/WO CONTRAST,2300179,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT KNEE LT BIOMET PROTOCOL  W/O CONTRAST,2300314,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE LT MAKO W/O CONTRAST,2300324,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE LT W/CONTRAST,2300108,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE LT W/O CONTRAST,2300102,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE LT W/WO CONTRAST,2300109,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE RT BIOMET PROTOCOL  W/O CONTRAST,2300315,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE RT MAKO PROTOCOL W/O CONTRAST,2300325,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE RT W/CONTRAST,2300106,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE RT W/O CONTRAST,2300101,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT KNEE RT W/WO CONTRAST,2300107,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT LDCT FOR LUNG CANCER SCREENING,2300056,CDM,352,RC,71271,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT LOW EXT W/ CONTRAST,2300125,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT LOW EXT W/O CONTRAST,2300120,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT LOW EXT W/WO CONTRAST,2300130,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT LOWER EXT LT VENOGRAM W/ CONTRAST,2300328,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT LOWER EXT RT VENOGRAM W/ CONTRAST,2300329,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT LOWER JAW,2300016,CDM,351,RC,70486,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT L-SPINE W/ W/O CONTRAST,2300119,CDM,352,RC,72133,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT L-SPINE W/CONTRAST,2300110,CDM,352,RC,72132,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT L-SPINE W/O CONTRAST,2300105,CDM,352,RC,72131,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT LTD/LOC FOLLOW-UP,2300210,CDM,350,RC,76380,HCPCS,Outpatient,,,2290.05,1717.54,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.64,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,72.48,2061.05,
CT MAX SINUS W/O CONTRAST,2300025,CDM,351,RC,70486,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT MAXIFACE W/ CONTRAST,2300030,CDM,351,RC,70487,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT MAXIFACE W/WO CONTRAST,2300035,CDM,351,RC,70488,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT NECK W/CONTRAST,2300040,CDM,351,RC,70491,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT NECK W/O CONTRAST,2300039,CDM,351,RC,70490,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT NECK W/WO CONTRAST,2300041,CDM,351,RC,70492,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ORBITS W/CONTRAST,2300021,CDM,351,RC,70481,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT ORBITS W/O CONTRAST,2300022,CDM,351,RC,70480,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT ORBITS W/WO CONTRAST,2300023,CDM,351,RC,70482,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT PELVIS W/ CONTRAST,2300161,CDM,352,RC,72193,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT PELVIS W/O CONTRAST,2300155,CDM,352,RC,72192,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT PELVIS W/WO CONTRAST,2300162,CDM,352,RC,72194,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT SCANOGRAM GROWTH STUDY,2300240,CDM,359,RC,77073,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,68.22,2061.05,
CT SHLDR LT BIOMET PROTOCOL W/O CONTRAST,2300312,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHLDR RT BIOMET PROTOCOL W/O CONTRAST,2300313,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER LT W/CONTRAST,2300156,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER LT W/O CONTRAST,2300157,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER LT W/WO CONTRAST,2300158,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER RT  W/CONTRAST,2300152,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER RT  W/O CONTRAST,2300153,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SHOULDER RT  W/WO CONTRAST,2300154,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT SINUSES W/O CONTRAST,2300205,CDM,351,RC,70486,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT SPIRAL ABDOMEN,2300200,CDM,352,RC,74176,HCPCS,Outpatient,,,2290.05,1717.54,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,287.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2061.05,
CT TEMPORAL BONES W/CONTRAST,2300020,CDM,351,RC,70481,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT TEMPORAL BONES W/O CONTRAST,2300019,CDM,351,RC,70480,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT TEMPORAL BONES W/WO CONTRAST,2300018,CDM,351,RC,70482,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT TIB-FIB LT W/CONTRAST,2300167,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TIB-FIB LT W/O CONTRAST,2300176,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TIB-FIB LT W/WO CONTRAST,2300168,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TIB-FIB RT W/CONTRAST,2300164,CDM,359,RC,73701,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TIB-FIB RT W/O CONTRAST,2300169,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TIB-FIB RT W/WO CONTRAST,2300166,CDM,359,RC,73702,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT TMJ W/O CONTRAST,2300026,CDM,351,RC,70336,HCPCS,Outpatient,,,2290.05,1717.54,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2061.05,
CT T-SPINE W/CONTRAST,2300095,CDM,352,RC,72129,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT T-SPINE W/O CONTRAST,2300090,CDM,352,RC,72128,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT T-SPINE W/WO CONTRAST,2300100,CDM,352,RC,72130,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT UP EXT LT VENOGRAM W/ CONTRAST,2300326,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT UP EXT RT VENOGRAM W/ CONTRAST,2300327,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT UP EXT W/O CONTRAST,2300140,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
CT UP EXT W/WO CONTRAST,2300150,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT VENOGRAM OF PELVIS WITH CONTRAST,2300317,CDM,352,RC,72193,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT WRIST LT  W/CONTRAST,2300193,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT WRIST LT W/O CONTRAST,2300194,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT WRIST LT W/WO CONTRAST,2300195,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT WRIST RT  W/CONTRAST,2300190,CDM,359,RC,73201,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT WRIST RT W/O CONTRAST,2300191,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CT WRIST RT W/WO CONTRAST,2300192,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CT**CALCIUM SCORING,2310163,CDM,350,RC,76497,HCPCS,Outpatient,,,2290.05,1717.54,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.64,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,72.48,2061.05,
CTA ABD/PELV STENT GRAFT PROTOCOL W/WO,2300347,CDM,350,RC,74174,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA ABDOMEN,2300138,CDM,350,RC,74175,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA ABDOMEN / PELVIS,2300142,CDM,350,RC,74174,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA ABDOMEN STENT GRAFT PROTOCOL W/WO,2300349,CDM,350,RC,74175,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA AORTO-ILIOF RO W/STENT GRF PRO W/WO,2300348,CDM,350,RC,75635,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA AORTO-ILIOFEMORAL RUNOFF,2300137,CDM,350,RC,75635,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA CHEST,2300133,CDM,350,RC,71275,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA CHEST PE PROTOCOL W/ CONTRAST,2300345,CDM,350,RC,71275,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA CHEST STENT GRAFT PROTOCOL W/WO,2300346,CDM,350,RC,71275,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA HEAD,2300131,CDM,350,RC,70496,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA HEART CORONARY ARTERIES AND BYPASS G,2300232,CDM,350,RC,75574,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,264.1,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA HEART W/CONTRAST,2300230,CDM,350,RC,75572,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,264.1,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA HEART W/CONTRAST CONGENITAL HEART DI,2300231,CDM,350,RC,75573,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,264.1,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA LOWER EXTREMITY,2300136,CDM,350,RC,73706,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA LT LOWER EXTREMITY W/ CONTRAST,2300343,CDM,350,RC,73706,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA LT UPPER EXTREMITY W/CONTRAST,2300341,CDM,350,RC,73206,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA NECK,2300132,CDM,350,RC,70498,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA NECK WITH CONTRAST,2300141,CDM,350,RC,70498,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA PELVIS,2300134,CDM,350,RC,72191,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA RT LOWER EXTREMITY W/ CONTRAST,2300344,CDM,350,RC,73706,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA RT UPPER EXTREMITY W/CONTRAST,2300342,CDM,350,RC,73206,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTA UPPER EXT TOS PROTOCOL WITH AND WITH,2300340,CDM,350,RC,73206,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
CTA UPPER EXTREMITY,2300135,CDM,350,RC,73206,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
C-TERMINAL TELOPEPTIDE CTX,220892,CDM,302,RC,82523,HCPCS,Outpatient,,,84.06,75.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,71.35,84.88,,57.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,63.05,75,,50.44,percent of total billed charges,75% of total billed charges for outpatient setting,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.25,80,,53.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.45,100,,,Fee Schedule,100% of Custom Fee Schedule,75.65,90,,60.52,percent of total billed charges,90% of total billed charges for outpatient setting,18.68,75.65,
CTV HEAD,2300268,CDM,350,RC,74174,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CTV NECK,2300269,CDM,350,RC,74174,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
CULT FECES  ISO & EXAM,201518,CDM,306,RC,87045,HCPCS,Outpatient,,,42.48,38.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,36.06,84.88,,28.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.86,75,,25.49,percent of total billed charges,75% of total billed charges for outpatient setting,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,80,,27.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,38.23,90,,30.58,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,38.23,
CULT FECES  ISO & EXAM EA PLATE,201519,CDM,306,RC,87046,HCPCS,Outpatient,,,42.48,38.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,36.06,84.88,,28.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.86,75,,25.49,percent of total billed charges,75% of total billed charges for outpatient setting,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,80,,27.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,38.23,90,,30.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.56,38.23,
CULTURE AEROBIC ROUTINE,222022,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE ANAEROBIC,222023,CDM,300,RC,87075,HCPCS,Outpatient,,,42.62,38.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,84.88,,28.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.97,75,,25.58,percent of total billed charges,75% of total billed charges for outpatient setting,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,80,,27.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of Custom Fee Schedule,38.36,90,,30.69,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,38.36,
CULTURE ANAEROBIC 2 WEEKS,222037,CDM,300,RC,87075,HCPCS,Outpatient,,,45,40.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,70,,25.2,percent of total billed charges,70% of total billed charges for outpatient setting,38.2,84.88,,30.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,33.75,75,,27,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,70,,25.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,80,,28.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of Custom Fee Schedule,40.5,90,,32.4,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,40.5,
CULTURE BLOOD AERO/ANA,222024,CDM,300,RC,87040,HCPCS,Outpatient,,,46.44,41.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,39.42,84.88,,31.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.83,75,,27.86,percent of total billed charges,75% of total billed charges for outpatient setting,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.15,80,,29.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.07,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of Custom Fee Schedule,41.8,90,,33.44,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,41.8,
CULTURE CHLAMYDIA ANY SOURCE,220066,CDM,310,RC,87110,HCPCS,Outpatient,,,88.2,79.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,74.86,84.88,,59.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.15,75,,52.92,percent of total billed charges,75% of total billed charges for outpatient setting,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,80,,56.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.15,100,,,Fee Schedule,100% of Custom Fee Schedule,79.38,90,,63.5,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,79.38,
CULTURE GENITAL,220576,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE LOWER RESP.SPUTUM,222025,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE NASAL,220371,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE RESPIRATORY,222028,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE SINUS,222026,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE STOOL,222004,CDM,300,RC,87045,HCPCS,Outpatient,,,42.48,38.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,36.06,84.88,,28.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.86,75,,25.49,percent of total billed charges,75% of total billed charges for outpatient setting,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,80,,27.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,38.23,90,,30.58,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,38.23,
CULTURE THROAT,220580,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CULTURE URINE,222029,CDM,300,RC,87086,HCPCS,Outpatient,,,36.32,32.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.42,70,,20.34,percent of total billed charges,70% of total billed charges for outpatient setting,30.83,84.88,,24.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.24,75,,21.79,percent of total billed charges,75% of total billed charges for outpatient setting,25.42,70,,20.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,80,,23.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of Custom Fee Schedule,32.69,90,,26.15,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,32.69,
"CULTURE,SPUTUM",222027,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
CUP 38MM HUM SHOULDER / 1307-38-706,335754,CDM,278,RC,C1713,HCPCS,Outpatient,,,2975,2975,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1785,60,,1428,percent of total billed charges,60% of total Billed charges for outpatient setting,2525.18,84.88,,2020.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2231.25,75,,1785,percent of total billed charges,75% of total billed charges for outpatient setting,1487.5,50,,1190,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.99,12.84,,305.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2380,80,,1904,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.99,12.84,,305.59,percent of total billed charges,12.84% of total billed charges,381.99,12.84,,305.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3123.75,105,,2499,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.25,35,,833,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1785,60,,1428,percent of total billed charges,60% of total billed charges for outpatient setting,381.99,3123.75,
CURETTES CEMENT / 5049-53,69159678,CDM,270,RC,,,Outpatient,,,128.4,128.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.88,70,,71.9,percent of total billed charges,70% of total billed charges for outpatient setting,108.99,84.88,,87.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.2,50,,51.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.3,75,,77.04,percent of total billed charges,75% of total billed charges for outpatient setting,89.88,70,,71.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,12.84,,13.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,80,,82.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,12.84,,13.19,percent of total billed charges,12.84% of total billed charges,16.49,12.84,,13.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.46,65,,66.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,35,,35.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,115.56,90,,92.45,percent of total billed charges,90% of total billed charges for outpatient setting,16.49,115.56,
CURI STRIP 0.25IN 3IN / 9892,5150121,CDM,272,RC,,,Outpatient,,,5.22,5.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,70,,2.92,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,84.88,,3.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.61,50,,2.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.92,75,,3.14,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,70,,2.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.18,80,,3.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.39,65,,2.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,35,,1.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.7,90,,3.76,percent of total billed charges,90% of total billed charges for outpatient setting,0.67,4.7,
CUSTOM EPIDURAL PACK,69159047,CDM,272,RC,,,Outpatient,,,154.93,154.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.45,70,,86.76,percent of total billed charges,70% of total billed charges for outpatient setting,131.5,84.88,,105.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.47,50,,61.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.2,75,,92.96,percent of total billed charges,75% of total billed charges for outpatient setting,108.45,70,,86.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.89,12.84,,15.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.94,80,,99.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.89,12.84,,15.91,percent of total billed charges,12.84% of total billed charges,19.89,12.84,,15.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.7,65,,80.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.23,35,,43.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.44,90,,111.55,percent of total billed charges,90% of total billed charges for outpatient setting,19.89,139.44,
CUT FORCEP HALO PKS / HACF0533,69160880,CDM,272,RC,,,Outpatient,,,2037.22,2037.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1426.05,70,,1140.84,percent of total billed charges,70% of total billed charges for outpatient setting,1729.19,84.88,,1383.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,1018.61,50,,814.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1527.92,75,,1222.34,percent of total billed charges,75% of total billed charges for outpatient setting,1426.05,70,,1140.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.58,12.84,,209.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.78,80,,1303.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.58,12.84,,209.26,percent of total billed charges,12.84% of total billed charges,261.58,12.84,,209.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1324.19,65,,1059.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.03,35,,570.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1833.5,90,,1466.8,percent of total billed charges,90% of total billed charges for outpatient setting,261.58,1833.5,
CUTTER 45MM-BLUE/ATB45,6152230,CDM,272,RC,,,Outpatient,,,1453.43,1453.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1017.4,70,,813.92,percent of total billed charges,70% of total billed charges for outpatient setting,1233.67,84.88,,986.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,726.72,50,,581.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090.07,75,,872.06,percent of total billed charges,75% of total billed charges for outpatient setting,1017.4,70,,813.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.62,12.84,,149.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.74,80,,930.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.62,12.84,,149.3,percent of total billed charges,12.84% of total billed charges,186.62,12.84,,149.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,944.73,65,,755.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.7,35,,406.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1308.09,90,,1046.47,percent of total billed charges,90% of total billed charges for outpatient setting,186.62,1308.09,
CUTTER 75MM/TLC75,6152233,CDM,272,RC,,,Outpatient,,,669.22,669.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.45,70,,374.76,percent of total billed charges,70% of total billed charges for outpatient setting,568.03,84.88,,454.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,334.61,50,,267.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.92,75,,401.54,percent of total billed charges,75% of total billed charges for outpatient setting,468.45,70,,374.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.93,12.84,,68.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.38,80,,428.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.93,12.84,,68.74,percent of total billed charges,12.84% of total billed charges,85.93,12.84,,68.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,434.99,65,,347.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.23,35,,187.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,602.3,90,,481.84,percent of total billed charges,90% of total billed charges for outpatient setting,85.93,602.3,
CUTTER LINEAR 55MM / TLC55,6150267,CDM,272,RC,,,Outpatient,,,480.62,480.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.43,70,,269.14,percent of total billed charges,70% of total billed charges for outpatient setting,407.95,84.88,,326.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.31,50,,192.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.47,75,,288.38,percent of total billed charges,75% of total billed charges for outpatient setting,336.43,70,,269.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.71,12.84,,49.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.5,80,,307.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.71,12.84,,49.37,percent of total billed charges,12.84% of total billed charges,61.71,12.84,,49.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,312.4,65,,249.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.22,35,,134.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,432.56,90,,346.05,percent of total billed charges,90% of total billed charges for outpatient setting,61.71,432.56,
CUTTER RELOAD 45MM-BLUE/6R45B,69160368,CDM,272,RC,,,Outpatient,,,526.04,526.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,446.5,84.88,,357.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,263.02,50,,210.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.53,75,,315.62,percent of total billed charges,75% of total billed charges for outpatient setting,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.83,80,,336.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,341.93,65,,273.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.11,35,,147.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.44,90,,378.75,percent of total billed charges,90% of total billed charges for outpatient setting,67.54,473.44,
CUTTER RELOAD 45MM-GREEN/TR45G,69159684,CDM,272,RC,,,Outpatient,,,526.04,526.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,446.5,84.88,,357.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,263.02,50,,210.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.53,75,,315.62,percent of total billed charges,75% of total billed charges for outpatient setting,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.83,80,,336.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,341.93,65,,273.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.11,35,,147.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.44,90,,378.75,percent of total billed charges,90% of total billed charges for outpatient setting,67.54,473.44,
CUTTER RELOAD 45MM-WHITE/TR45W,6152232,CDM,272,RC,,,Outpatient,,,526.04,526.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,446.5,84.88,,357.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,263.02,50,,210.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.53,75,,315.62,percent of total billed charges,75% of total billed charges for outpatient setting,368.23,70,,294.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.83,80,,336.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,67.54,12.84,,54.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,341.93,65,,273.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.11,35,,147.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.44,90,,378.75,percent of total billed charges,90% of total billed charges for outpatient setting,67.54,473.44,
CUTTER RELOAD 75MM / TCR75,6152234,CDM,272,RC,,,Outpatient,,,281.19,281.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,70,,157.46,percent of total billed charges,70% of total billed charges for outpatient setting,238.67,84.88,,190.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,140.6,50,,112.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.89,75,,168.71,percent of total billed charges,75% of total billed charges for outpatient setting,196.83,70,,157.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.1,12.84,,28.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.95,80,,179.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.1,12.84,,28.88,percent of total billed charges,12.84% of total billed charges,36.1,12.84,,28.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,182.77,65,,146.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,35,,78.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,253.07,90,,202.46,percent of total billed charges,90% of total billed charges for outpatient setting,36.1,253.07,
CV ISE LINEARITY SET 5X5ML / K726M-5,70000000,CDM,255,RC,,,Outpatient,,,110.46,110.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,93.76,84.88,,75.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.23,50,,44.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.85,75,,66.28,percent of total billed charges,75% of total billed charges for outpatient setting,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.37,80,,70.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.8,65,,57.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,35,,30.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.41,90,,79.53,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,99.41,
CYANOCOBALAMIN 1000 MCG/ML (B12):INJ,3303168,CDM,250,RC,,,Outpatient,,,51.91,51.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,70,,29.07,percent of total billed charges,70% of total billed charges for outpatient setting,44.06,84.88,,35.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.96,50,,20.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.93,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.34,70,,29.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.67,12.84,,5.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.53,80,,33.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.67,12.84,,5.34,percent of total billed charges,12.84% of total billed charges,6.67,12.84,,5.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.74,65,,26.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.17,35,,14.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.72,90,,37.38,percent of total billed charges,90% of total billed charges for outpatient setting,6.67,46.72,
CYCLOBENZAPRINE (FLEXERIL) TAB :10MG,3300876,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CYCLOBENZAPRINE (genFLEXERIL) 10MG TAB,3300877,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
CYCLOPENTOLATE (CYCLGYL) OPTH SOL 1%:5ML,3300879,CDM,259,RC,,,Outpatient,,,48.73,48.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.11,70,,27.29,percent of total billed charges,70% of total billed charges for outpatient setting,41.36,84.88,,33.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.37,50,,19.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.55,75,,29.24,percent of total billed charges,75% of total billed charges for outpatient setting,34.11,70,,27.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.26,12.84,,5.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.98,80,,31.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.26,12.84,,5.01,percent of total billed charges,12.84% of total billed charges,6.26,12.84,,5.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.67,65,,25.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.06,35,,13.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.86,90,,35.09,percent of total billed charges,90% of total billed charges for outpatient setting,6.26,43.86,
CYCLOPENTOLATE 1%(genCYCLOGYL)OPHTH 2ML,3300881,CDM,250,RC,,,Outpatient,,,80.5,80.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.35,70,,45.08,percent of total billed charges,70% of total billed charges for outpatient setting,68.33,84.88,,54.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.25,50,,32.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.38,75,,48.3,percent of total billed charges,75% of total billed charges for outpatient setting,56.35,70,,45.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,12.84,,8.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,80,,51.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,12.84,,8.27,percent of total billed charges,12.84% of total billed charges,10.34,12.84,,8.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.33,65,,41.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.18,35,,22.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.45,90,,57.96,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,72.45,
CYCLOPENTOLATE 2%(genCYCLOGYL)OPHTH 5ML,3309973,CDM,250,RC,,,Outpatient,,,129.78,129.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,110.16,84.88,,88.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.89,50,,51.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.34,75,,77.87,percent of total billed charges,75% of total billed charges for outpatient setting,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,80,,83.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.36,65,,67.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.42,35,,36.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.8,90,,93.44,percent of total billed charges,90% of total billed charges for outpatient setting,16.66,116.8,
CYCLOPENTOLATE(CYCLOGEYL)OPTH SOL 2%:5ML,3300880,CDM,259,RC,,,Outpatient,,,69.28,69.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.5,70,,38.8,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,84.88,,47.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.64,50,,27.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.96,75,,41.57,percent of total billed charges,75% of total billed charges for outpatient setting,48.5,70,,38.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.42,80,,44.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.03,65,,36.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.25,35,,19.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.35,90,,49.88,percent of total billed charges,90% of total billed charges for outpatient setting,8.9,62.35,
CYCLOPETLATE (CYCLOGY)OPTH SOL 1% :2ML,3300878,CDM,259,RC,,,Outpatient,,,11.74,11.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,70,,6.58,percent of total billed charges,70% of total billed charges for outpatient setting,9.96,84.88,,7.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.87,50,,4.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.81,75,,7.05,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,70,,6.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,80,,7.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.63,65,,6.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,35,,3.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.57,90,,8.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.51,10.57,
CYCLOSPORIN,201259,CDM,300,RC,80158,HCPCS,Outpatient,,,81.23,73.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.86,70,,45.49,percent of total billed charges,70% of total billed charges for outpatient setting,68.95,84.88,,55.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.92,75,,48.74,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,70,,45.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.98,80,,51.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,73.11,90,,58.49,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,73.11,
CYCLOSPORINE (NEORAL) CAP : 100 MG,3300883,CDM,259,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
CYCLOSPORINE (NEORAL) CAP : 25 MG,3300882,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CYPROHEPTADINE (PERIACTIN) TAB : 4 MG,3300884,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
CYSTOGRAFIN : 300ML,3302235,CDM,255,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
CYSTOGRAFIN SOLN 30% 100ML,3302240,CDM,255,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
CYSTOGRAM 3+ VWS,2400760,CDM,320,RC,74430,HCPCS,Outpatient,,,1131.44,848.58,,527.98,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,960.37,84.88,,768.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,848.58,75,,678.86,percent of total billed charges,75% of total billed charges for outpatient setting,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,560.98,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,145.28,12.84,,116.224,percent of total billed charges,12.84% of total billed charges,577.48,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,905.15,80,,724.12,percent of total billed charges,80% of total billed charges for outpatient setting,461.98,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,1018.3,90,,814.64,percent of total billed charges,90% of total billed charges for outpatient setting,128,1018.3,
CYSTOGRAPHIN 300ML,245002,CDM,250,RC,,,Outpatient,,,129.78,129.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,110.16,84.88,,88.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.89,50,,51.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.34,75,,77.87,percent of total billed charges,75% of total billed charges for outpatient setting,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,80,,83.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.36,65,,67.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.42,35,,36.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.8,90,,93.44,percent of total billed charges,90% of total billed charges for outpatient setting,16.66,116.8,
CYSTOURETHRO RETRO,2400770,CDM,320,RC,74450,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
CYSTOURETHRO VOIDING,2400775,CDM,320,RC,74455,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
CYTO CONSTITUTIONAL MICROARRAY ANALYSIS,201257,CDM,301,RC,81228,HCPCS,Outpatient,,,2250,2025,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,70,,1260,percent of total billed charges,70% of total billed charges for outpatient setting,1909.8,84.88,,1527.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1251.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1687.5,75,,1350,percent of total billed charges,75% of total billed charges for outpatient setting,1575,70,,1260,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,80,,1440,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765,100,,,Fee Schedule,100% of Custom Fee Schedule,2025,90,,1620,percent of total billed charges,90% of total billed charges for outpatient setting,288.9,2025,
CYTO EVAL OF FNA STUDY FOR ADEQUACY SPEC,900006,CDM,311,RC,88172,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,18.51,535.12,
"CYTOGENICS/MOLECULAR CYTO,INTERP/REPORT",201038,CDM,300,RC,88291,HCPCS,Outpatient,,,451.41,406.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.99,70,,252.79,percent of total billed charges,70% of total billed charges for outpatient setting,383.16,84.88,,306.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,225.71,50,,180.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,338.56,75,,270.85,percent of total billed charges,75% of total billed charges for outpatient setting,315.99,70,,252.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.13,80,,288.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,100,,,Fee Schedule,100% of Custom Fee Schedule,406.27,90,,325.02,percent of total billed charges,90% of total billed charges for outpatient setting,6.07,406.27,
CYTOHISTOLOGY TO DET ADEQUACY EA  ADDTL,201659,CDM,311,RC,88177,HCPCS,Outpatient,,,314.37,282.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.06,70,,176.05,percent of total billed charges,70% of total billed charges for outpatient setting,266.84,84.88,,213.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.78,75,,188.62,percent of total billed charges,75% of total billed charges for outpatient setting,220.06,70,,176.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.5,80,,201.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.93,90,,226.34,percent of total billed charges,90% of total billed charges for outpatient setting,18.36,282.93,
CYTOLOGY EVAL OF FNA  EA ADDITIONAL,900011,CDM,311,RC,88177,HCPCS,Outpatient,,,33.2,29.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.24,70,,18.59,percent of total billed charges,70% of total billed charges for outpatient setting,28.18,84.88,,22.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.9,75,,19.92,percent of total billed charges,75% of total billed charges for outpatient setting,23.24,70,,18.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.56,80,,21.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.88,90,,23.9,percent of total billed charges,90% of total billed charges for outpatient setting,18.36,29.88,
CYTOPATHOLOGY CELLULAR ENHANCEMENT TECH,900040,CDM,311,RC,88112,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,178.52,
CYTOPATHOLOGY CONCENTRATION SMEARS,900002,CDM,311,RC,88108,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,23.6,121.4,
CYTOPATHOLOGY EXTENDED STUDY MULT STAINS,900004,CDM,311,RC,88162,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,22.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,22.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,22.49,178.52,
CYTOPATHOLOGY INTERP AND REPORT,900007,CDM,311,RC,88173,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,37.04,178.52,
CYTOPATHOLOGY SMEARS SCREENING INTERP,900003,CDM,311,RC,88160,HCPCS,Outpatient,,,98.34,88.51,,35.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,83.47,84.88,,66.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.76,75,,59.01,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,37.63,170,,,Fee Schedule,170% of Medicare OPPS rate,47.59,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.74,175,,,Fee Schedule,175% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.67,80,,62.94,percent of total billed charges,80% of total billed charges for outpatient setting,30.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,27.67,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,88.51,90,,70.81,percent of total billed charges,90% of total billed charges for outpatient setting,17.06,88.51,
CYTOPATHOLOGY URINARY TRACT 3-5 MANUAL,900048,CDM,311,RC,88120,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.12,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,73.12,535.12,
D10% 250ML INJECTION,3313325,CDM,258,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
D10% SOLN: 1000ML,3302499,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5 0.9% NS/ KCL 10 MEQ /1000 ML SOLN,3303769,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
D5 0.9% NS/ KCL 20 MEQ /1000ML SOLN,3303770,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
D5 0.9% NS/ KCL 30 MEQ/1000ML SOLN,3303771,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
D5 0.9% NS/ KCL 40 MEQ/1000ML SOLN,3303772,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
D5W 0.45%NS /KCL 10MEQ/1000ML  SOLN,3302942,CDM,250,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W 0.45%NS WITH 30MEQ KCL SOLN: 1000 ML,3302943,CDM,250,RC,,,Outpatient,,,148.26,148.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,125.84,84.88,,100.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.13,50,,59.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.2,75,,88.96,percent of total billed charges,75% of total billed charges for outpatient setting,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.61,80,,94.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.37,65,,77.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,35,,41.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.43,90,,106.74,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,133.43,
D5W 1/2 NS/KCL 20mEq /1000ML SOLN,3302502,CDM,258,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
D5W 1/2 NS/KCL 40mEq / 1000ML SOLN,3302504,CDM,258,RC,,,Outpatient,,,26.82,26.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,22.76,84.88,,18.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.41,50,,10.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.12,75,,16.1,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.46,80,,17.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.43,65,,13.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,35,,7.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.14,90,,19.31,percent of total billed charges,90% of total billed charges for outpatient setting,3.44,24.14,
D5W 1/4 NS/KCL 20mEq /1000ML SOLN,3302503,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W 5% SOLN 1000ML,3302491,CDM,258,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
D5W 5% SOLN: 500ML (NON PVP),3302484,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W/0.2% NS SOLN 1000ML,3302496,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W/0.45%NS SOLN 1000ML,3302495,CDM,258,RC,J7799,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
D5W/0.9% NS SOLN 1000ML,3302498,CDM,258,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
D5W/NS 0.225% SOLN  500ML,3302488,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W/NS 0.33% SOLN: 1000ML,3302497,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W/NS 0.45% SOLN: 500ML,3302486,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5W/NS 0.9% SOLN: 500ML,3302487,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
D5WLR SOLN 1000ML,3302493,CDM,258,RC,J7120,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DABIGATRAN ETEXILATE (PRADAXA)150MG:TAB,3305160,CDM,259,RC,,,Outpatient,,,20.17,20.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.12,70,,11.3,percent of total billed charges,70% of total billed charges for outpatient setting,17.12,84.88,,13.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.09,50,,8.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.13,75,,12.1,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,70,,11.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,12.84,,2.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,80,,12.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,12.84,,2.07,percent of total billed charges,12.84% of total billed charges,2.59,12.84,,2.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.11,65,,10.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,35,,5.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.15,90,,14.52,percent of total billed charges,90% of total billed charges for outpatient setting,2.59,18.15,
DAKINS SOLN 1/2 STR:BOTTLE,3303260,CDM,259,RC,,,Outpatient,,,32.91,32.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,70,,18.43,percent of total billed charges,70% of total billed charges for outpatient setting,27.93,84.88,,22.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.46,50,,13.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.68,75,,19.74,percent of total billed charges,75% of total billed charges for outpatient setting,23.04,70,,18.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.33,80,,21.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.39,65,,17.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,35,,9.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.62,90,,23.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,29.62,
DALBAVANCIN (DALVANCE) 500mg inj,3308832,CDM,636,RC,J0875,HCPCS,Outpatient,,,5410.93,5410.93,,24.25,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3787.65,70,,3030.12,percent of total billed charges,70% of total billed charges for outpatient setting,4592.8,84.88,,3674.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4058.2,75,,3246.56,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,25.77,170,,,Fee Schedule,170% of Medicare OPPS rate,32.59,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,694.76,12.84,,555.808,percent of total billed charges,12.84% of total billed charges,26.53,175,,,Fee Schedule,175% of Medicare OPPS rate,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4328.74,80,,3462.99,percent of total billed charges,80% of total billed charges for outpatient setting,21.22,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,18.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,694.76,12.84,,555.81,percent of total billed charges,12.84% of total billed charges,694.76,12.84,,555.81,percent of total billed charges,12.84% of total billed charges,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3517.1,65,,2813.68,percent of total billed charges,65% of total billed charges for outpatient setting,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,15.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,15.12,100,,,Fee Schedule,100% of Custom Fee Schedule,4869.84,90,,3895.87,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,4869.84,
DALTEPARIN (FRAGMIN) :2500 U/0.2 ML,3302756,CDM,636,RC,J1645,HCPCS,Outpatient,,,76.43,76.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.5,70,,42.8,percent of total billed charges,70% of total billed charges for outpatient setting,64.87,84.88,,51.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.32,75,,45.86,percent of total billed charges,75% of total billed charges for outpatient setting,53.5,70,,42.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,12.84,,7.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.14,80,,48.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,12.84,,7.85,percent of total billed charges,12.84% of total billed charges,9.81,12.84,,7.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.68,65,,39.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,100,,,Fee Schedule,100% of Custom Fee Schedule,68.79,90,,55.03,percent of total billed charges,90% of total billed charges for outpatient setting,9.81,68.79,
DALTEPARIN (FRAGMN) INJ 5MU/0.2ML :0.2ML,3300885,CDM,250,RC,,,Outpatient,,,67.13,67.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.99,70,,37.59,percent of total billed charges,70% of total billed charges for outpatient setting,56.98,84.88,,45.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.57,50,,26.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.35,75,,40.28,percent of total billed charges,75% of total billed charges for outpatient setting,46.99,70,,37.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.7,80,,42.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.63,65,,34.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.5,35,,18.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.42,90,,48.34,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,60.42,
DALTEPARIN NA(FRAGMIN)5000 IU/0.2ML:INJ.,3302953,CDM,636,RC,J1645,HCPCS,Outpatient,,,102.39,102.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.67,70,,57.34,percent of total billed charges,70% of total billed charges for outpatient setting,86.91,84.88,,69.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,76.79,75,,61.43,percent of total billed charges,75% of total billed charges for outpatient setting,71.67,70,,57.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.91,80,,65.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.55,65,,53.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,100,,,Fee Schedule,100% of Custom Fee Schedule,92.15,90,,73.72,percent of total billed charges,90% of total billed charges for outpatient setting,12.78,92.15,
DANTROLENE (DANTRIUM) 20MG POWDER VL,3314157,CDM,258,RC,,,Outpatient,,,204.88,204.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.42,70,,114.74,percent of total billed charges,70% of total billed charges for outpatient setting,173.9,84.88,,139.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.44,50,,81.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.66,75,,122.93,percent of total billed charges,75% of total billed charges for outpatient setting,143.42,70,,114.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.31,12.84,,21.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.9,80,,131.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.31,12.84,,21.05,percent of total billed charges,12.84% of total billed charges,26.31,12.84,,21.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.17,65,,106.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.71,35,,57.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.39,90,,147.51,percent of total billed charges,90% of total billed charges for outpatient setting,26.31,184.39,
DANTROLENE (DANTRIUM) CAP : 25MG,3300886,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
DANTROLENE (RYANODEX) 250MG INJ PWD VL,3314158,CDM,258,RC,,,Outpatient,,,10324.13,10324.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7226.89,70,,5781.51,percent of total billed charges,70% of total billed charges for outpatient setting,8763.12,84.88,,7010.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,5162.07,50,,4129.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7743.1,75,,6194.48,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1325.62,12.84,,1060.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8259.3,80,,6607.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1325.62,12.84,,1060.5,percent of total billed charges,12.84% of total billed charges,1325.62,12.84,,1060.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6710.68,65,,5368.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3613.45,35,,2890.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9291.72,90,,7433.38,percent of total billed charges,90% of total billed charges for outpatient setting,1325.62,9291.72,
DAPSONE TAB: 100 MG,3303092,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DAPSONE TAB: 25 MG,3300887,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DAPTOMYCIN (CUBICIN) 500MG: INJ,3303304,CDM,250,RC,,,Outpatient,,,963.9,963.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,70,,539.78,percent of total billed charges,70% of total billed charges for outpatient setting,818.16,84.88,,654.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,481.95,50,,385.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,722.93,75,,578.34,percent of total billed charges,75% of total billed charges for outpatient setting,674.73,70,,539.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.76,12.84,,99.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.12,80,,616.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.76,12.84,,99.01,percent of total billed charges,12.84% of total billed charges,123.76,12.84,,99.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,626.54,65,,501.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.37,35,,269.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,867.51,90,,694.01,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,867.51,
DARBEPOETIN (ARANESP)SURECLICK:100MCG,3303216,CDM,636,RC,J0881,HCPCS,Outpatient,,,1813.73,1813.73,,5.05,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1269.61,70,,1015.69,percent of total billed charges,70% of total billed charges for outpatient setting,1539.49,84.88,,1231.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1360.3,75,,1088.24,percent of total billed charges,75% of total billed charges for outpatient setting,1269.61,70,,1015.69,percent of total billed charges,70% of total billed charges for outpatient setting,5.37,170,,,Fee Schedule,170% of Medicare OPPS rate,6.79,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,232.88,12.84,,186.304,percent of total billed charges,12.84% of total billed charges,5.53,175,,,Fee Schedule,175% of Medicare OPPS rate,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1450.98,80,,1160.78,percent of total billed charges,80% of total billed charges for outpatient setting,4.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,3.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,232.88,12.84,,186.3,percent of total billed charges,12.84% of total billed charges,232.88,12.84,,186.3,percent of total billed charges,12.84% of total billed charges,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1178.92,65,,943.14,percent of total billed charges,65% of total billed charges for outpatient setting,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4.38,100,,,Fee Schedule,100% of Custom Fee Schedule,1632.36,90,,1305.89,percent of total billed charges,90% of total billed charges for outpatient setting,3.16,1632.36,
DARIFENACIN (ENABLEX) ER 7.5MG: TAB,3303271,CDM,259,RC,,,Outpatient,,,17.08,17.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,70,,9.57,percent of total billed charges,70% of total billed charges for outpatient setting,14.5,84.88,,11.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.54,50,,6.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.81,75,,10.25,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,70,,9.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,80,,10.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.1,65,,8.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.98,35,,4.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.37,90,,12.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.19,15.37,
DART 18MM CHONDRAL / AR-4005B-18,69161724,CDM,278,RC,,,Outpatient,,,539.15,539.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.49,60,,258.79,percent of total billed charges,60% of total Billed charges for outpatient setting,457.63,84.88,,366.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,269.58,50,,215.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,404.36,75,,323.49,percent of total billed charges,75% of total billed charges for outpatient setting,269.58,50,,215.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.23,12.84,,55.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.32,80,,345.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.23,12.84,,55.38,percent of total billed charges,12.84% of total billed charges,69.23,12.84,,55.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,539.15,65,,431.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.7,35,,150.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,323.49,60,,258.79,percent of total billed charges,60% of total billed charges for outpatient setting,69.23,539.15,
DDAVP INJ 4MCG/ML 1ML AMP,3302549,CDM,636,RC,J2597,HCPCS,Outpatient,,,240.86,240.86,,12.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.6,70,,134.88,percent of total billed charges,70% of total billed charges for outpatient setting,204.44,84.88,,163.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,180.65,75,,144.52,percent of total billed charges,75% of total billed charges for outpatient setting,168.6,70,,134.88,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,170,,,Fee Schedule,170% of Medicare OPPS rate,16.36,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,30.93,12.84,,24.744,percent of total billed charges,12.84% of total billed charges,13.31,175,,,Fee Schedule,175% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.69,80,,154.15,percent of total billed charges,80% of total billed charges for outpatient setting,10.65,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,9.51,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,30.93,12.84,,24.74,percent of total billed charges,12.84% of total billed charges,30.93,12.84,,24.74,percent of total billed charges,12.84% of total billed charges,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156.56,65,,125.25,percent of total billed charges,65% of total billed charges for outpatient setting,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.3,100,,,Fee Schedule,100% of Custom Fee Schedule,216.77,90,,173.42,percent of total billed charges,90% of total billed charges for outpatient setting,6.3,216.77,
DDAVP SOL 0.1MG/ML : 5ML,3302550,CDM,250,RC,,,Outpatient,,,487.2,487.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.04,70,,272.83,percent of total billed charges,70% of total billed charges for outpatient setting,413.54,84.88,,330.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.6,50,,194.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.4,75,,292.32,percent of total billed charges,75% of total billed charges for outpatient setting,341.04,70,,272.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.56,12.84,,50.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.76,80,,311.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.56,12.84,,50.05,percent of total billed charges,12.84% of total billed charges,62.56,12.84,,50.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.68,65,,253.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.52,35,,136.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.48,90,,350.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.56,438.48,
D-DIMER,200877,CDM,300,RC,85378,HCPCS,Outpatient,,,43.74,39.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,70,,24.5,percent of total billed charges,70% of total billed charges for outpatient setting,37.13,84.88,,29.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.81,75,,26.25,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,70,,24.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.99,80,,27.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.41,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of Custom Fee Schedule,39.37,90,,31.5,percent of total billed charges,90% of total billed charges for outpatient setting,6.9,39.37,
D-DIMER  QUANTITATIVE,222008,CDM,300,RC,85379,HCPCS,Outpatient,,,45.81,41.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,84.88,,31.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.36,75,,27.49,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,80,,29.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,100,,,Fee Schedule,100% of Custom Fee Schedule,41.23,90,,32.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,41.23,
"DEAMIDATED GLIADIN ANTIBODY, EA Ig CLASS",201095,CDM,302,RC,86258,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,35,,15.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,48.81,
DEAMINATED GLIADIN AB IGA,220924,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
"DEBRIDE NAILS, 1-5",5100167,CDM,510,RC,,,Outpatient,,,253.49,253.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,215.16,84.88,,172.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,126.75,50,,101.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.12,75,,152.1,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.79,80,,162.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,164.77,65,,131.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.72,35,,70.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.14,90,,182.51,percent of total billed charges,90% of total billed charges for outpatient setting,32.55,228.14,
"DEBRIDE NAILS, 6 OR >",5100168,CDM,510,RC,,,Outpatient,,,253.49,253.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,215.16,84.88,,172.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,126.75,50,,101.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.12,75,,152.1,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.79,80,,162.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,164.77,65,,131.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.72,35,,70.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.14,90,,182.51,percent of total billed charges,90% of total billed charges for outpatient setting,32.55,228.14,
DECALCIFICATION PROCEDURE,900009,CDM,310,RC,88311,HCPCS,Outpatient,,,30.27,27.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.19,70,,16.95,percent of total billed charges,70% of total billed charges for outpatient setting,25.69,84.88,,20.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.7,75,,18.16,percent of total billed charges,75% of total billed charges for outpatient setting,21.19,70,,16.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,80,,19.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,90,,21.79,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,27.24,
DEFIB PADS PEDI QUIKCOMB / 11996-000093,5150198,CDM,270,RC,,,Outpatient,,,129.95,129.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.97,70,,72.78,percent of total billed charges,70% of total billed charges for outpatient setting,110.3,84.88,,88.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.98,50,,51.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.46,75,,77.97,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,70,,72.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,12.84,,13.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.96,80,,83.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,12.84,,13.35,percent of total billed charges,12.84% of total billed charges,16.69,12.84,,13.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.47,65,,67.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.48,35,,36.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.96,90,,93.57,percent of total billed charges,90% of total billed charges for outpatient setting,16.69,116.96,
DEFIB PADS-ADULT QUIK-CMB / 11996-000017,6150629,CDM,270,RC,,,Outpatient,,,257.16,257.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.01,70,,144.01,percent of total billed charges,70% of total billed charges for outpatient setting,218.28,84.88,,174.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.58,50,,102.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.87,75,,154.3,percent of total billed charges,75% of total billed charges for outpatient setting,180.01,70,,144.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,12.84,,26.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.73,80,,164.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,12.84,,26.42,percent of total billed charges,12.84% of total billed charges,33.02,12.84,,26.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.15,65,,133.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.01,35,,72.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,231.44,90,,185.15,percent of total billed charges,90% of total billed charges for outpatient setting,33.02,231.44,
DEMECLOCYCLINE (DECLOMYCIN) 150MG TAB:,3300889,CDM,259,RC,,,Outpatient,,,13.69,13.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,11.62,84.88,,9.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.85,50,,5.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.27,75,,8.22,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.95,80,,8.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.9,65,,7.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,35,,3.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.32,90,,9.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.32,
DEMECLOCYCLINE (DECLOMYCIN) 300MG TAB:,3300888,CDM,259,RC,,,Outpatient,,,24.87,24.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.41,70,,13.93,percent of total billed charges,70% of total billed charges for outpatient setting,21.11,84.88,,16.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.44,50,,9.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.65,75,,14.92,percent of total billed charges,75% of total billed charges for outpatient setting,17.41,70,,13.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,80,,15.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,3.19,12.84,,2.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.17,65,,12.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,35,,6.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.38,90,,17.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.19,22.38,
DEMEROL INJ 100MG/ML: 1ML,3302524,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DEMEROL INJ 100MG/ML: 1ML,3302529,CDM,250,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
DEMEROL INJ 50MG/ML: 1ML,3302530,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DEMEROL INJ 50MG: 1ML,3302525,CDM,250,RC,,,Outpatient,,,67.4,67.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,57.21,84.88,,45.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.7,50,,26.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.55,75,,40.44,percent of total billed charges,75% of total billed charges for outpatient setting,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,80,,43.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.81,65,,35.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,35,,18.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.66,90,,48.53,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,60.66,
DEMEROL INJ 75MG/ML: 1ML,3302526,CDM,250,RC,,,Outpatient,,,117.74,117.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.42,70,,65.94,percent of total billed charges,70% of total billed charges for outpatient setting,99.94,84.88,,79.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.87,50,,47.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.31,75,,70.65,percent of total billed charges,75% of total billed charges for outpatient setting,82.42,70,,65.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,12.84,,12.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.19,80,,75.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,12.84,,12.1,percent of total billed charges,12.84% of total billed charges,15.12,12.84,,12.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.53,65,,61.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.21,35,,32.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.97,90,,84.78,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,105.97,
DEMEROL SYRINGE 10MG/ML,3302522,CDM,250,RC,,,Outpatient,,,72.6,72.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.82,70,,40.66,percent of total billed charges,70% of total billed charges for outpatient setting,61.62,84.88,,49.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.3,50,,29.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.45,75,,43.56,percent of total billed charges,75% of total billed charges for outpatient setting,50.82,70,,40.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,12.84,,7.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.08,80,,46.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,12.84,,7.46,percent of total billed charges,12.84% of total billed charges,9.32,12.84,,7.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.19,65,,37.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,35,,20.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.34,90,,52.27,percent of total billed charges,90% of total billed charges for outpatient setting,9.32,65.34,
DEMEROL SYRUP 50MG/5ML :UD,3302523,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DEMIPULSE GENERATOR MODEL 103,69161754,CDM,278,RC,C1767,HCPCS,Outpatient,,,3091.96,3091.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1855.18,60,,1484.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2624.46,84.88,,2099.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2318.97,75,,1855.18,percent of total billed charges,75% of total billed charges for outpatient setting,1545.98,50,,1236.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.01,12.84,,317.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2473.57,80,,1978.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.01,12.84,,317.61,percent of total billed charges,12.84% of total billed charges,397.01,12.84,,317.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3246.56,105,,2597.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.19,35,,865.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1855.18,60,,1484.14,percent of total billed charges,60% of total billed charges for outpatient setting,397.01,3246.56,
DENOSUMAB (PROLIA) 1ML/UNIT (WASTAGE),3305388,CDM,636,RC,J0897,HCPCS,Outpatient,,,53.61,53.61,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.53,70,,30.02,percent of total billed charges,70% of total billed charges for outpatient setting,45.5,84.88,,36.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.81,50,,21.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.21,75,,32.17,percent of total billed charges,75% of total billed charges for outpatient setting,37.53,70,,30.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,12.84,,5.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,80,,34.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,6.88,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.85,65,,27.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.76,35,,15.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.25,90,,38.6,percent of total billed charges,90% of total billed charges for outpatient setting,6.88,48.25,
DENOSUMAB (PROLIA) 60MG/ML: 1MG/UNIT,3305278,CDM,636,RC,J0897,HCPCS,Outpatient,,,66.65,66.65,,36.01,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,46.66,70,,37.33,percent of total billed charges,70% of total billed charges for outpatient setting,56.57,84.88,,45.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.99,75,,39.99,percent of total billed charges,75% of total billed charges for outpatient setting,46.66,70,,37.33,percent of total billed charges,70% of total billed charges for outpatient setting,38.26,170,,,Fee Schedule,170% of Medicare OPPS rate,48.39,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.56,12.84,,6.848,percent of total billed charges,12.84% of total billed charges,39.39,175,,,Fee Schedule,175% of Medicare OPPS rate,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.32,80,,42.66,percent of total billed charges,80% of total billed charges for outpatient setting,31.51,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,28.13,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.32,65,,34.66,percent of total billed charges,65% of total billed charges for outpatient setting,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,17,100,,,Fee Schedule,100% of Custom Fee Schedule,59.99,90,,47.99,percent of total billed charges,90% of total billed charges for outpatient setting,8.56,59.99,
DEPAKOTE ER 500MG TAB,3303076,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DEPAKOTE ER TAB  250 MG :,3302997,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DEPAKOTE TAB : 125 MG,3302229,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DEPERIDINE (DEMEROL) TAB: 50MG,3301483,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DERMABOND PEN / DNX12,69160541,CDM,272,RC,,,Outpatient,,,101.18,101.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.83,70,,56.66,percent of total billed charges,70% of total billed charges for outpatient setting,85.88,84.88,,68.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.59,50,,40.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.89,75,,60.71,percent of total billed charges,75% of total billed charges for outpatient setting,70.83,70,,56.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.99,12.84,,10.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.94,80,,64.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.99,12.84,,10.39,percent of total billed charges,12.84% of total billed charges,12.99,12.84,,10.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.77,65,,52.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.41,35,,28.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.06,90,,72.85,percent of total billed charges,90% of total billed charges for outpatient setting,12.99,91.06,
DERMABOND POPPER MINI / DHVM12,6152058,CDM,272,RC,,,Outpatient,,,59.9,59.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.93,70,,33.54,percent of total billed charges,70% of total billed charges for outpatient setting,50.84,84.88,,40.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.95,50,,23.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.93,75,,35.94,percent of total billed charges,75% of total billed charges for outpatient setting,41.93,70,,33.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.69,12.84,,6.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.92,80,,38.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.69,12.84,,6.15,percent of total billed charges,12.84% of total billed charges,7.69,12.84,,6.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.94,65,,31.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,35,,16.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.91,90,,43.13,percent of total billed charges,90% of total billed charges for outpatient setting,7.69,53.91,
DERMACARRIER 1.5 TO 1 / 2195-012,6152965,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,101.86,84.88,,81.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,60,50,,48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,75,,72,percent of total billed charges,75% of total billed charges for outpatient setting,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,80,,76.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78,65,,62.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,35,,33.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108,90,,86.4,percent of total billed charges,90% of total billed charges for outpatient setting,15.41,108,
DERMACARRIER 3 to 1/2195-013,69159781,CDM,272,RC,,,Outpatient,,,213.95,213.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.77,70,,119.82,percent of total billed charges,70% of total billed charges for outpatient setting,181.6,84.88,,145.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,106.98,50,,85.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.46,75,,128.37,percent of total billed charges,75% of total billed charges for outpatient setting,149.77,70,,119.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.47,12.84,,21.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.16,80,,136.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.47,12.84,,21.98,percent of total billed charges,12.84% of total billed charges,27.47,12.84,,21.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,139.07,65,,111.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.88,35,,59.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,192.56,90,,154.05,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,192.56,
DERMOPLAST 0.5% SPRAY: 82.50GM,3302635,CDM,259,RC,,,Outpatient,,,38.46,38.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,70,,21.54,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,84.88,,26.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.23,50,,15.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.85,75,,23.08,percent of total billed charges,75% of total billed charges for outpatient setting,26.92,70,,21.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.77,80,,24.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25,65,,20,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,35,,10.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.61,90,,27.69,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.61,
DESFLURANE (SUPRAN)INH 240ML 15MIN INC,3302623,CDM,250,RC,,,Outpatient,,,9.24,9.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,7.84,84.88,,6.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.62,50,,3.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.93,75,,5.54,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.39,80,,5.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.01,65,,4.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,35,,2.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.32,90,,6.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.32,
DESIPRAMINE,220030,CDM,300,RC,80335,HCPCS,Outpatient,,,131.95,118.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.37,70,,73.9,percent of total billed charges,70% of total billed charges for outpatient setting,112,84.88,,89.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.98,50,,52.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.96,75,,79.17,percent of total billed charges,75% of total billed charges for outpatient setting,92.37,70,,73.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,12.84,,13.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.56,80,,84.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,12.84,,13.55,percent of total billed charges,12.84% of total billed charges,16.94,12.84,,13.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.76,90,,95.01,percent of total billed charges,90% of total billed charges for outpatient setting,16.94,118.76,
DESIPRAMINE (NORPRAMIN) TAB : 25 MG,3300890,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DESIPRAMINE (NORPRAMIN) TAB : 25 MG,3300891,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
DESLORATADINE CLARINEX  5MG  TAB,3303040,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DESMOPRESSIN (DDAVP) INJ 4MCG/ML 1ML,3300893,CDM,636,RC,J2597,HCPCS,Outpatient,,,223.42,223.42,,12.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156.39,70,,125.11,percent of total billed charges,70% of total billed charges for outpatient setting,189.64,84.88,,151.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,167.57,75,,134.06,percent of total billed charges,75% of total billed charges for outpatient setting,156.39,70,,125.11,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,170,,,Fee Schedule,170% of Medicare OPPS rate,16.36,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,28.69,12.84,,22.952,percent of total billed charges,12.84% of total billed charges,13.31,175,,,Fee Schedule,175% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,178.74,80,,142.99,percent of total billed charges,80% of total billed charges for outpatient setting,10.65,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,9.51,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,28.69,12.84,,22.95,percent of total billed charges,12.84% of total billed charges,28.69,12.84,,22.95,percent of total billed charges,12.84% of total billed charges,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,145.22,65,,116.18,percent of total billed charges,65% of total billed charges for outpatient setting,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.61,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.3,100,,,Fee Schedule,100% of Custom Fee Schedule,201.08,90,,160.86,percent of total billed charges,90% of total billed charges for outpatient setting,6.3,201.08,
DESMOPRESSIN (DDAVP) SOL 0.1MG/ML :5ML,3300892,CDM,250,RC,,,Outpatient,,,487.2,487.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.04,70,,272.83,percent of total billed charges,70% of total billed charges for outpatient setting,413.54,84.88,,330.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.6,50,,194.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.4,75,,292.32,percent of total billed charges,75% of total billed charges for outpatient setting,341.04,70,,272.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.56,12.84,,50.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.76,80,,311.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.56,12.84,,50.05,percent of total billed charges,12.84% of total billed charges,62.56,12.84,,50.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.68,65,,253.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.52,35,,136.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.48,90,,350.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.56,438.48,
DETERMINATIVE HISTOCHEMISTRY OF CYTOCHEM,200397,CDM,314,RC,88319,HCPCS,Outpatient,,,1453.08,1307.77,,939.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1017.16,70,,813.73,percent of total billed charges,70% of total billed charges for outpatient setting,1233.37,84.88,,986.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,752.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1089.81,75,,871.85,percent of total billed charges,75% of total billed charges for outpatient setting,1017.16,70,,813.73,percent of total billed charges,70% of total billed charges for outpatient setting,998.32,170,,,Fee Schedule,170% of Medicare OPPS rate,1262.58,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,186.58,12.84,,149.264,percent of total billed charges,12.84% of total billed charges,1027.68,175,,,Fee Schedule,175% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1162.46,80,,929.97,percent of total billed charges,80% of total billed charges for outpatient setting,822.14,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,734.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,186.58,12.84,,149.26,percent of total billed charges,12.84% of total billed charges,186.58,12.84,,149.26,percent of total billed charges,12.84% of total billed charges,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1307.77,90,,1046.22,percent of total billed charges,90% of total billed charges for outpatient setting,186.58,1307.77,
DEVICE 20CC INFLAT ENCORE / M0067101140,131004,CDM,272,RC,,,Outpatient,,,160.8,160.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.56,70,,90.05,percent of total billed charges,70% of total billed charges for outpatient setting,136.49,84.88,,109.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.4,50,,64.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.6,75,,96.48,percent of total billed charges,75% of total billed charges for outpatient setting,112.56,70,,90.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,12.84,,16.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.64,80,,102.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,12.84,,16.52,percent of total billed charges,12.84% of total billed charges,20.65,12.84,,16.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.52,65,,83.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.28,35,,45.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144.72,90,,115.78,percent of total billed charges,90% of total billed charges for outpatient setting,20.65,144.72,
DEVICE 5 SYNCHFIX GRAVITY / 86SYN005,71000599,CDM,278,RC,C1713,HCPCS,Outpatient,,,3412.5,3412.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,60,,1638,percent of total billed charges,60% of total Billed charges for outpatient setting,2896.53,84.88,,2317.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.38,75,,2047.5,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,50,,1365,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.17,12.84,,350.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,80,,2184,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.17,12.84,,350.54,percent of total billed charges,12.84% of total billed charges,438.17,12.84,,350.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3583.13,105,,2866.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1194.38,35,,955.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2047.5,60,,1638,percent of total billed charges,60% of total billed charges for outpatient setting,438.17,3583.13,
DEVICE 60ML ENDO INFLATION / MAJ-1740,1865157,CDM,272,RC,,,Outpatient,,,175,175,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,70,,98,percent of total billed charges,70% of total billed charges for outpatient setting,148.54,84.88,,118.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,87.5,50,,70,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.25,75,,105,percent of total billed charges,75% of total billed charges for outpatient setting,122.5,70,,98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,12.84,,17.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,80,,112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,12.84,,17.98,percent of total billed charges,12.84% of total billed charges,22.47,12.84,,17.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,113.75,65,,91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.25,35,,49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,157.5,90,,126,percent of total billed charges,90% of total billed charges for outpatient setting,22.47,157.5,
DEVICE ADULT LARGE CPAP MASK/ SNL-20,2390173,CDM,271,RC,,,Outpatient,,,133.87,133.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.71,70,,74.97,percent of total billed charges,70% of total billed charges for outpatient setting,113.63,84.88,,90.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.94,50,,53.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.4,75,,80.32,percent of total billed charges,75% of total billed charges for outpatient setting,93.71,70,,74.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,12.84,,13.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.1,80,,85.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,12.84,,13.75,percent of total billed charges,12.84% of total billed charges,17.19,12.84,,13.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.02,65,,69.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.85,35,,37.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.48,90,,96.38,percent of total billed charges,90% of total billed charges for outpatient setting,17.19,120.48,
DEVICE ADULT MED CPAP KIT / SSM-20,2390176,CDM,271,RC,,,Outpatient,,,214.2,214.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.94,70,,119.95,percent of total billed charges,70% of total billed charges for outpatient setting,181.81,84.88,,145.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.1,50,,85.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,75,,128.52,percent of total billed charges,75% of total billed charges for outpatient setting,149.94,70,,119.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,12.84,,22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.36,80,,137.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,12.84,,22,percent of total billed charges,12.84% of total billed charges,27.5,12.84,,22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,139.23,65,,111.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.97,35,,59.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,192.78,90,,154.22,percent of total billed charges,90% of total billed charges for outpatient setting,27.5,192.78,
DEVICE AFFIRM INFLATION / 658.909S,70000562,CDM,272,RC,,,Outpatient,,,519.12,519.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,70,,290.7,percent of total billed charges,70% of total billed charges for outpatient setting,440.63,84.88,,352.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.56,50,,207.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.34,75,,311.47,percent of total billed charges,75% of total billed charges for outpatient setting,363.38,70,,290.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,12.84,,53.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.3,80,,332.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,12.84,,53.33,percent of total billed charges,12.84% of total billed charges,66.66,12.84,,53.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,337.43,65,,269.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.69,35,,145.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,467.21,90,,373.77,percent of total billed charges,90% of total billed charges for outpatient setting,66.66,467.21,
DEVICE AMPLIFEYE SCOPE / EYE-102,70000823,CDM,272,RC,,,Outpatient,,,110.25,110.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,93.58,84.88,,74.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.13,50,,44.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.69,75,,66.15,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,80,,70.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.66,65,,57.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.59,35,,30.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.23,90,,79.38,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,99.23,
DEVICE CAPIO SLIM SUTURE / M0068318261,70000144,CDM,278,RC,,,Outpatient,,,1888.87,1888.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.32,60,,906.66,percent of total billed charges,60% of total Billed charges for outpatient setting,1603.27,84.88,,1282.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,944.44,50,,755.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1416.65,75,,1133.32,percent of total billed charges,75% of total billed charges for outpatient setting,944.44,50,,755.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.53,12.84,,194.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1511.1,80,,1208.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.53,12.84,,194.02,percent of total billed charges,12.84% of total billed charges,242.53,12.84,,194.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1888.87,65,,1511.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.1,35,,528.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1133.32,60,,906.66,percent of total billed charges,60% of total billed charges for outpatient setting,242.53,1888.87,
DEVICE CAPIO SUTURING / 831125,70000145,CDM,272,RC,C2631,HCPCS,Outpatient,,,1887.35,1887.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1321.15,70,,1056.92,percent of total billed charges,70% of total billed charges for outpatient setting,1601.98,84.88,,1281.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.51,75,,1132.41,percent of total billed charges,75% of total billed charges for outpatient setting,1321.15,70,,1056.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.34,12.84,,193.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1509.88,80,,1207.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.34,12.84,,193.87,percent of total billed charges,12.84% of total billed charges,242.34,12.84,,193.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1226.78,65,,981.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.57,35,,528.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1698.62,90,,1358.9,percent of total billed charges,90% of total billed charges for outpatient setting,242.34,1698.62,
DEVICE INFLATION AERIS / QL2530,69169538,CDM,272,RC,,,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,212.63,90,,170.1,percent of total billed charges,90% of total billed charges for outpatient setting,30.33,212.63,
DEVICE PIRANHA 1.1MM 115CM / M00650516,70000815,CDM,272,RC,C2631,HCPCS,Outpatient,,,1222.24,1222.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.57,70,,684.46,percent of total billed charges,70% of total billed charges for outpatient setting,1037.44,84.88,,829.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.68,75,,733.34,percent of total billed charges,75% of total billed charges for outpatient setting,855.57,70,,684.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.94,12.84,,125.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,977.79,80,,782.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.94,12.84,,125.55,percent of total billed charges,12.84% of total billed charges,156.94,12.84,,125.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,794.46,65,,635.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.78,35,,342.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1100.02,90,,880.02,percent of total billed charges,90% of total billed charges for outpatient setting,156.94,1100.02,
DEVICE SOLARA MRI CRTP / W1TR03,70000645,CDM,278,RC,C2621,HCPCS,Outpatient,,,13894,13894,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8336.4,60,,6669.12,percent of total billed charges,60% of total Billed charges for outpatient setting,11793.23,84.88,,9434.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.5,75,,8336.4,percent of total billed charges,75% of total billed charges for outpatient setting,6947,50,,5557.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1783.99,12.84,,1427.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11115.2,80,,8892.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1783.99,12.84,,1427.19,percent of total billed charges,12.84% of total billed charges,1783.99,12.84,,1427.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14588.7,105,,11670.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4862.9,35,,3890.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8336.4,60,,6669.12,percent of total billed charges,60% of total billed charges for outpatient setting,1783.99,14588.7,
DEVICE STATLOCK PICC / VPPDFP,184655,CDM,271,RC,,,Outpatient,,,30.51,30.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.36,70,,17.09,percent of total billed charges,70% of total billed charges for outpatient setting,25.9,84.88,,20.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.26,50,,12.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.88,75,,18.3,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,70,,17.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,12.84,,3.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,80,,19.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,3.92,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.83,65,,15.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.68,35,,8.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.46,90,,21.97,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,27.46,
DEVICE SYMPHION FLUID MGMT / FG-0202,71000190,CDM,272,RC,,,Outpatient,,,1596,1596,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1117.2,70,,893.76,percent of total billed charges,70% of total billed charges for outpatient setting,1354.68,84.88,,1083.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,798,50,,638.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1197,75,,957.6,percent of total billed charges,75% of total billed charges for outpatient setting,1117.2,70,,893.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.93,12.84,,163.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1276.8,80,,1021.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.93,12.84,,163.94,percent of total billed charges,12.84% of total billed charges,204.93,12.84,,163.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1037.4,65,,829.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.6,35,,446.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1436.4,90,,1149.12,percent of total billed charges,90% of total billed charges for outpatient setting,204.93,1436.4,
DEXAMETHASONE,222600,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
DEXAMETHASONE (DECADRON) INJ 4MG/ML:30ML,3300901,CDM,250,RC,,,Outpatient,,,21.17,21.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,17.97,84.88,,14.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.59,50,,8.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.88,75,,12.7,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,80,,13.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.76,65,,11.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,35,,5.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.05,90,,15.24,percent of total billed charges,90% of total billed charges for outpatient setting,2.72,19.05,
DEXAMETHASONE (DECADRON) SOL 1%  5ML,3300897,CDM,259,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,70,,28,percent of total billed charges,70% of total billed charges for outpatient setting,42.44,84.88,,33.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,25,50,,20,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,75,,30,percent of total billed charges,75% of total billed charges for outpatient setting,35,70,,28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40,80,,32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,6.42,12.84,,5.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.5,65,,26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.5,35,,14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45,90,,36,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,45,
DEXAMETHASONE (DECADRON) TAB : 0.5 MG,3300894,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DEXAMETHASONE (DECADRON)INJ 4MG/ML :30ML,3300899,CDM,250,RC,,,Outpatient,,,45.3,45.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.71,70,,25.37,percent of total billed charges,70% of total billed charges for outpatient setting,38.45,84.88,,30.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.65,50,,18.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.98,75,,27.18,percent of total billed charges,75% of total billed charges for outpatient setting,31.71,70,,25.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,12.84,,4.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,80,,28.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.82,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.45,65,,23.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,35,,12.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.77,90,,32.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.82,40.77,
DEXAMETHASONE (genDECADRON) 4 MG TAB,3300896,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DEXAMETHASONE (genDECADRON) 4MG/ML 1ML,3300898,CDM,250,RC,J1100,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.12,2.92,
DEXAMETHASONE (genDECADRON) 4MG/ML 5ML,3300900,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DEXAMETHASONE (genDECADRON)10MG/ML 1 ML,3307002,CDM,250,RC,J1100,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.12,2.92,
DEXAMETHASONE 0.4MG (DEXTENZA) OCULAR,3313871,CDM,636,RC,J1096,HCPCS,Outpatient,,,1942.5,1942.5,,208.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1359.75,70,,1087.8,percent of total billed charges,70% of total billed charges for outpatient setting,1648.79,84.88,,1319.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,149.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1456.88,75,,1165.5,percent of total billed charges,75% of total billed charges for outpatient setting,1359.75,70,,1087.8,percent of total billed charges,70% of total billed charges for outpatient setting,222.02,170,,,Fee Schedule,170% of Medicare OPPS rate,280.79,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,249.42,12.84,,199.536,percent of total billed charges,12.84% of total billed charges,228.55,175,,,Fee Schedule,175% of Medicare OPPS rate,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1554,80,,1243.2,percent of total billed charges,80% of total billed charges for outpatient setting,182.84,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,163.25,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,249.42,12.84,,199.54,percent of total billed charges,12.84% of total billed charges,249.42,12.84,,199.54,percent of total billed charges,12.84% of total billed charges,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1262.63,65,,1010.1,percent of total billed charges,65% of total billed charges for outpatient setting,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.6,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.98,100,,,Fee Schedule,100% of Custom Fee Schedule,1748.25,90,,1398.6,percent of total billed charges,90% of total billed charges for outpatient setting,130.6,1748.25,
DEXAMETHSONE(DECADRON)ELX 0.5MG/ML:100ML,3300895,CDM,250,RC,,,Outpatient,,,33.57,33.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.5,70,,18.8,percent of total billed charges,70% of total billed charges for outpatient setting,28.49,84.88,,22.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.79,50,,13.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.18,75,,20.14,percent of total billed charges,75% of total billed charges for outpatient setting,23.5,70,,18.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.86,80,,21.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.82,65,,17.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,35,,9.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.21,90,,24.17,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,30.21,
DEXTROSE 10% INJ USP 1000ML/ 2B1064,3359006,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 20% SOL : 500 ML,3300903,CDM,258,RC,,,Outpatient,,,327.21,327.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.05,70,,183.24,percent of total billed charges,70% of total billed charges for outpatient setting,277.74,84.88,,222.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,163.61,50,,130.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.41,75,,196.33,percent of total billed charges,75% of total billed charges for outpatient setting,229.05,70,,183.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.01,12.84,,33.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.77,80,,209.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.01,12.84,,33.61,percent of total billed charges,12.84% of total billed charges,42.01,12.84,,33.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,212.69,65,,170.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.52,35,,91.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,294.49,90,,235.59,percent of total billed charges,90% of total billed charges for outpatient setting,42.01,294.49,
DEXTROSE 25% SOL 10 ML SYRINGE,3300902,CDM,258,RC,,,Outpatient,,,53.75,53.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.63,70,,30.1,percent of total billed charges,70% of total billed charges for outpatient setting,45.62,84.88,,36.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.88,50,,21.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.31,75,,32.25,percent of total billed charges,75% of total billed charges for outpatient setting,37.63,70,,30.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,12.84,,5.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43,80,,34.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,12.84,,5.52,percent of total billed charges,12.84% of total billed charges,6.9,12.84,,5.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.94,65,,27.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.81,35,,15.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,90% of total billed charges for outpatient setting,6.9,48.38,
DEXTROSE 5% .2% NACL 500ML/ 2B1093Q,3359013,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .2% NACL INJ 1000ML/ 2B1094,3359014,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .33% NACL 1000ML/ 2B1084,3359012,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .45% NACL INJ 1000ML/ 2B1074,3359011,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .45% NACL INJ 500ML/ 2B1073Q,3359010,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .9% NACL INJ 1000ML/ 2B1064,3359009,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% .9% NACL INJ 500ML/ 2B1063Q,3359008,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% in WATER SOL: 500 ML,3308833,CDM,258,RC,J7060,HCPCS,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,100,,,Fee Schedule,100% of Custom Fee Schedule,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,1.91,136.1,
DEXTROSE 5% INJ SNG 100ML/ 2B50087,3359004,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% INJ USP 1000ML/ 2B0064,3359003,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% INJ USP 150ML / 2B0061,3359000,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% INJ USP 250ML/ 2B0062Q,3359001,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% INJ USP 500ML/ 2B0063Q,3359002,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% LACT RINGER 1000ML/ 2B2074,3359024,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
DEXTROSE 5% SOL: 250 ML,3300904,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
DEXTROSE 50%  500C,3302855,CDM,250,RC,,,Outpatient,,,406.2,406.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.34,70,,227.47,percent of total billed charges,70% of total billed charges for outpatient setting,344.78,84.88,,275.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.1,50,,162.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.65,75,,243.72,percent of total billed charges,75% of total billed charges for outpatient setting,284.34,70,,227.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.16,12.84,,41.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.96,80,,259.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.16,12.84,,41.73,percent of total billed charges,12.84% of total billed charges,52.16,12.84,,41.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.03,65,,211.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.17,35,,113.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.58,90,,292.46,percent of total billed charges,90% of total billed charges for outpatient setting,52.16,365.58,
DEXTROSE 50% LFS SOL  50 ML SYRINGE,3300905,CDM,250,RC,J7799,HCPCS,Outpatient,,,57.54,57.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,70,,32.22,percent of total billed charges,70% of total billed charges for outpatient setting,48.84,84.88,,39.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.16,75,,34.53,percent of total billed charges,75% of total billed charges for outpatient setting,40.28,70,,32.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.39,12.84,,5.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.03,80,,36.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.39,12.84,,5.91,percent of total billed charges,12.84% of total billed charges,7.39,12.84,,5.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.4,65,,29.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.14,35,,16.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.79,90,,41.43,percent of total billed charges,90% of total billed charges for outpatient setting,7.39,51.79,
DEXTROSE 70% 2000 ML BAG: INJ,3303080,CDM,250,RC,,,Outpatient,,,201.58,201.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.11,70,,112.89,percent of total billed charges,70% of total billed charges for outpatient setting,171.1,84.88,,136.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.79,50,,80.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.19,75,,120.95,percent of total billed charges,75% of total billed charges for outpatient setting,141.11,70,,112.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.26,80,,129.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,25.88,12.84,,20.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.03,65,,104.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.55,35,,56.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.42,90,,145.14,percent of total billed charges,90% of total billed charges for outpatient setting,25.88,181.42,
DHEA,220795,CDM,301,RC,82626,HCPCS,Outpatient,,,113.72,102.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.6,70,,63.68,percent of total billed charges,70% of total billed charges for outpatient setting,96.53,84.88,,77.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.29,75,,68.23,percent of total billed charges,75% of total billed charges for outpatient setting,79.6,70,,63.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.98,80,,72.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.9,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.93,100,,,Fee Schedule,100% of Custom Fee Schedule,102.35,90,,81.88,percent of total billed charges,90% of total billed charges for outpatient setting,25.27,102.35,
DHEA-S,220723,CDM,301,RC,82627,HCPCS,Outpatient,,,100.04,90.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.03,70,,56.02,percent of total billed charges,70% of total billed charges for outpatient setting,84.91,84.88,,67.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,75.03,75,,60.02,percent of total billed charges,75% of total billed charges for outpatient setting,70.03,70,,56.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.03,80,,64.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.16,100,,,Fee Schedule,100% of Custom Fee Schedule,90.04,90,,72.03,percent of total billed charges,90% of total billed charges for outpatient setting,22.23,90.04,
DHT DIHYDROTESTOSTERONE,220256,CDM,301,RC,82642,HCPCS,Outpatient,,,69.89,62.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.92,70,,39.14,percent of total billed charges,70% of total billed charges for outpatient setting,59.32,84.88,,47.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,52.42,75,,41.94,percent of total billed charges,75% of total billed charges for outpatient setting,48.92,70,,39.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.91,80,,44.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.65,100,,,Fee Schedule,100% of Custom Fee Schedule,62.9,90,,50.32,percent of total billed charges,90% of total billed charges for outpatient setting,25.18,62.9,
DIAGNOSTIC 3D TOMOSYNTHESIS BILATERAL,2710100,CDM,401,RC,G0279,HCPCS,Outpatient,,,316.58,316.58,,34.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,221.61,70,,177.29,percent of total billed charges,70% of total billed charges for outpatient setting,268.71,84.88,,214.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.44,75,,189.95,percent of total billed charges,75% of total billed charges for outpatient setting,221.61,70,,177.29,percent of total billed charges,70% of total billed charges for outpatient setting,72.23,170,,,Fee Schedule,170% of Medicare OPPS rate,45.95,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,37.4,175,,,Fee Schedule,175% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.26,80,,202.61,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,26.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.39,100,,,Fee Schedule,100% of Custom Fee Schedule,284.92,90,,227.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.37,284.92,
DIAGNOSTIC 3D TOMOSYNTHESIS UNILATERAL,2710105,CDM,401,RC,G0279,HCPCS,Outpatient,,,316.58,316.58,,34.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,221.61,70,,177.29,percent of total billed charges,70% of total billed charges for outpatient setting,268.71,84.88,,214.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.44,75,,189.95,percent of total billed charges,75% of total billed charges for outpatient setting,221.61,70,,177.29,percent of total billed charges,70% of total billed charges for outpatient setting,72.23,170,,,Fee Schedule,170% of Medicare OPPS rate,45.95,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,37.4,175,,,Fee Schedule,175% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.26,80,,202.61,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,26.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,40.65,12.84,,32.52,percent of total billed charges,12.84% of total billed charges,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.39,100,,,Fee Schedule,100% of Custom Fee Schedule,284.92,90,,227.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.37,284.92,
DIALATOR 15FRX10CM URO BALLOON / 225136,69169552,CDM,272,RC,,,Outpatient,,,987.24,987.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.07,70,,552.86,percent of total billed charges,70% of total billed charges for outpatient setting,837.97,84.88,,670.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,493.62,50,,394.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,740.43,75,,592.34,percent of total billed charges,75% of total billed charges for outpatient setting,691.07,70,,552.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.76,12.84,,101.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.79,80,,631.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.76,12.84,,101.41,percent of total billed charges,12.84% of total billed charges,126.76,12.84,,101.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,641.71,65,,513.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.53,35,,276.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,888.52,90,,710.82,percent of total billed charges,90% of total billed charges for outpatient setting,126.76,888.52,
DIALATOR 15FRX4CM UROMX BALLOON / 225121,6150759,CDM,272,RC,,,Outpatient,,,987.24,987.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.07,70,,552.86,percent of total billed charges,70% of total billed charges for outpatient setting,837.97,84.88,,670.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,493.62,50,,394.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,740.43,75,,592.34,percent of total billed charges,75% of total billed charges for outpatient setting,691.07,70,,552.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.76,12.84,,101.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.79,80,,631.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.76,12.84,,101.41,percent of total billed charges,12.84% of total billed charges,126.76,12.84,,101.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,641.71,65,,513.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.53,35,,276.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,888.52,90,,710.82,percent of total billed charges,90% of total billed charges for outpatient setting,126.76,888.52,
DIALATOR 18FRX10CM URO BALLOON / 225137,69169553,CDM,272,RC,,,Outpatient,,,977.13,977.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.99,70,,547.19,percent of total billed charges,70% of total billed charges for outpatient setting,829.39,84.88,,663.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,488.57,50,,390.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,732.85,75,,586.28,percent of total billed charges,75% of total billed charges for outpatient setting,683.99,70,,547.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.46,12.84,,100.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.7,80,,625.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.46,12.84,,100.37,percent of total billed charges,12.84% of total billed charges,125.46,12.84,,100.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.13,65,,508.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,35,,273.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,879.42,90,,703.54,percent of total billed charges,90% of total billed charges for outpatient setting,125.46,879.42,
DIALATOR 18FRx4CM UROMAX BALLOON/ 225122,6150778,CDM,272,RC,,,Outpatient,,,1255.94,1255.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.16,70,,703.33,percent of total billed charges,70% of total billed charges for outpatient setting,1066.04,84.88,,852.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,627.97,50,,502.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,941.96,75,,753.57,percent of total billed charges,75% of total billed charges for outpatient setting,879.16,70,,703.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.26,12.84,,129.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.75,80,,803.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.26,12.84,,129.01,percent of total billed charges,12.84% of total billed charges,161.26,12.84,,129.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,816.36,65,,653.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.58,35,,351.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1130.35,90,,904.28,percent of total billed charges,90% of total billed charges for outpatient setting,161.26,1130.35,
DIALATOR 21FRX4CM / 225123,69162883,CDM,272,RC,,,Outpatient,,,977.16,977.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.01,70,,547.21,percent of total billed charges,70% of total billed charges for outpatient setting,829.41,84.88,,663.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,488.58,50,,390.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,732.87,75,,586.3,percent of total billed charges,75% of total billed charges for outpatient setting,684.01,70,,547.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.47,12.84,,100.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.73,80,,625.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.47,12.84,,100.38,percent of total billed charges,12.84% of total billed charges,125.47,12.84,,100.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.15,65,,508.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.01,35,,273.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,879.44,90,,703.55,percent of total billed charges,90% of total billed charges for outpatient setting,125.47,879.44,
DIALATOR 24FRX4CM URO BALLOON / 225124,69162768,CDM,272,RC,,,Outpatient,,,977.16,977.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.01,70,,547.21,percent of total billed charges,70% of total billed charges for outpatient setting,829.41,84.88,,663.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,488.58,50,,390.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,732.87,75,,586.3,percent of total billed charges,75% of total billed charges for outpatient setting,684.01,70,,547.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.47,12.84,,100.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.73,80,,625.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.47,12.84,,100.38,percent of total billed charges,12.84% of total billed charges,125.47,12.84,,100.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.15,65,,508.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.01,35,,273.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,879.44,90,,703.55,percent of total billed charges,90% of total billed charges for outpatient setting,125.47,879.44,
DIAMOX: ACETAZOLAMIDE 500 MG INJ,3303277,CDM,250,RC,,,Outpatient,,,219.24,219.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.47,70,,122.78,percent of total billed charges,70% of total billed charges for outpatient setting,186.09,84.88,,148.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.62,50,,87.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.43,75,,131.54,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,70,,122.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.15,12.84,,22.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.39,80,,140.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.15,12.84,,22.52,percent of total billed charges,12.84% of total billed charges,28.15,12.84,,22.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.51,65,,114.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.73,35,,61.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,197.32,90,,157.86,percent of total billed charges,90% of total billed charges for outpatient setting,28.15,197.32,
DIATX ZN: TAB,3303138,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
DIAZEPAM  5MG/ML  2ML CARPUJECT,3300909,CDM,636,RC,J3360,HCPCS,Outpatient,,,147.32,147.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.12,70,,82.5,percent of total billed charges,70% of total billed charges for outpatient setting,125.05,84.88,,100.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,110.49,75,,88.39,percent of total billed charges,75% of total billed charges for outpatient setting,103.12,70,,82.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,12.84,,15.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,80,,94.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,12.84,,15.14,percent of total billed charges,12.84% of total billed charges,18.92,12.84,,15.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.76,65,,76.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of Custom Fee Schedule,132.59,90,,106.07,percent of total billed charges,90% of total billed charges for outpatient setting,7.36,132.59,
DIAZEPAM  genericVALIUM 5MG TAB,3300907,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIAZEPAM (VALIUM) INJ 5MG/ML:1ML,3300910,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,70,,3.92,percent of total billed charges,70% of total billed charges for outpatient setting,5.94,84.88,,4.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.5,50,,2.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.25,75,,4.2,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,70,,3.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.6,80,,4.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.55,65,,3.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,35,,1.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.3,90,,5.04,percent of total billed charges,90% of total billed charges for outpatient setting,0.9,6.3,
DIAZEPAM (VALIUM) TAB : 2 MG,3300906,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DIAZEPAM (VALIUM) TAB 2MG:,3300908,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DIAZEPAM INJ 5MG/ML 1ML UD CHG,3302558,CDM,250,RC,,,Outpatient,,,146.59,146.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.61,70,,82.09,percent of total billed charges,70% of total billed charges for outpatient setting,124.43,84.88,,99.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.3,50,,58.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.94,75,,87.95,percent of total billed charges,75% of total billed charges for outpatient setting,102.61,70,,82.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.82,12.84,,15.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.27,80,,93.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.82,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,18.82,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.28,65,,76.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,35,,41.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.93,90,,105.54,percent of total billed charges,90% of total billed charges for outpatient setting,18.82,131.93,
DIAZEPAM VALIUM 5MG PER ML MULTI 10ML,3310331,CDM,636,RC,J3360,HCPCS,Outpatient,,,177.87,177.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.51,70,,99.61,percent of total billed charges,70% of total billed charges for outpatient setting,150.98,84.88,,120.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,133.4,75,,106.72,percent of total billed charges,75% of total billed charges for outpatient setting,124.51,70,,99.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,12.84,,18.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.3,80,,113.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,12.84,,18.27,percent of total billed charges,12.84% of total billed charges,22.84,12.84,,18.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.62,65,,92.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of Custom Fee Schedule,160.08,90,,128.06,percent of total billed charges,90% of total billed charges for outpatient setting,7.36,160.08,
DIAZEPAM: 10 MG TABS,3302957,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DIAZOXIDE (HYPERSTAT) INJ 300MG : 20ML,3300911,CDM,250,RC,,,Outpatient,,,391.46,391.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.02,70,,219.22,percent of total billed charges,70% of total billed charges for outpatient setting,332.27,84.88,,265.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,195.73,50,,156.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.6,75,,234.88,percent of total billed charges,75% of total billed charges for outpatient setting,274.02,70,,219.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,12.84,,40.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.17,80,,250.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,12.84,,40.21,percent of total billed charges,12.84% of total billed charges,50.26,12.84,,40.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,254.45,65,,203.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.01,35,,109.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.31,90,,281.85,percent of total billed charges,90% of total billed charges for outpatient setting,50.26,352.31,
DICLOFENAC (genVOLTAREN)TOP GEL 1% 100GM,3313610,CDM,259,RC,,,Outpatient,,,128.14,128.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.7,70,,71.76,percent of total billed charges,70% of total billed charges for outpatient setting,108.77,84.88,,87.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.07,50,,51.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.11,75,,76.89,percent of total billed charges,75% of total billed charges for outpatient setting,89.7,70,,71.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.51,80,,82.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,16.45,12.84,,13.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,83.29,65,,66.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.85,35,,35.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,115.33,90,,92.26,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,115.33,
DICLOFENAC (VOLTAREN) OPTH SOL 0.1%:2.5,3300912,CDM,259,RC,,,Outpatient,,,86.89,86.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.82,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,73.75,84.88,,59,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.45,50,,34.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.17,75,,52.14,percent of total billed charges,75% of total billed charges for outpatient setting,60.82,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.51,80,,55.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.48,65,,45.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.41,35,,24.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.2,90,,62.56,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,78.2,
DICLOFENAC (VOLTAREN) OPTH SOL 0.1%:5ML,3300913,CDM,259,RC,,,Outpatient,,,141.81,141.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.27,70,,79.42,percent of total billed charges,70% of total billed charges for outpatient setting,120.37,84.88,,96.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.91,50,,56.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.36,75,,85.09,percent of total billed charges,75% of total billed charges for outpatient setting,99.27,70,,79.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,12.84,,14.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.45,80,,90.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,12.84,,14.57,percent of total billed charges,12.84% of total billed charges,18.21,12.84,,14.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.18,65,,73.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,35,,39.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.63,90,,102.1,percent of total billed charges,90% of total billed charges for outpatient setting,18.21,127.63,
DICLOFENAC (VOLTAREN) TAB : 25 MG,3300914,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DICLOFENAC NA (VOLTAREN) 50MG:TAB,3303294,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
DICLOXACILLIN (DYNAPEN) TAB : 250 MG,3300915,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DICLOXACILLIN : 250 MG,3303212,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
DICYCLOMINE (BENTYL)  CAPSULE 10MG,3308598,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DICYCLOMINE (BENTYL) CAP : 10 MG,3300916,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DICYCLOMINE 10MG/5ML SOLN.(ORAL),3304050,CDM,259,RC,,,Outpatient,,,2.85,2.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,70,,1.6,percent of total billed charges,70% of total billed charges for outpatient setting,2.42,84.88,,1.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.43,50,,1.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.14,75,,1.71,percent of total billed charges,75% of total billed charges for outpatient setting,2,70,,1.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.37,12.84,,0.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,80,,1.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.37,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,0.37,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.85,65,,1.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,35,,0.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.57,90,,2.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.37,2.57,
DIFLORASONE DIACE.(APEXICON)30GM:CRM,3303143,CDM,259,RC,,,Outpatient,,,190.05,190.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.04,70,,106.43,percent of total billed charges,70% of total billed charges for outpatient setting,161.31,84.88,,129.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,95.03,50,,76.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.54,75,,114.03,percent of total billed charges,75% of total billed charges for outpatient setting,133.04,70,,106.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.04,80,,121.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.53,65,,98.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.52,35,,53.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171.05,90,,136.84,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,171.05,
DIGITAL MAMMO DIAGNOSTIC BIL w CAD PP,2710041,CDM,403,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
DIGITAL MAMMO NEEDLE LOCALIZATION,2700050,CDM,320,RC,19281,HCPCS,Outpatient,,,917.7,688.28,,892.21,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,642.39,70,,513.91,percent of total billed charges,70% of total billed charges for outpatient setting,778.94,84.88,,623.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,796.72,50,,637.38,percent of total billed charges,50% of total Billed charges for outpatient setting,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,688.28,75,,550.62,percent of total billed charges,75% of total billed charges for outpatient setting,642.39,70,,513.91,percent of total billed charges,70% of total billed charges for outpatient setting,947.98,170,,,Fee Schedule,170% of Medicare OPPS rate,1198.91,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,117.83,12.84,,94.264,percent of total billed charges,12.84% of total billed charges,975.86,175,,,Fee Schedule,175% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,734.16,80,,587.33,percent of total billed charges,80% of total billed charges for outpatient setting,780.68,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,697.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,117.83,12.84,,94.26,percent of total billed charges,12.84% of total billed charges,117.83,12.84,,94.26,percent of total billed charges,12.84% of total billed charges,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,825.93,90,,660.74,percent of total billed charges,90% of total billed charges for outpatient setting,116.88,1198.91,
DIGITAL MAMMO SCREEN BIL w CAD  PP,2710045,CDM,403,RC,77067,HCPCS,Outpatient,,,281.09,281.09,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,196.76,70,,157.41,percent of total billed charges,70% of total billed charges for outpatient setting,238.59,84.88,,190.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,210.82,75,,168.66,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,70,,157.41,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,36.09,12.84,,28.872,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,224.87,80,,179.9,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,36.09,12.84,,28.87,percent of total billed charges,12.84% of total billed charges,36.09,12.84,,28.87,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,252.98,90,,202.38,percent of total billed charges,90% of total billed charges for outpatient setting,36.09,281.76,
DIGITAL MAMMO SCREENING BIL IMPLANTS CAD,2710040,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
DIGITAL MAMMO SPOT COMPRESSION,2700026,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
DIGITAL MAMMOGRAPHY AXILLARY,2710039,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
DIGITAL MAMMOGRAPHY DIAG BIL w/ CAD,2710034,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
DIGITAL MAMMOGRAPHY DIAG IMPLANTS w/ CAD,2710038,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
DIGITAL MAMMOGRAPHY DIAG UNI w CAD,2710035,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
DIGITAL MAMMOGRAPHY DIAGNOSTIC BILATERAL,2710031,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
DIGITAL MAMMOGRAPHY DIAGNOSTIC UNILAT,2710032,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
DIGITAL MAMMOGRAPHY SCREENING BIL W/CAD,2710036,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
DIGITAL MAMMOGRAPHY SCREENING UNI w CAD,2710037,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
DIGITAL MAMMOGRAPHY SCREENING UNILATERAL,2700025,CDM,403,RC,77067,HCPCS,Outpatient,,,301.5,301.5,,131.7,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,281.76,170,,,Fee Schedule,170% of Medicare OPPS rate,176.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,144.04,175,,,Fee Schedule,175% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,115.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,102.89,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.31,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.27,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,281.76,
DIGITEX 2-0 SUTURE CARTRIDGE / 52027,69162572,CDM,272,RC,,,Outpatient,,,159.71,159.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.8,70,,89.44,percent of total billed charges,70% of total billed charges for outpatient setting,135.56,84.88,,108.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.86,50,,63.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.78,75,,95.82,percent of total billed charges,75% of total billed charges for outpatient setting,111.8,70,,89.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.51,12.84,,16.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.77,80,,102.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.51,12.84,,16.41,percent of total billed charges,12.84% of total billed charges,20.51,12.84,,16.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,103.81,65,,83.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.9,35,,44.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.74,90,,114.99,percent of total billed charges,90% of total billed charges for outpatient setting,20.51,143.74,
DIGITEX SUTURE DEL DEVICE / 52025,69162571,CDM,272,RC,,,Outpatient,,,1470,1470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,70,,823.2,percent of total billed charges,70% of total billed charges for outpatient setting,1247.74,84.88,,998.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,735,50,,588,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1102.5,75,,882,percent of total billed charges,75% of total billed charges for outpatient setting,1029,70,,823.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,80,,940.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,955.5,65,,764.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,35,,411.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1323,90,,1058.4,percent of total billed charges,90% of total billed charges for outpatient setting,188.75,1323,
DIGOXIN,220029,CDM,300,RC,80162,HCPCS,Outpatient,,,59.76,53.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,50.72,84.88,,40.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.82,75,,35.86,percent of total billed charges,75% of total billed charges for outpatient setting,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.81,80,,38.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.39,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of Custom Fee Schedule,53.78,90,,43.02,percent of total billed charges,90% of total billed charges for outpatient setting,13.28,53.78,
DIGOXIN  0.25MG PER ML INJ 2ML,3300921,CDM,636,RC,J1160,HCPCS,Outpatient,,,22.93,22.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,70,,12.84,percent of total billed charges,70% of total billed charges for outpatient setting,19.46,84.88,,15.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.2,75,,13.76,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,70,,12.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.34,80,,14.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.9,65,,11.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of Custom Fee Schedule,20.64,90,,16.51,percent of total billed charges,90% of total billed charges for outpatient setting,2.94,20.64,
DIGOXIN (LANOXICAPS) CAP: 0.1 MG,3300917,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DIGOXIN (LANOXIN) 0.25MG/ML INJ :2ML,3300922,CDM,250,RC,,,Outpatient,,,6.14,6.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,70,,3.44,percent of total billed charges,70% of total billed charges for outpatient setting,5.21,84.88,,4.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.07,50,,2.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.61,75,,3.69,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,70,,3.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.79,12.84,,0.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,80,,3.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.79,12.84,,0.63,percent of total billed charges,12.84% of total billed charges,0.79,12.84,,0.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.99,65,,3.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,35,,1.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.53,90,,4.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.79,5.53,
DIGOXIN (LANOXIN) TAB  0.125 MG,3300918,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIGOXIN (LANOXIN) TAB: 0.25 MG,3300919,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DIGOXIN QN,201140,CDM,300,RC,80162,HCPCS,Outpatient,,,59.76,53.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,50.72,84.88,,40.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.82,75,,35.86,percent of total billed charges,75% of total billed charges for outpatient setting,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.81,80,,38.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.39,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of Custom Fee Schedule,53.78,90,,43.02,percent of total billed charges,90% of total billed charges for outpatient setting,13.28,53.78,
DIHYDROERGTNE (MIGRANAL) INJ 4MG/ML:1ML,3300923,CDM,250,RC,,,Outpatient,,,60.56,60.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,51.4,84.88,,41.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.28,50,,24.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.42,75,,36.34,percent of total billed charges,75% of total billed charges for outpatient setting,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.45,80,,38.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.36,65,,31.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.2,35,,16.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.5,90,,43.6,percent of total billed charges,90% of total billed charges for outpatient setting,7.78,54.5,
DILANTIN 100MG CAP:,3302571,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DILANTIN 100MG CAP: UD,3302572,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILANTIN 125MG/5ML LIQ:240ML,3302574,CDM,259,RC,,,Outpatient,,,94.22,94.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.95,70,,52.76,percent of total billed charges,70% of total billed charges for outpatient setting,79.97,84.88,,63.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.11,50,,37.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.67,75,,56.54,percent of total billed charges,75% of total billed charges for outpatient setting,65.95,70,,52.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,12.84,,9.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.38,80,,60.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,12.84,,9.68,percent of total billed charges,12.84% of total billed charges,12.1,12.84,,9.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.24,65,,48.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.98,35,,26.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.8,90,,67.84,percent of total billed charges,90% of total billed charges for outpatient setting,12.1,84.8,
DILANTIN 50/ML INJ : 2ML,3302570,CDM,250,RC,,,Outpatient,,,11.42,11.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.99,70,,6.39,percent of total billed charges,70% of total billed charges for outpatient setting,9.69,84.88,,7.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.71,50,,4.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,70,,6.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.42,65,,5.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,35,,3.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.28,90,,8.22,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.28,
DILANTIN 50/ML INJ: 5ML,3302569,CDM,250,RC,,,Outpatient,,,12.09,12.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,70,,6.77,percent of total billed charges,70% of total billed charges for outpatient setting,10.26,84.88,,8.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.05,50,,4.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.07,75,,7.26,percent of total billed charges,75% of total billed charges for outpatient setting,8.46,70,,6.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,80,,7.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.86,65,,6.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,35,,3.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.88,90,,8.7,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,10.88,
DILANTIN CHEW: 50MG,3302573,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILATION OF NEPHROSTOMY,2400795,CDM,320,RC,74485,HCPCS,Outpatient,,,5696.28,4272.21,,2567.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3987.4,70,,3189.92,percent of total billed charges,70% of total billed charges for outpatient setting,4835,84.88,,3868,percent of total billed charges,84.88% of total billed charges for outpatient setting,2358.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4272.21,75,,3417.77,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,2727.63,170,,,Fee Schedule,170% of Medicare OPPS rate,3449.66,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,731.4,12.84,,585.12,percent of total billed charges,12.84% of total billed charges,2807.86,175,,,Fee Schedule,175% of Medicare OPPS rate,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4557.02,80,,3645.62,percent of total billed charges,80% of total billed charges for outpatient setting,2246.29,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,2005.61,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,731.4,12.84,,585.12,percent of total billed charges,12.84% of total billed charges,731.4,12.84,,585.12,percent of total billed charges,12.84% of total billed charges,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1604.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1433.21,100,,,Fee Schedule,100% of Custom Fee Schedule,5126.65,90,,4101.32,percent of total billed charges,90% of total billed charges for outpatient setting,128,5126.65,
DILATOR 11-13MM FIXED / BD-400P-1380,1865147,CDM,272,RC,,,Outpatient,,,536,536,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,454.96,84.88,,363.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402,75,,321.6,percent of total billed charges,75% of total billed charges for outpatient setting,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.8,80,,343.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.4,65,,278.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.4,90,,385.92,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.4,
DILATOR 13.5-15.5MM FIXED / BD-400P-1580,1865148,CDM,272,RC,,,Outpatient,,,536,536,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,454.96,84.88,,363.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402,75,,321.6,percent of total billed charges,75% of total billed charges for outpatient setting,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.8,80,,343.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.4,65,,278.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.4,90,,385.92,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.4,
DILATOR 16-18MM FIXED EZDILATE / BD-400P,1865149,CDM,272,RC,,,Outpatient,,,562.4,562.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.68,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,477.37,84.88,,381.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.2,50,,224.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.8,75,,337.44,percent of total billed charges,75% of total billed charges for outpatient setting,393.68,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.92,80,,359.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,365.56,65,,292.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.84,35,,157.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.16,90,,404.93,percent of total billed charges,90% of total billed charges for outpatient setting,72.21,506.16,
DILATOR 8.5-10.5MM FIXED / BD-400P-1080,1865146,CDM,272,RC,,,Outpatient,,,536,536,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,454.96,84.88,,363.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402,75,,321.6,percent of total billed charges,75% of total billed charges for outpatient setting,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.8,80,,343.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.4,65,,278.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,35,,150.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.4,90,,385.92,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,482.4,
DILATOR ESOPHAGEAL FIXED WIRE / 5838,69160953,CDM,272,RC,,,Outpatient,,,744.07,744.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,631.57,84.88,,505.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,372.04,50,,297.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.05,75,,446.44,percent of total billed charges,75% of total billed charges for outpatient setting,520.85,70,,416.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.26,80,,476.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,95.54,12.84,,76.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.65,65,,386.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.42,35,,208.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.66,90,,535.73,percent of total billed charges,90% of total billed charges for outpatient setting,95.54,669.66,
DILAUDID TAB 2MG:,3302577,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DILAUDID TAB 2MG:,3302579,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILAUDID TAB 4MG:,3302575,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DILAUDID TAB 4MG:,3302576,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (CARDIZEM) CAP : 120 MG,3300933,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DILTIAZEM (CARDIZEM) INJ 5MG/ML :5ML,3300927,CDM,250,RC,,,Outpatient,,,12.95,12.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,10.99,84.88,,8.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.48,50,,5.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.71,75,,7.77,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,70,,7.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.36,80,,8.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.42,65,,6.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,35,,3.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.66,90,,9.33,percent of total billed charges,90% of total billed charges for outpatient setting,1.66,11.66,
DILTIAZEM (CARDIZEM) INJ 5MG/ML :5ML,3300932,CDM,250,RC,,,Outpatient,,,23.05,23.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,70,,12.91,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.53,50,,9.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.29,75,,13.83,percent of total billed charges,75% of total billed charges for outpatient setting,16.14,70,,12.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,12.84,,2.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.44,80,,14.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,12.84,,2.37,percent of total billed charges,12.84% of total billed charges,2.96,12.84,,2.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.98,65,,11.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,35,,6.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.75,90,,16.6,percent of total billed charges,90% of total billed charges for outpatient setting,2.96,20.75,
DILTIAZEM (CARDIZEM) INJ 5MG/ML :5ML,3300937,CDM,250,RC,,,Outpatient,,,71.93,71.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.35,70,,40.28,percent of total billed charges,70% of total billed charges for outpatient setting,61.05,84.88,,48.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.97,50,,28.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.95,75,,43.16,percent of total billed charges,75% of total billed charges for outpatient setting,50.35,70,,40.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.24,12.84,,7.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.54,80,,46.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.24,12.84,,7.39,percent of total billed charges,12.84% of total billed charges,9.24,12.84,,7.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.75,65,,37.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.18,35,,20.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.74,90,,51.79,percent of total billed charges,90% of total billed charges for outpatient setting,9.24,64.74,
DILTIAZEM (CARDIZEM) TAB : 60 MG,3300925,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM CD) CAP 240 MG,3300938,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM CD) CAP 300MG,3300934,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM CD) CAP 360MG,3303246,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM) 5MG/ML INJ 25ML,3303337,CDM,250,RC,,,Outpatient,,,53.62,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.53,70,,30.02,percent of total billed charges,70% of total billed charges for outpatient setting,45.51,84.88,,36.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.81,50,,21.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.22,75,,32.18,percent of total billed charges,75% of total billed charges for outpatient setting,37.53,70,,30.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,12.84,,5.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.9,80,,34.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,6.88,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.85,65,,27.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.77,35,,15.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.26,90,,38.61,percent of total billed charges,90% of total billed charges for outpatient setting,6.88,48.26,
DILTIAZEM (genCARDIZEM) CAP 120 MG,3300935,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM) CAP 90 MG,3300928,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM) ER CAP 240 MG,3300931,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM) ER CAP120 MG,3300930,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DILTIAZEM (genCARDIZEM) TAB 30 MG,3300924,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DILTIAZEM (genericCARDIZEM CD) 180 MG,3300936,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DILTIAZEM 50MG/10ML,3302669,CDM,250,RC,,,Outpatient,,,77.61,77.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,70,,43.46,percent of total billed charges,70% of total billed charges for outpatient setting,65.88,84.88,,52.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.81,50,,31.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.21,75,,46.57,percent of total billed charges,75% of total billed charges for outpatient setting,54.33,70,,43.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.09,80,,49.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.45,65,,40.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,35,,21.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.85,90,,55.88,percent of total billed charges,90% of total billed charges for outpatient setting,9.97,69.85,
DILTIAZEM SR (CARDIZEM) CAP : 90 MG,3300929,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DIMENHYDRINATE TAB: 50 MG,3300939,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
DIOVAN(VALSARTAN) 40MG: TAB,3302917,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DIPHENHYDRAMINE (BENADRYL) CAP : 25 MG,3300940,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DIPHENHYDRAMINE (BENADRYL) CPLT :25MG UD,3300942,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DIPHENHYDRAMINE (CALADRYL) LOT : 180 ML,3300947,CDM,259,RC,,,Outpatient,,,14.52,14.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.16,70,,8.13,percent of total billed charges,70% of total billed charges for outpatient setting,12.32,84.88,,9.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.26,50,,5.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.89,75,,8.71,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,70,,8.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.62,80,,9.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.44,65,,7.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.08,35,,4.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.07,90,,10.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.86,13.07,
DIPHENHYDRAMINE (DIPHENHIST) 2% CM :30GM,3300948,CDM,259,RC,,,Outpatient,,,8.9,8.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,84.88,,6.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.45,50,,3.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.68,75,,5.34,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,80,,5.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.79,65,,4.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.01,90,,6.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,8.01,
DIPHENHYDRAMINE (genBENADRYL) 50MG CAP,3300944,CDM,259,RC,Q0163,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.03,2.92,
DIPHENHYDRAMINE MINI TAB 25 MG,3302946,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIPHENHYDRAMINE(BENADRYL)LIQ 12.5MG:120,3300945,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIPHENHYDRAMINE(genBENADRYL)50MG/1ml inj,3300946,CDM,636,RC,J1200,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIPHENHYDRAMINE(genBENADRYL)CAP 25MG U/D,3300941,CDM,259,RC,Q0163,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.03,2.92,
DIPHENOXYLATE (LOMOTIL) 2.5MG TAB UD,3300950,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DIPHENOXYLATE (LOMOTIL) TAB: 2.5MG,3300949,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DIPHTH PERTUSS(ACELL)BOOSTRIX:0.5ML,3304130,CDM,636,RC,90714,HCPCS,Outpatient,,,156.16,156.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.31,70,,87.45,percent of total billed charges,70% of total billed charges for outpatient setting,132.55,84.88,,106.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,117.12,75,,93.7,percent of total billed charges,75% of total billed charges for outpatient setting,109.31,70,,87.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,12.84,,16.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.93,80,,99.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,12.84,,16.04,percent of total billed charges,12.84% of total billed charges,20.05,12.84,,16.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.5,65,,81.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,100% of Custom Fee Schedule,140.54,90,,112.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,140.54,
DIPIVEFRIN (PROPINE) OPTH SOL 0.1% : 5ML,3300951,CDM,259,RC,,,Outpatient,,,36.39,36.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,30.89,84.88,,24.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.2,50,,14.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.29,75,,21.83,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.11,80,,23.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.65,65,,18.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,35,,10.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.75,90,,26.2,percent of total billed charges,90% of total billed charges for outpatient setting,4.67,32.75,
DIPIVEFRIN (PROPINE) OPTH SOL 0.1% : 5ML,3300952,CDM,259,RC,,,Outpatient,,,37.95,37.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,32.21,84.88,,25.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.98,50,,15.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.46,75,,22.77,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.36,80,,24.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.67,65,,19.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,35,,10.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.16,90,,27.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.87,34.16,
DIPIVEFRIN (PROPINE) OPTH SOL 0.1% : 5ML,3300953,CDM,259,RC,,,Outpatient,,,64.5,64.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.15,70,,36.12,percent of total billed charges,70% of total billed charges for outpatient setting,54.75,84.88,,43.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.25,50,,25.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,75,,38.7,percent of total billed charges,75% of total billed charges for outpatient setting,45.15,70,,36.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,12.84,,6.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.6,80,,41.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,8.28,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.93,65,,33.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.58,35,,18.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.05,90,,46.44,percent of total billed charges,90% of total billed charges for outpatient setting,8.28,58.05,
DIPRIVAN 1%: 20 ML BRAND NAME,3303050,CDM,250,RC,,,Outpatient,,,141.87,141.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.31,70,,79.45,percent of total billed charges,70% of total billed charges for outpatient setting,120.42,84.88,,96.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.94,50,,56.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.4,75,,85.12,percent of total billed charges,75% of total billed charges for outpatient setting,99.31,70,,79.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,12.84,,14.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,80,,90.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,12.84,,14.58,percent of total billed charges,12.84% of total billed charges,18.22,12.84,,14.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.22,65,,73.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.65,35,,39.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.68,90,,102.14,percent of total billed charges,90% of total billed charges for outpatient setting,18.22,127.68,
DIPTHERIA ANTITOXOID ANTIBODIES,220149,CDM,302,RC,86317,HCPCS,Outpatient,,,67.46,60.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.26,84.88,,45.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,100,,,Fee Schedule,100% of Custom Fee Schedule,60.71,90,,48.57,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,60.71,
"DIPYRIDAMLE, INJ PER 10 MG",3300956,CDM,250,RC,,,Outpatient,,,56.26,56.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,70,,31.5,percent of total billed charges,70% of total billed charges for outpatient setting,47.75,84.88,,38.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.13,50,,22.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.2,75,,33.76,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,70,,31.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,12.84,,5.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.01,80,,36.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,7.22,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.57,65,,29.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,35,,15.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.63,90,,40.5,percent of total billed charges,90% of total billed charges for outpatient setting,7.22,50.63,
DIPYRIDAMOLE (AGGRENOX) CAP : 25 MG,3300959,CDM,259,RC,,,Outpatient,,,4.58,4.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,70,,2.57,percent of total billed charges,70% of total billed charges for outpatient setting,3.89,84.88,,3.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.29,50,,1.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.44,75,,2.75,percent of total billed charges,75% of total billed charges for outpatient setting,3.21,70,,2.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.59,12.84,,0.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.66,80,,2.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.59,12.84,,0.47,percent of total billed charges,12.84% of total billed charges,0.59,12.84,,0.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.98,65,,2.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,35,,1.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.12,90,,3.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.59,4.12,
DIPYRIDAMOLE (PERSANTINE) TAB : 25 MG,3300954,CDM,259,RC,J1245,HCPCS,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,100,,,Fee Schedule,100% of Custom Fee Schedule,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DIPYRIDAMOLE (PERSANTINE) TAB : 75 MG,3303170,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
DIPYRIDAMOLE (PERSANTINE)INJ 5MG/ML:10ML,3300955,CDM,250,RC,,,Outpatient,,,80.87,80.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.61,70,,45.29,percent of total billed charges,70% of total billed charges for outpatient setting,68.64,84.88,,54.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.44,50,,32.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.65,75,,48.52,percent of total billed charges,75% of total billed charges for outpatient setting,56.61,70,,45.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,12.84,,8.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.7,80,,51.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,12.84,,8.3,percent of total billed charges,12.84% of total billed charges,10.38,12.84,,8.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.57,65,,42.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.3,35,,22.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.78,90,,58.22,percent of total billed charges,90% of total billed charges for outpatient setting,10.38,72.78,
DIPYRIDAMOLE (PERSANTINE)INJ 5MG/ML:10ML,3300958,CDM,250,RC,,,Outpatient,,,404.09,404.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.86,70,,226.29,percent of total billed charges,70% of total billed charges for outpatient setting,342.99,84.88,,274.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.05,50,,161.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.07,75,,242.46,percent of total billed charges,75% of total billed charges for outpatient setting,282.86,70,,226.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,12.84,,41.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.27,80,,258.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,12.84,,41.51,percent of total billed charges,12.84% of total billed charges,51.89,12.84,,41.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,262.66,65,,210.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.43,35,,113.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.68,90,,290.94,percent of total billed charges,90% of total billed charges for outpatient setting,51.89,363.68,
DIPYRIDAMOLE (PERSANTNE)INJ 5MG/ML :10ML,3300957,CDM,250,RC,,,Outpatient,,,326.72,326.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.7,70,,182.96,percent of total billed charges,70% of total billed charges for outpatient setting,277.32,84.88,,221.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,163.36,50,,130.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.04,75,,196.03,percent of total billed charges,75% of total billed charges for outpatient setting,228.7,70,,182.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.95,12.84,,33.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.38,80,,209.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.95,12.84,,33.56,percent of total billed charges,12.84% of total billed charges,41.95,12.84,,33.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,212.37,65,,169.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.35,35,,91.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,294.05,90,,235.24,percent of total billed charges,90% of total billed charges for outpatient setting,41.95,294.05,
DIRECT BILIRUBIN,201145,CDM,300,RC,82248,HCPCS,Outpatient,,,22.59,20.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,20.33,
DIRECT COOMBS,201347,CDM,300,RC,86880,HCPCS,Outpatient,,,221.87,199.68,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.31,70,,124.25,percent of total billed charges,70% of total billed charges for outpatient setting,188.32,84.88,,150.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,166.4,75,,133.12,percent of total billed charges,75% of total billed charges for outpatient setting,155.31,70,,124.25,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,177.5,80,,142,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,199.68,90,,159.74,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,199.68,
DISOPYRAMIDE (NORPACE) CAP : 15 MG,3300960,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DISP BIOPSY INSTRU / MC1820,7601560,CDM,272,RC,,,Outpatient,,,141,141,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.7,70,,78.96,percent of total billed charges,70% of total billed charges for outpatient setting,119.68,84.88,,95.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.5,50,,56.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.75,75,,84.6,percent of total billed charges,75% of total billed charges for outpatient setting,98.7,70,,78.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.8,80,,90.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.65,65,,73.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.35,35,,39.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.9,90,,101.52,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,126.9,
DISP INSTR BIOTENDONESIS SCR  AR-1676DS,69161478,CDM,272,RC,,,Outpatient,,,795.35,795.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.75,70,,445.4,percent of total billed charges,70% of total billed charges for outpatient setting,675.09,84.88,,540.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,397.68,50,,318.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.51,75,,477.21,percent of total billed charges,75% of total billed charges for outpatient setting,556.75,70,,445.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.12,12.84,,81.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.28,80,,509.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.12,12.84,,81.7,percent of total billed charges,12.84% of total billed charges,102.12,12.84,,81.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,516.98,65,,413.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.37,35,,222.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,715.82,90,,572.66,percent of total billed charges,90% of total billed charges for outpatient setting,102.12,715.82,
DISP SIGMOIDOSCOPE PROBE / 53130,6152225,CDM,270,RC,,,Outpatient,,,23.85,23.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,20.24,84.88,,16.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.93,50,,9.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.89,75,,14.31,percent of total billed charges,75% of total billed charges for outpatient setting,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,80,,15.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.5,65,,12.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,35,,6.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.47,90,,17.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.06,21.47,
DISP SUCTION TUBING SET (LIPO),69159041,CDM,272,RC,,,Outpatient,,,55.83,55.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,70,,31.26,percent of total billed charges,70% of total billed charges for outpatient setting,47.39,84.88,,37.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.92,50,,22.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.87,75,,33.5,percent of total billed charges,75% of total billed charges for outpatient setting,39.08,70,,31.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.17,12.84,,5.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,80,,35.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.17,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,7.17,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.29,65,,29.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.54,35,,15.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.25,90,,40.2,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,50.25,
DISPOSABLE ACTIVE CORD / DAC,6150604,CDM,270,RC,,,Outpatient,,,95.04,95.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.53,70,,53.22,percent of total billed charges,70% of total billed charges for outpatient setting,80.67,84.88,,64.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.52,50,,38.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.28,75,,57.02,percent of total billed charges,75% of total billed charges for outpatient setting,66.53,70,,53.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,12.84,,9.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.03,80,,60.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,12.84,,9.76,percent of total billed charges,12.84% of total billed charges,12.2,12.84,,9.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.78,65,,49.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,35,,26.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.54,90,,68.43,percent of total billed charges,90% of total billed charges for outpatient setting,12.2,85.54,
DISSECTOR 3.0MM / AR-7300DS,69162763,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
DISSECTOR 3.5MM / AR-8350DS,69169463,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
DISSECTOR 4.0MM / AR-8400DS,69161147,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
DISSECTOR 4.0MM TORPEDO / AR-8400TD,69162397,CDM,272,RC,,,Outpatient,,,424.2,424.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,360.06,84.88,,288.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.1,50,,169.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,75,,254.52,percent of total billed charges,75% of total billed charges for outpatient setting,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.36,80,,271.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.73,65,,220.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.47,35,,118.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.78,90,,305.42,percent of total billed charges,90% of total billed charges for outpatient setting,54.47,381.78,
DISSECTOR 5MM EXCALIBUR  / AR-8500EX,69162400,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
DISTAL ATTACHMENT / D-201-15004,69169036,CDM,272,RC,,,Outpatient,,,169.17,169.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.42,70,,94.74,percent of total billed charges,70% of total billed charges for outpatient setting,143.59,84.88,,114.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.59,50,,67.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.88,75,,101.5,percent of total billed charges,75% of total billed charges for outpatient setting,118.42,70,,94.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.72,12.84,,17.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.34,80,,108.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.72,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,21.72,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.96,65,,87.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.21,35,,47.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.25,90,,121.8,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,152.25,
DISTAL BICEPS IMPLANT BIOCMP / AR-2260BC,69162811,CDM,278,RC,,,Outpatient,,,2310,2310,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,60,,1108.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1960.73,84.88,,1568.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1155,50,,924,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1732.5,75,,1386,percent of total billed charges,75% of total billed charges for outpatient setting,1155,50,,924,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.6,12.84,,237.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1848,80,,1478.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.6,12.84,,237.28,percent of total billed charges,12.84% of total billed charges,296.6,12.84,,237.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2425.5,105,,1940.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.5,35,,646.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1386,60,,1108.8,percent of total billed charges,60% of total billed charges for outpatient setting,296.6,2425.5,
DISTAL BICEPS REPAIR IMPLANT AR-2260,69161433,CDM,278,RC,,,Outpatient,,,3313.99,3313.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1988.39,60,,1590.71,percent of total billed charges,60% of total Billed charges for outpatient setting,2812.91,84.88,,2250.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,1657,50,,1325.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2485.49,75,,1988.39,percent of total billed charges,75% of total billed charges for outpatient setting,1657,50,,1325.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.52,12.84,,340.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2651.19,80,,2120.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.52,12.84,,340.42,percent of total billed charges,12.84% of total billed charges,425.52,12.84,,340.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3479.69,105,,2783.75,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.9,35,,927.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1988.39,60,,1590.71,percent of total billed charges,60% of total billed charges for outpatient setting,425.52,3479.69,
DISTRACTION PINS 12MM,69161950,CDM,278,RC,,,Outpatient,,,886.83,886.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.1,60,,425.68,percent of total billed charges,60% of total Billed charges for outpatient setting,752.74,84.88,,602.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,443.42,50,,354.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,665.12,75,,532.1,percent of total billed charges,75% of total billed charges for outpatient setting,443.42,50,,354.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.87,12.84,,91.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.46,80,,567.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.87,12.84,,91.1,percent of total billed charges,12.84% of total billed charges,113.87,12.84,,91.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,886.83,65,,709.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.39,35,,248.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,532.1,60,,425.68,percent of total billed charges,60% of total billed charges for outpatient setting,113.87,886.83,
DISULFIRAM (ANTABUSE) TAB : 250 MG,3300961,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DIVALPROEX (DEPAKOTE SPRINK) TAB : 125MG,3300962,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DIVALPROEX (DEPAKOTE) TAB: 250 MG,3300963,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DIVALPROEX SODIUM (DEPAKOTE) TAB: 500 MG,3300964,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DNU,220940,CDM,302,RC,,,Outpatient,,,86.81,78.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,73.68,84.88,,58.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.41,50,,34.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.11,75,,52.09,percent of total billed charges,75% of total billed charges for outpatient setting,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.45,80,,55.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,11.15,12.84,,8.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,35,,24.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.13,90,,62.5,percent of total billed charges,90% of total billed charges for outpatient setting,11.15,78.13,
DOBUTAMINE (DOBUTREX) INJ : 12.5 MG,3300965,CDM,250,RC,,,Outpatient,,,154.19,154.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.93,70,,86.34,percent of total billed charges,70% of total billed charges for outpatient setting,130.88,84.88,,104.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.1,50,,61.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.64,75,,92.51,percent of total billed charges,75% of total billed charges for outpatient setting,107.93,70,,86.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,12.84,,15.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.35,80,,98.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,12.84,,15.84,percent of total billed charges,12.84% of total billed charges,19.8,12.84,,15.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.22,65,,80.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,35,,43.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.77,90,,111.02,percent of total billed charges,90% of total billed charges for outpatient setting,19.8,138.77,
DOBUTAMINE 250 MG: INJ,3000399,CDM,636,RC,J1250,HCPCS,Outpatient,,,255.65,255.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.96,70,,143.17,percent of total billed charges,70% of total billed charges for outpatient setting,217,84.88,,173.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,191.74,75,,153.39,percent of total billed charges,75% of total billed charges for outpatient setting,178.96,70,,143.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.52,80,,163.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.17,65,,132.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.38,100,,,Fee Schedule,100% of Custom Fee Schedule,230.09,90,,184.07,percent of total billed charges,90% of total billed charges for outpatient setting,6.38,230.09,
DOBUTAMINE 500MG/D5W 250ML: PREMIX,3302666,CDM,250,RC,,,Outpatient,,,75.62,75.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.19,84.88,,51.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.81,50,,30.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.72,75,,45.38,percent of total billed charges,75% of total billed charges for outpatient setting,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.5,80,,48.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.15,65,,39.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,35,,21.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.06,90,,54.45,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,68.06,
DOCUSATE (COLACE) LIQ 150MG: 10ML UD,3300971,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOCUSATE (THEREVAC SB) ENEMA : 283 MG,3300972,CDM,259,RC,,,Outpatient,,,44.48,44.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,37.75,84.88,,30.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.24,50,,17.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.36,75,,26.69,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,70,,24.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.58,80,,28.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,5.71,12.84,,4.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.91,65,,23.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.57,35,,12.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.03,90,,32.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.71,40.03,
DOCUSATE 250 MG: CAP,3303089,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DOCUSATE CALCIUM 240 MG: SURFAK,3302751,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DOCUSATE SOD (COLACE) CAP : 100 MG,3300966,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOCUSATE SOD (COLACE) CAP : 100 MG,3300967,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOCUSATE SOD (COLACE) CAP : 100 MG U/D,3300968,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOCUSATE SOD (COLACE) LIQ: 150MG/15ML,3300969,CDM,259,RC,,,Outpatient,,,37.68,37.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,70,,21.1,percent of total billed charges,70% of total billed charges for outpatient setting,31.98,84.88,,25.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.84,50,,15.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.26,75,,22.61,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,70,,21.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,12.84,,3.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.14,80,,24.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,12.84,,3.87,percent of total billed charges,12.84% of total billed charges,4.84,12.84,,3.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.49,65,,19.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,35,,10.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.91,90,,27.13,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,33.91,
DOCUSATE SOD (genericCOLACE) CAP 100 MG,3300970,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DOCUSATE SOD W/CAS(PERI COLACE)SYRUP:UD,3300761,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOME 32MM PATELLA ATTUNE / 1518-20-032,71000258,CDM,278,RC,C1776,HCPCS,Outpatient,,,1458,1458,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.8,60,,699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1237.55,84.88,,990.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.5,75,,874.8,percent of total billed charges,75% of total billed charges for outpatient setting,729,50,,583.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.4,80,,933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1458,65,,1166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.3,35,,408.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,874.8,60,,699.84,percent of total billed charges,60% of total billed charges for outpatient setting,187.21,1458,
DOME 35MM PATELLA ATTUNE / 1518-20-035,71000454,CDM,278,RC,C1776,HCPCS,Outpatient,,,1458,1458,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.8,60,,699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1237.55,84.88,,990.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.5,75,,874.8,percent of total billed charges,75% of total billed charges for outpatient setting,729,50,,583.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.4,80,,933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1458,65,,1166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.3,35,,408.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,874.8,60,,699.84,percent of total billed charges,60% of total billed charges for outpatient setting,187.21,1458,
DOME 38MM PATELLA ATTUNE / 1518-20-038,71000264,CDM,278,RC,C1776,HCPCS,Outpatient,,,1458,1458,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.8,60,,699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1237.55,84.88,,990.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.5,75,,874.8,percent of total billed charges,75% of total billed charges for outpatient setting,729,50,,583.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.4,80,,933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1458,65,,1166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.3,35,,408.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,874.8,60,,699.84,percent of total billed charges,60% of total billed charges for outpatient setting,187.21,1458,
DOME 41MM PATELLA ATTUNE / 1518-20-041,71000956,CDM,278,RC,C1776,HCPCS,Outpatient,,,1458,1458,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.8,60,,699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1237.55,84.88,,990.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.5,75,,874.8,percent of total billed charges,75% of total billed charges for outpatient setting,729,50,,583.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.4,80,,933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,187.21,12.84,,149.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1458,65,,1166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.3,35,,408.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,874.8,60,,699.84,percent of total billed charges,60% of total billed charges for outpatient setting,187.21,1458,
DONEPEZIL (ARICEPT) 10MG TAB,3300974,CDM,259,RC,,,Outpatient,,,14.01,14.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,11.89,84.88,,9.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.01,50,,5.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.51,75,,8.41,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.21,80,,8.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.11,65,,7.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,35,,3.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.61,90,,10.09,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,12.61,
DONEPEZIL (ARICEPT) 5MG TAB,3303010,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DONEPEZIL (ARICEPT) TAB: 10 MG,3300973,CDM,259,RC,,,Outpatient,,,12.48,12.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,70,,6.99,percent of total billed charges,70% of total billed charges for outpatient setting,10.59,84.88,,8.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.36,75,,7.49,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,70,,6.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,35,,3.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.23,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.23,
DONNATAL ELIXER: 1OZ,3302896,CDM,259,RC,,,Outpatient,,,3.45,3.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,70,,1.94,percent of total billed charges,70% of total billed charges for outpatient setting,2.93,84.88,,2.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.73,50,,1.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.59,75,,2.07,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,70,,1.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.44,12.84,,0.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,80,,2.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.44,12.84,,0.35,percent of total billed charges,12.84% of total billed charges,0.44,12.84,,0.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.24,65,,1.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,35,,0.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.11,90,,2.49,percent of total billed charges,90% of total billed charges for outpatient setting,0.44,3.11,
DOPAMINE (INTROPIN) INJ 40 MG/ML :5 ML,3300975,CDM,250,RC,,,Outpatient,,,5.92,5.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,84.88,,4.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.96,50,,2.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.44,75,,3.55,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,70,,3.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,80,,3.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.85,65,,3.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,35,,1.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.33,90,,4.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.33,
DOPAMINE HCL D5W 800MG SOL 250 ML,3300976,CDM,250,RC,J1265,HCPCS,Outpatient,,,73.96,73.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.77,70,,41.42,percent of total billed charges,70% of total billed charges for outpatient setting,62.78,84.88,,50.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.47,75,,44.38,percent of total billed charges,75% of total billed charges for outpatient setting,51.77,70,,41.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,12.84,,7.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.17,80,,47.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,12.84,,7.6,percent of total billed charges,12.84% of total billed charges,9.5,12.84,,7.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.07,65,,38.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,100,,,Fee Schedule,100% of Custom Fee Schedule,66.56,90,,53.25,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,66.56,
DOPPLER ECHO COMPLETE (ADD ON),2600020,CDM,480,RC,93320,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
DOPPLER ECHO FOLLOW-UP/LIMITED (ADD ON),2600011,CDM,480,RC,93321,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
DORZOLAMIDE (COSOPT) OPTH SOL 2-0.5%:10,3300981,CDM,259,RC,,,Outpatient,,,248.01,248.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.61,70,,138.89,percent of total billed charges,70% of total billed charges for outpatient setting,210.51,84.88,,168.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.01,50,,99.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.01,75,,148.81,percent of total billed charges,75% of total billed charges for outpatient setting,173.61,70,,138.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.41,80,,158.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.21,65,,128.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.8,35,,69.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.21,90,,178.57,percent of total billed charges,90% of total billed charges for outpatient setting,31.84,223.21,
DORZOLAMIDE (COSOPT) OPTH SOL 2-0.5%:5,3300979,CDM,259,RC,,,Outpatient,,,124.01,124.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.81,70,,69.45,percent of total billed charges,70% of total billed charges for outpatient setting,105.26,84.88,,84.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.01,50,,49.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.01,75,,74.41,percent of total billed charges,75% of total billed charges for outpatient setting,86.81,70,,69.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.92,12.84,,12.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.21,80,,79.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.92,12.84,,12.74,percent of total billed charges,12.84% of total billed charges,15.92,12.84,,12.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.61,65,,64.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.4,35,,34.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111.61,90,,89.29,percent of total billed charges,90% of total billed charges for outpatient setting,15.92,111.61,
DORZOLAMIDE (COSOPT)OPTH SOL 2-0.5% :5ML,3300980,CDM,259,RC,,,Outpatient,,,118.21,118.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.75,70,,66.2,percent of total billed charges,70% of total billed charges for outpatient setting,100.34,84.88,,80.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.11,50,,47.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.66,75,,70.93,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,70,,66.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.18,12.84,,12.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.57,80,,75.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.18,12.84,,12.14,percent of total billed charges,12.84% of total billed charges,15.18,12.84,,12.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.84,65,,61.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.37,35,,33.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.39,90,,85.11,percent of total billed charges,90% of total billed charges for outpatient setting,15.18,106.39,
DORZOLAMIDE (TRUSOPT) 2%: OPTH DROPS,3303215,CDM,259,RC,,,Outpatient,,,107,107,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.9,70,,59.92,percent of total billed charges,70% of total billed charges for outpatient setting,90.82,84.88,,72.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.5,50,,42.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.25,75,,64.2,percent of total billed charges,75% of total billed charges for outpatient setting,74.9,70,,59.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.74,12.84,,10.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.6,80,,68.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.74,12.84,,10.99,percent of total billed charges,12.84% of total billed charges,13.74,12.84,,10.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.55,65,,55.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.45,35,,29.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.3,90,,77.04,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,96.3,
DORZOLAMIDE (TRUSOPT) OPTH SOL 2% : 5ML,3300978,CDM,259,RC,,,Outpatient,,,69.28,69.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.5,70,,38.8,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,84.88,,47.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.64,50,,27.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.96,75,,41.57,percent of total billed charges,75% of total billed charges for outpatient setting,48.5,70,,38.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.42,80,,44.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,8.9,12.84,,7.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.03,65,,36.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.25,35,,19.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.35,90,,49.88,percent of total billed charges,90% of total billed charges for outpatient setting,8.9,62.35,
DORZOLAMIDE (TRUSOPT) OPTH SOL 2% : 5ML,3300977,CDM,259,RC,,,Outpatient,,,72.66,72.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.86,70,,40.69,percent of total billed charges,70% of total billed charges for outpatient setting,61.67,84.88,,49.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.33,50,,29.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.5,75,,43.6,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,70,,40.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.33,12.84,,7.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.13,80,,46.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.33,12.84,,7.46,percent of total billed charges,12.84% of total billed charges,9.33,12.84,,7.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.23,65,,37.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,35,,20.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.39,90,,52.31,percent of total billed charges,90% of total billed charges for outpatient setting,9.33,65.39,
DOTAREM 10ML INJ / 368220011,7304096,CDM,636,RC,A9575,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,59.42,84.88,,47.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,52.5,75,,42,percent of total billed charges,75% of total billed charges for outpatient setting,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,80,,44.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.5,65,,36.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,100,,,Fee Schedule,100% of Custom Fee Schedule,63,90,,50.4,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,63,
DOTAREM 15ML INJ / 368220012,70000659,CDM,636,RC,A9575,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,70,,50.4,percent of total billed charges,70% of total billed charges for outpatient setting,76.39,84.88,,61.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.5,75,,54,percent of total billed charges,75% of total billed charges for outpatient setting,63,70,,50.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,80,,57.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.5,65,,46.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,100,,,Fee Schedule,100% of Custom Fee Schedule,81,90,,64.8,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,81,
DOTAREM 20ML INJ / 368220013,70000660,CDM,636,RC,A9575,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,101.86,84.88,,81.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,90,75,,72,percent of total billed charges,75% of total billed charges for outpatient setting,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,80,,76.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78,65,,62.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,100,,,Fee Schedule,100% of Custom Fee Schedule,108,90,,86.4,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,108,
DOUGHNUT PILLOW,69169037,CDM,272,RC,E0190,HCPCS,Outpatient,,,51.14,51.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.8,70,,28.64,percent of total billed charges,70% of total billed charges for outpatient setting,43.41,84.88,,34.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.57,50,,20.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.36,75,,30.69,percent of total billed charges,75% of total billed charges for outpatient setting,35.8,70,,28.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.57,12.84,,5.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.91,80,,32.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.57,12.84,,5.26,percent of total billed charges,12.84% of total billed charges,6.57,12.84,,5.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.24,65,,26.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,35,,14.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.03,90,,36.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.57,46.03,
DOXAPRAM (DOPRAM) INJ 20MG/ML :20 ML,3300982,CDM,250,RC,,,Outpatient,,,229.4,229.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,70,,128.46,percent of total billed charges,70% of total billed charges for outpatient setting,194.71,84.88,,155.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.7,50,,91.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.05,75,,137.64,percent of total billed charges,75% of total billed charges for outpatient setting,160.58,70,,128.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.45,12.84,,23.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.52,80,,146.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.45,12.84,,23.56,percent of total billed charges,12.84% of total billed charges,29.45,12.84,,23.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.11,65,,119.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.29,35,,64.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.46,90,,165.17,percent of total billed charges,90% of total billed charges for outpatient setting,29.45,206.46,
DOXAZOSIN (CARDURA) TAB : 2 MG,3300984,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
DOXAZOSIN (CARDURA) TAB : 4 MG,3300983,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXAZOSIN (genericCARDURA) TAB 4 MG TAB,3303013,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DOXEPIN (genericSINEQUAN) 25 MG,3303166,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DOXEPIN (SINEQUAN) CAP : 10 MG,3300985,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXEPIN (SINEQUAN) CAP : 100 MG,3300987,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXEPIN (SINEQUAN) CAP : 25 MG,3300986,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXEPIN (SINEQUAN): 50 MG,3306759,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
DOXYCYCLINE (genDORYX) 100MG CAP,3314047,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DOXYCYCLINE (genVIBRAMYCIN) 100MG TAB,3300989,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DOXYCYCLINE (VIBRAMYCIN) CAP : 100 MG,3300990,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXYCYCLINE (VIBRAMYCIN) CAP :100 MG U/D,3300988,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DOXYCYCLINE 100 MG INJ,3300991,CDM,250,RC,,,Outpatient,,,123.92,123.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.74,70,,69.39,percent of total billed charges,70% of total billed charges for outpatient setting,105.18,84.88,,84.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.96,50,,49.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.94,75,,74.35,percent of total billed charges,75% of total billed charges for outpatient setting,86.74,70,,69.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,12.84,,12.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.14,80,,79.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,12.84,,12.73,percent of total billed charges,12.84% of total billed charges,15.91,12.84,,12.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.55,65,,64.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,35,,34.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111.53,90,,89.22,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,111.53,
DOYLE II NASAL/SEPTAL SPLINT / 1524055,69161229,CDM,272,RC,,,Outpatient,,,237.93,237.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,201.95,84.88,,161.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.97,50,,95.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.45,75,,142.76,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.34,80,,152.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.65,65,,123.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.28,35,,66.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.14,90,,171.31,percent of total billed charges,90% of total billed charges for outpatient setting,30.55,214.14,
DR. LEARY'S SWISH AND SWALLOW:5 OZ,3303240,CDM,259,RC,,,Outpatient,,,52.86,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,44.87,84.88,,35.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.43,50,,21.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.65,75,,31.72,percent of total billed charges,75% of total billed charges for outpatient setting,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.29,80,,33.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.36,65,,27.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,35,,14.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.57,90,,38.06,percent of total billed charges,90% of total billed charges for outpatient setting,6.79,47.57,
DRAIN 1/8 HEMOVAC / 0043610,6150968,CDM,272,RC,,,Outpatient,,,51.59,51.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.11,70,,28.89,percent of total billed charges,70% of total billed charges for outpatient setting,43.79,84.88,,35.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.8,50,,20.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.69,75,,30.95,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,70,,28.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,12.84,,5.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.27,80,,33.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,12.84,,5.3,percent of total billed charges,12.84% of total billed charges,6.62,12.84,,5.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.53,65,,26.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.06,35,,14.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.43,90,,37.14,percent of total billed charges,90% of total billed charges for outpatient setting,6.62,46.43,
DRAIN 10MM FLAT 3/4 FLTD / 072213,69161346,CDM,272,RC,,,Outpatient,,,101.04,101.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.73,70,,56.58,percent of total billed charges,70% of total billed charges for outpatient setting,85.76,84.88,,68.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.52,50,,40.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.78,75,,60.62,percent of total billed charges,75% of total billed charges for outpatient setting,70.73,70,,56.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,12.84,,10.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.83,80,,64.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,12.84,,10.38,percent of total billed charges,12.84% of total billed charges,12.97,12.84,,10.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.68,65,,52.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.36,35,,28.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.94,90,,72.75,percent of total billed charges,90% of total billed charges for outpatient setting,12.97,90.94,
DRAIN 3/16 SILICONE HEMOVAC,69159675,CDM,270,RC,,,Outpatient,,,165.12,165.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.58,70,,92.46,percent of total billed charges,70% of total billed charges for outpatient setting,140.15,84.88,,112.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.56,50,,66.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.84,75,,99.07,percent of total billed charges,75% of total billed charges for outpatient setting,115.58,70,,92.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.2,12.84,,16.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.1,80,,105.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.2,12.84,,16.96,percent of total billed charges,12.84% of total billed charges,21.2,12.84,,16.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,107.33,65,,85.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.79,35,,46.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,148.61,90,,118.89,percent of total billed charges,90% of total billed charges for outpatient setting,21.2,148.61,
DRAIN 7FR FLAT JP SIL / SU130-131,69159080,CDM,272,RC,,,Outpatient,,,38.56,38.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.99,70,,21.59,percent of total billed charges,70% of total billed charges for outpatient setting,32.73,84.88,,26.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.28,50,,15.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.92,75,,23.14,percent of total billed charges,75% of total billed charges for outpatient setting,26.99,70,,21.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,12.84,,3.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,80,,24.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,12.84,,3.96,percent of total billed charges,12.84% of total billed charges,4.95,12.84,,3.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.06,65,,20.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.5,35,,10.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.7,90,,27.76,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,34.7,
DRAIN BAG ADAPTER / CMS-610,70000729,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
DRAIN KIT 10MM FLAT SILCNE / SU130-1361,70000037,CDM,270,RC,,,Outpatient,,,53.36,53.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,70,,29.88,percent of total billed charges,70% of total billed charges for outpatient setting,45.29,84.88,,36.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.68,50,,21.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.02,75,,32.02,percent of total billed charges,75% of total billed charges for outpatient setting,37.35,70,,29.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.85,12.84,,5.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.69,80,,34.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.85,12.84,,5.48,percent of total billed charges,12.84% of total billed charges,6.85,12.84,,5.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.68,65,,27.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,35,,14.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.02,90,,38.42,percent of total billed charges,90% of total billed charges for outpatient setting,6.85,48.02,
DRAIN PENROSE 1/2IN // DYND50423,6150898,CDM,272,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
DRAIN PENROSE 1/4IN / 30416-025,6150042,CDM,272,RC,,,Outpatient,,,4.32,4.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,84.88,,2.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.16,50,,1.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.24,75,,2.59,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,80,,2.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.81,65,,2.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,35,,1.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.89,90,,3.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.89,
DRAIN PENROSE 3/4 X 18 /30416-075,6150043,CDM,272,RC,,,Outpatient,,,8.72,8.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.1,70,,4.88,percent of total billed charges,70% of total billed charges for outpatient setting,7.4,84.88,,5.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.36,50,,3.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.54,75,,5.23,percent of total billed charges,75% of total billed charges for outpatient setting,6.1,70,,4.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,80,,5.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,65,,4.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,35,,2.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.85,90,,6.28,percent of total billed charges,90% of total billed charges for outpatient setting,1.12,7.85,
"DRAIN, 3/16 PVC HEMOVAC/0043630",69159676,CDM,270,RC,,,Outpatient,,,168.38,168.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.87,70,,94.3,percent of total billed charges,70% of total billed charges for outpatient setting,142.92,84.88,,114.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.19,50,,67.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.29,75,,101.03,percent of total billed charges,75% of total billed charges for outpatient setting,117.87,70,,94.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.62,12.84,,17.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.7,80,,107.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.62,12.84,,17.3,percent of total billed charges,12.84% of total billed charges,21.62,12.84,,17.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.45,65,,87.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,35,,47.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.54,90,,121.23,percent of total billed charges,90% of total billed charges for outpatient setting,21.62,151.54,
DRAINS 10FR ROUND BLAKE / 072226,6150306,CDM,272,RC,,,Outpatient,,,111.12,111.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.78,70,,62.22,percent of total billed charges,70% of total billed charges for outpatient setting,94.32,84.88,,75.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.56,50,,44.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.34,75,,66.67,percent of total billed charges,75% of total billed charges for outpatient setting,77.78,70,,62.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.27,12.84,,11.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.9,80,,71.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.27,12.84,,11.42,percent of total billed charges,12.84% of total billed charges,14.27,12.84,,11.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.23,65,,57.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.89,35,,31.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.01,90,,80.01,percent of total billed charges,90% of total billed charges for outpatient setting,14.27,100.01,
DRAINS 15FR RND BLAKE HUBLESS / 2228,6150307,CDM,272,RC,,,Outpatient,,,96.39,96.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.47,70,,53.98,percent of total billed charges,70% of total billed charges for outpatient setting,81.82,84.88,,65.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.2,50,,38.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.29,75,,57.83,percent of total billed charges,75% of total billed charges for outpatient setting,67.47,70,,53.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,12.84,,9.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.11,80,,61.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,12.84,,9.9,percent of total billed charges,12.84% of total billed charges,12.38,12.84,,9.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.65,65,,50.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.74,35,,26.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.75,90,,69.4,percent of total billed charges,90% of total billed charges for outpatient setting,12.38,86.75,
DRAINS 15FR RND HUBLESS  w/trocar  2229,69161844,CDM,272,RC,,,Outpatient,,,114.54,114.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.18,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,97.22,84.88,,77.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.27,50,,45.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.91,75,,68.73,percent of total billed charges,75% of total billed charges for outpatient setting,80.18,70,,64.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,12.84,,11.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.63,80,,73.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,12.84,,11.77,percent of total billed charges,12.84% of total billed charges,14.71,12.84,,11.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.45,65,,59.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.09,35,,32.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.09,90,,82.47,percent of total billed charges,90% of total billed charges for outpatient setting,14.71,103.09,
DRAINS 19FR RND BLAKE HUB-LESS / 072230,6150308,CDM,272,RC,,,Outpatient,,,101.37,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.96,70,,56.77,percent of total billed charges,70% of total billed charges for outpatient setting,86.04,84.88,,68.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.69,50,,40.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.03,75,,60.82,percent of total billed charges,75% of total billed charges for outpatient setting,70.96,70,,56.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.02,12.84,,10.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.1,80,,64.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.02,12.84,,10.42,percent of total billed charges,12.84% of total billed charges,13.02,12.84,,10.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.89,65,,52.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.48,35,,28.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.23,90,,72.98,percent of total billed charges,90% of total billed charges for outpatient setting,13.02,91.23,
DRAPE 10X18IN INSTR POUCH / D1018L,69161964,CDM,272,RC,,,Outpatient,,,28.54,28.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,70,,15.98,percent of total billed charges,70% of total billed charges for outpatient setting,24.22,84.88,,19.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.27,50,,11.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.41,75,,17.13,percent of total billed charges,75% of total billed charges for outpatient setting,19.98,70,,15.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.66,12.84,,2.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.83,80,,18.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.66,12.84,,2.93,percent of total billed charges,12.84% of total billed charges,3.66,12.84,,2.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.55,65,,14.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,35,,7.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.69,90,,20.55,percent of total billed charges,90% of total billed charges for outpatient setting,3.66,25.69,
DRAPE 125X83IN STERI ISOLATION / 6617,365921,CDM,272,RC,,,Outpatient,,,100.68,100.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.48,70,,56.38,percent of total billed charges,70% of total billed charges for outpatient setting,85.46,84.88,,68.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.34,50,,40.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.51,75,,60.41,percent of total billed charges,75% of total billed charges for outpatient setting,70.48,70,,56.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,12.84,,10.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.54,80,,64.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,12.84,,10.34,percent of total billed charges,12.84% of total billed charges,12.93,12.84,,10.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.44,65,,52.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.24,35,,28.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.61,90,,72.49,percent of total billed charges,90% of total billed charges for outpatient setting,12.93,90.61,
DRAPE 14X30 FOOT SWITCH / DYNJE5700,70000227,CDM,271,RC,,,Outpatient,,,22.95,22.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.48,84.88,,15.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.48,50,,9.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,75,,13.77,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,80,,14.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.92,65,,11.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,35,,6.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,2.95,20.66,
DRAPE 15X26 UTILITY ADH / 7553,496371,CDM,272,RC,,,Outpatient,,,4.23,4.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,3.59,84.88,,2.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.12,50,,1.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.17,75,,2.54,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,80,,2.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.75,65,,2.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,35,,1.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.81,90,,3.05,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.81,
DRAPE 18X24IN INCISE / D1010,129548,CDM,272,RC,,,Outpatient,,,10.89,10.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,9.24,84.88,,7.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.45,50,,4.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.17,75,,6.54,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.71,80,,6.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.08,65,,5.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,35,,3.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.8,90,,7.84,percent of total billed charges,90% of total billed charges for outpatient setting,1.4,9.8,
DRAPE 23X17 IOBAN LG / 6650EZ,6150416,CDM,272,RC,,,Outpatient,,,39.14,39.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.4,70,,21.92,percent of total billed charges,70% of total billed charges for outpatient setting,33.22,84.88,,26.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.57,50,,15.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.36,75,,23.49,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,70,,21.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,12.84,,4.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.31,80,,25.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,12.84,,4.02,percent of total billed charges,12.84% of total billed charges,5.03,12.84,,4.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.44,65,,20.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.7,35,,10.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.23,90,,28.18,percent of total billed charges,90% of total billed charges for outpatient setting,5.03,35.23,
DRAPE 24X18IN INVISISHIELD / DYNJSD1010,157330,CDM,272,RC,,,Outpatient,,,7.67,7.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.37,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,84.88,,5.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,75,,4.6,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,35,,2.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.9,90,,5.52,percent of total billed charges,90% of total billed charges for outpatient setting,0.98,6.9,
DRAPE 3/4 / 9349,6150214,CDM,272,RC,,,Outpatient,,,12.06,12.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,10.24,84.88,,8.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.03,50,,4.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,75,,7.24,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.65,80,,7.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.84,65,,6.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,35,,3.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.85,90,,8.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,10.85,
DRAPE 40X48 EYE / 8065104020,69161819,CDM,272,RC,,,Outpatient,,,40.95,40.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.67,70,,22.94,percent of total billed charges,70% of total billed charges for outpatient setting,34.76,84.88,,27.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.48,50,,16.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.71,75,,24.57,percent of total billed charges,75% of total billed charges for outpatient setting,28.67,70,,22.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,12.84,,4.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.76,80,,26.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,12.84,,4.21,percent of total billed charges,12.84% of total billed charges,5.26,12.84,,4.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.62,65,,21.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.33,35,,11.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.86,90,,29.49,percent of total billed charges,90% of total billed charges for outpatient setting,5.26,36.86,
DRAPE 86X138 BILATERAL EXTREMITY / 29417,6150064,CDM,272,RC,,,Outpatient,,,55.72,55.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39,70,,31.2,percent of total billed charges,70% of total billed charges for outpatient setting,47.3,84.88,,37.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.86,50,,22.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.79,75,,33.43,percent of total billed charges,75% of total billed charges for outpatient setting,39,70,,31.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.58,80,,35.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,7.15,12.84,,5.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.22,65,,28.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,35,,15.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.15,90,,40.12,percent of total billed charges,90% of total billed charges for outpatient setting,7.15,50.15,
DRAPE ABDOMINAL LITHOTOMY / 29146,6150061,CDM,272,RC,,,Outpatient,,,77.63,77.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.34,70,,43.47,percent of total billed charges,70% of total billed charges for outpatient setting,65.89,84.88,,52.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.82,50,,31.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.22,75,,46.58,percent of total billed charges,75% of total billed charges for outpatient setting,54.34,70,,43.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.1,80,,49.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.46,65,,40.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,35,,21.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.87,90,,55.9,percent of total billed charges,90% of total billed charges for outpatient setting,9.97,69.87,
DRAPE BARIATRIC / DYNJP3105,69161529,CDM,272,RC,,,Outpatient,,,104.09,104.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,88.35,84.88,,70.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.05,50,,41.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.07,75,,62.46,percent of total billed charges,75% of total billed charges for outpatient setting,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.37,12.84,,10.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.27,80,,66.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.37,12.84,,10.7,percent of total billed charges,12.84% of total billed charges,13.37,12.84,,10.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.66,65,,54.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.43,35,,29.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.68,90,,74.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.37,93.68,
DRAPE BEACH CHAIR SHLDR W/POUCH / 29369,69169652,CDM,272,RC,,,Outpatient,,,102.3,102.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.61,70,,57.29,percent of total billed charges,70% of total billed charges for outpatient setting,86.83,84.88,,69.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.15,50,,40.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.73,75,,61.38,percent of total billed charges,75% of total billed charges for outpatient setting,71.61,70,,57.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.14,12.84,,10.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.84,80,,65.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.14,12.84,,10.51,percent of total billed charges,12.84% of total billed charges,13.14,12.84,,10.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.5,65,,53.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.81,35,,28.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.07,90,,73.66,percent of total billed charges,90% of total billed charges for outpatient setting,13.14,92.07,
DRAPE C-ARM / 4951,6150067,CDM,270,RC,,,Outpatient,,,29.68,29.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.78,70,,16.62,percent of total billed charges,70% of total billed charges for outpatient setting,25.19,84.88,,20.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.84,50,,11.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.26,75,,17.81,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,70,,16.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,80,,18.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.29,65,,15.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.39,35,,8.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.71,90,,21.37,percent of total billed charges,90% of total billed charges for outpatient setting,3.81,26.71,
DRAPE C-ARM FULL 36X44 / 2951,6152895,CDM,272,RC,,,Outpatient,,,102.35,102.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,70,,57.32,percent of total billed charges,70% of total billed charges for outpatient setting,86.87,84.88,,69.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.18,50,,40.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.76,75,,61.41,percent of total billed charges,75% of total billed charges for outpatient setting,71.65,70,,57.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.14,12.84,,10.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.88,80,,65.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.14,12.84,,10.51,percent of total billed charges,12.84% of total billed charges,13.14,12.84,,10.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.53,65,,53.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,35,,28.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.12,90,,73.7,percent of total billed charges,90% of total billed charges for outpatient setting,13.14,92.12,
DRAPE C-ARMOR TUBE CVR / 5523,69162297,CDM,272,RC,,,Outpatient,,,180.65,180.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.46,70,,101.17,percent of total billed charges,70% of total billed charges for outpatient setting,153.34,84.88,,122.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.33,50,,72.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.49,75,,108.39,percent of total billed charges,75% of total billed charges for outpatient setting,126.46,70,,101.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.52,80,,115.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.42,65,,93.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.23,35,,50.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.59,90,,130.07,percent of total billed charges,90% of total billed charges for outpatient setting,23.2,162.59,
DRAPE CHEST BREAST / 29420,6150895,CDM,272,RC,,,Outpatient,,,39.69,39.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,33.69,84.88,,26.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.85,50,,15.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.77,75,,23.82,percent of total billed charges,75% of total billed charges for outpatient setting,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.75,80,,25.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.8,65,,20.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.89,35,,11.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.72,90,,28.58,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,35.72,
DRAPE ENDOSCOPY / 9458,6153115,CDM,270,RC,,,Outpatient,,,57.47,57.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.23,70,,32.18,percent of total billed charges,70% of total billed charges for outpatient setting,48.78,84.88,,39.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.74,50,,22.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.1,75,,34.48,percent of total billed charges,75% of total billed charges for outpatient setting,40.23,70,,32.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.38,12.84,,5.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.98,80,,36.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.38,12.84,,5.9,percent of total billed charges,12.84% of total billed charges,7.38,12.84,,5.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.36,65,,29.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.11,35,,16.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.72,90,,41.38,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,51.72,
DRAPE EXTREMITY W/ARMBRD / 29435,6150062,CDM,272,RC,,,Outpatient,,,70.98,70.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.69,70,,39.75,percent of total billed charges,70% of total billed charges for outpatient setting,60.25,84.88,,48.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.49,50,,28.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.24,75,,42.59,percent of total billed charges,75% of total billed charges for outpatient setting,49.69,70,,39.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,80,,45.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.14,65,,36.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,35,,19.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.88,90,,51.1,percent of total billed charges,90% of total billed charges for outpatient setting,9.11,63.88,
DRAPE EYE / 8441,6152129,CDM,272,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,15.28,84.88,,12.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,9,50,,7.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,75,,10.8,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,80,,11.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.7,65,,9.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,35,,5.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.2,90,,12.96,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,16.2,
DRAPE HAND / 29427,6150065,CDM,272,RC,,,Outpatient,,,47.18,47.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.03,70,,26.42,percent of total billed charges,70% of total billed charges for outpatient setting,40.05,84.88,,32.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.59,50,,18.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.39,75,,28.31,percent of total billed charges,75% of total billed charges for outpatient setting,33.03,70,,26.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,12.84,,4.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,80,,30.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,12.84,,4.85,percent of total billed charges,12.84% of total billed charges,6.06,12.84,,4.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.67,65,,24.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.51,35,,13.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.46,90,,33.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.06,42.46,
DRAPE HIP / 59439,69161941,CDM,272,RC,,,Outpatient,,,162.85,162.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,70,,91.2,percent of total billed charges,70% of total billed charges for outpatient setting,138.23,84.88,,110.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.43,50,,65.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.14,75,,97.71,percent of total billed charges,75% of total billed charges for outpatient setting,114,70,,91.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.91,12.84,,16.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.28,80,,104.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.91,12.84,,16.73,percent of total billed charges,12.84% of total billed charges,20.91,12.84,,16.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.85,65,,84.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57,35,,45.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.57,90,,117.26,percent of total billed charges,90% of total billed charges for outpatient setting,20.91,146.57,
DRAPE INSTR POUCH 1018 / D1018,760165,CDM,272,RC,,,Outpatient,,,10.44,10.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,70,,5.85,percent of total billed charges,70% of total billed charges for outpatient setting,8.86,84.88,,7.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.22,50,,4.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.83,75,,6.26,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,70,,5.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,80,,6.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.79,65,,5.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,35,,2.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.4,90,,7.52,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.4,
DRAPE INTRMT PANEL CENTURION 8065103820,69169872,CDM,272,RC,,,Outpatient,,,23.28,23.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,70,,13.04,percent of total billed charges,70% of total billed charges for outpatient setting,19.76,84.88,,15.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.64,50,,9.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.46,75,,13.97,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,70,,13.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,80,,14.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,2.99,12.84,,2.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.13,65,,12.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,35,,6.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.95,90,,16.76,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,20.95,
DRAPE IOBAN MED 13X13 / 6640EZ,69161719,CDM,272,RC,,,Outpatient,,,27.3,27.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.11,70,,15.29,percent of total billed charges,70% of total billed charges for outpatient setting,23.17,84.88,,18.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.65,50,,10.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.48,75,,16.38,percent of total billed charges,75% of total billed charges for outpatient setting,19.11,70,,15.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.84,80,,17.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.75,65,,14.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,35,,7.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.57,90,,19.66,percent of total billed charges,90% of total billed charges for outpatient setting,3.51,24.57,
DRAPE IRRIG POUCH 1016 / D1016,6150977,CDM,272,RC,,,Outpatient,,,39.28,39.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,33.34,84.88,,26.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.64,50,,15.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.46,75,,23.57,percent of total billed charges,75% of total billed charges for outpatient setting,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,80,,25.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.53,65,,20.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,35,,11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.35,90,,28.28,percent of total billed charges,90% of total billed charges for outpatient setting,5.04,35.35,
DRAPE LAPAROTOMY // DYNJP3003,6150063,CDM,270,RC,,,Outpatient,,,38.66,38.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,70,,21.65,percent of total billed charges,70% of total billed charges for outpatient setting,32.81,84.88,,26.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.33,50,,15.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29,75,,23.2,percent of total billed charges,75% of total billed charges for outpatient setting,27.06,70,,21.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.93,80,,24.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.13,65,,20.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,35,,10.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.79,90,,27.83,percent of total billed charges,90% of total billed charges for outpatient setting,4.96,34.79,
DRAPE LAVH  29474,69161387,CDM,272,RC,,,Outpatient,,,114.69,114.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.28,70,,64.22,percent of total billed charges,70% of total billed charges for outpatient setting,97.35,84.88,,77.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.35,50,,45.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.02,75,,68.82,percent of total billed charges,75% of total billed charges for outpatient setting,80.28,70,,64.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,12.84,,11.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.75,80,,73.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,12.84,,11.78,percent of total billed charges,12.84% of total billed charges,14.73,12.84,,11.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.55,65,,59.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,35,,32.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.22,90,,82.58,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,103.22,
DRAPE LEGGINS / 8421,6150978,CDM,272,RC,,,Outpatient,,,19.35,19.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,16.42,84.88,,13.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.68,50,,7.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.51,75,,11.61,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,70,,10.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,80,,12.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.48,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.58,65,,10.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,35,,5.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.42,90,,13.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.48,17.42,
DRAPE LITHOTOMY W/ POUCH(cysto),6150893,CDM,272,RC,,,Outpatient,,,96.82,96.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.77,70,,54.22,percent of total billed charges,70% of total billed charges for outpatient setting,82.18,84.88,,65.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.41,50,,38.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.62,75,,58.1,percent of total billed charges,75% of total billed charges for outpatient setting,67.77,70,,54.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.43,12.84,,9.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.46,80,,61.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.43,12.84,,9.94,percent of total billed charges,12.84% of total billed charges,12.43,12.84,,9.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.93,65,,50.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,35,,27.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.14,90,,69.71,percent of total billed charges,90% of total billed charges for outpatient setting,12.43,87.14,
DRAPE LITHOTOMY W/FLUID POUCH/ DYNJP9001,69162794,CDM,270,RC,,,Outpatient,,,67.2,67.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,70,,37.63,percent of total billed charges,70% of total billed charges for outpatient setting,57.04,84.88,,45.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.6,50,,26.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,75,,40.32,percent of total billed charges,75% of total billed charges for outpatient setting,47.04,70,,37.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,12.84,,6.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.76,80,,43.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,8.63,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.68,65,,34.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,35,,18.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.48,90,,48.38,percent of total billed charges,90% of total billed charges for outpatient setting,8.63,60.48,
DRAPE MICROSCOPE / 306071-0000-000,69161711,CDM,272,RC,,,Outpatient,,,127.35,127.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.15,70,,71.32,percent of total billed charges,70% of total billed charges for outpatient setting,108.09,84.88,,86.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.68,50,,50.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.51,75,,76.41,percent of total billed charges,75% of total billed charges for outpatient setting,89.15,70,,71.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,12.84,,13.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.88,80,,81.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,12.84,,13.08,percent of total billed charges,12.84% of total billed charges,16.35,12.84,,13.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.78,65,,66.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.57,35,,35.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.62,90,,91.7,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,114.62,
DRAPE MINOR PROCEDURE / 29496,6150894,CDM,272,RC,,,Outpatient,,,36.75,36.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,70,,20.58,percent of total billed charges,70% of total billed charges for outpatient setting,31.19,84.88,,24.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.38,50,,14.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.56,75,,22.05,percent of total billed charges,75% of total billed charges for outpatient setting,25.73,70,,20.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,12.84,,3.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,80,,23.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.72,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.89,65,,19.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.86,35,,10.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.08,90,,26.46,percent of total billed charges,90% of total billed charges for outpatient setting,4.72,33.08,
DRAPE OPMI MICROSCOPE,69159315,CDM,272,RC,,,Outpatient,,,63.56,63.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.49,70,,35.59,percent of total billed charges,70% of total billed charges for outpatient setting,53.95,84.88,,43.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.78,50,,25.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.67,75,,38.14,percent of total billed charges,75% of total billed charges for outpatient setting,44.49,70,,35.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,12.84,,6.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.85,80,,40.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,12.84,,6.53,percent of total billed charges,12.84% of total billed charges,8.16,12.84,,6.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.31,65,,33.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,35,,17.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.2,90,,45.76,percent of total billed charges,90% of total billed charges for outpatient setting,8.16,57.2,
DRAPE ROBOT BASE VELYS / 451570018,71000430,CDM,272,RC,,,Outpatient,,,332.6,332.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.82,70,,186.26,percent of total billed charges,70% of total billed charges for outpatient setting,282.31,84.88,,225.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,166.3,50,,133.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.45,75,,199.56,percent of total billed charges,75% of total billed charges for outpatient setting,232.82,70,,186.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.71,12.84,,34.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.08,80,,212.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.71,12.84,,34.17,percent of total billed charges,12.84% of total billed charges,42.71,12.84,,34.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,216.19,65,,172.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.41,35,,93.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.34,90,,239.47,percent of total billed charges,90% of total billed charges for outpatient setting,42.71,299.34,
DRAPE ROBOT SATEL VELYS / 451570019,71000431,CDM,272,RC,,,Outpatient,,,217.4,217.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.18,70,,121.74,percent of total billed charges,70% of total billed charges for outpatient setting,184.53,84.88,,147.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.7,50,,86.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.05,75,,130.44,percent of total billed charges,75% of total billed charges for outpatient setting,152.18,70,,121.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.91,12.84,,22.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.92,80,,139.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.91,12.84,,22.33,percent of total billed charges,12.84% of total billed charges,27.91,12.84,,22.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.31,65,,113.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.09,35,,60.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,195.66,90,,156.53,percent of total billed charges,90% of total billed charges for outpatient setting,27.91,195.66,
DRAPE STERI / 1010,6150859,CDM,272,RC,,,Outpatient,,,7.65,7.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,70,,4.29,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,84.88,,5.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.83,50,,3.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,75,,4.59,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,70,,4.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,80,,4.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.97,65,,3.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,35,,2.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.89,90,,5.51,percent of total billed charges,90% of total billed charges for outpatient setting,0.98,6.89,
DRAPE STERI 1015 / 1015,6150486,CDM,272,RC,,,Outpatient,,,24.75,24.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,70,,13.86,percent of total billed charges,70% of total billed charges for outpatient setting,21.01,84.88,,16.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.38,50,,9.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.56,75,,14.85,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,70,,13.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,80,,15.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.09,65,,12.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,35,,6.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.28,90,,17.82,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,22.28,
DRAPE STERI 1030 / 1030,69169118,CDM,272,RC,,,Outpatient,,,18.96,18.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,16.09,84.88,,12.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.48,50,,7.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.22,75,,11.38,percent of total billed charges,75% of total billed charges for outpatient setting,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.17,80,,12.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.32,65,,9.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.64,35,,5.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.06,90,,13.65,percent of total billed charges,90% of total billed charges for outpatient setting,2.43,17.06,
DRAPE STERI 1040/M1040,6153028,CDM,270,RC,,,Outpatient,,,30.17,30.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,70,,16.9,percent of total billed charges,70% of total billed charges for outpatient setting,25.61,84.88,,20.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.09,50,,12.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.63,75,,18.1,percent of total billed charges,75% of total billed charges for outpatient setting,21.12,70,,16.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.14,80,,19.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.61,65,,15.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,35,,8.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.15,90,,21.72,percent of total billed charges,90% of total billed charges for outpatient setting,3.87,27.15,
DRAPE THYROID T / DYNJP7003H,69162415,CDM,272,RC,,,Outpatient,,,66.62,66.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.63,70,,37.3,percent of total billed charges,70% of total billed charges for outpatient setting,56.55,84.88,,45.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.31,50,,26.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.97,75,,39.98,percent of total billed charges,75% of total billed charges for outpatient setting,46.63,70,,37.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,80,,42.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,8.55,12.84,,6.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.3,65,,34.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.32,35,,18.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.96,90,,47.97,percent of total billed charges,90% of total billed charges for outpatient setting,8.55,59.96,
DRAPE TRANSVERSE LAPAROTOMY / 29421,6150066,CDM,272,RC,,,Outpatient,,,35.21,35.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.65,70,,19.72,percent of total billed charges,70% of total billed charges for outpatient setting,29.89,84.88,,23.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.61,50,,14.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.41,75,,21.13,percent of total billed charges,75% of total billed charges for outpatient setting,24.65,70,,19.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.17,80,,22.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.89,65,,18.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.32,35,,9.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.69,90,,25.35,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,31.69,
DRAPE TRIMANO / AR-1648,71000704,CDM,272,RC,,,Outpatient,,,113.4,113.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,96.25,84.88,,77,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.7,50,,45.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,75,,68.04,percent of total billed charges,75% of total billed charges for outpatient setting,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,80,,72.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.71,65,,58.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.69,35,,31.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.06,90,,81.65,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.06,
DRAPE U 60X72IN / 8476,6150896,CDM,272,RC,,,Outpatient,,,16.38,16.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,70,,9.18,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,84.88,,11.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.19,50,,6.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.29,75,,9.83,percent of total billed charges,75% of total billed charges for outpatient setting,11.47,70,,9.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,80,,10.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.65,65,,8.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,35,,4.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.74,90,,11.79,percent of total billed charges,90% of total billed charges for outpatient setting,2.1,14.74,
DRAPE UNDER BUTCKS CNTRL POUCH / 8482,6151007,CDM,272,RC,,,Outpatient,,,27.2,27.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,23.09,84.88,,18.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.6,50,,10.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.4,75,,16.32,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,80,,17.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,65,,14.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,35,,7.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.48,90,,19.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,24.48,
DRAPE WARMER FLUID / ITB100,6150998,CDM,272,RC,,,Outpatient,,,224.4,224.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.08,70,,125.66,percent of total billed charges,70% of total billed charges for outpatient setting,190.47,84.88,,152.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.2,50,,89.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,75,,134.64,percent of total billed charges,75% of total billed charges for outpatient setting,157.08,70,,125.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.52,80,,143.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.86,65,,116.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.54,35,,62.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,201.96,90,,161.57,percent of total billed charges,90% of total billed charges for outpatient setting,28.81,201.96,
DRESSING 11X6 OPSITE / 4986,69160721,CDM,272,RC,,,Outpatient,,,22.59,22.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.3,50,,9.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,2.9,12.84,,2.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.68,65,,11.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,35,,6.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,20.33,
DRESSING 1IN BIOPATCH / 4152,114484,CDM,272,RC,,,Outpatient,,,42.56,42.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.79,70,,23.83,percent of total billed charges,70% of total billed charges for outpatient setting,36.12,84.88,,28.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.28,50,,17.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,75,,25.54,percent of total billed charges,75% of total billed charges for outpatient setting,29.79,70,,23.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,12.84,,4.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.05,80,,27.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,12.84,,4.37,percent of total billed charges,12.84% of total billed charges,5.46,12.84,,4.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.66,65,,22.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.9,35,,11.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.3,90,,30.64,percent of total billed charges,90% of total billed charges for outpatient setting,5.46,38.3,
DRESSING 2.37X2.75 OPSITE / 30165-007X,5150146,CDM,272,RC,A6257,HCPCS,Outpatient,,,1.8,1.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,70,,1.01,percent of total billed charges,70% of total billed charges for outpatient setting,1.53,84.88,,1.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,75,,1.08,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,70,,1.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,80,,1.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.17,65,,0.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,90,,1.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.23,1.62,
DRESSING 2.75IN TEGADERM / 1624W,365754,CDM,272,RC,,,Outpatient,,,1.79,1.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,70,,1,percent of total billed charges,70% of total billed charges for outpatient setting,1.52,84.88,,1.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.9,50,,0.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.34,75,,1.07,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,70,,1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,80,,1.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.16,65,,0.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,35,,0.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.61,90,,1.29,percent of total billed charges,90% of total billed charges for outpatient setting,0.23,1.61,
DRESSING 3 X8  ADAPTIC STRL,5150090,CDM,272,RC,,,Outpatient,,,7.52,7.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,70,,4.21,percent of total billed charges,70% of total billed charges for outpatient setting,6.38,84.88,,5.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.76,50,,3.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.64,75,,4.51,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,70,,4.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,12.84,,0.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,80,,4.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.97,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.89,65,,3.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,35,,2.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.77,90,,5.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.97,6.77,
DRESSING 4X8IN TELFA ISLAND / 7541,6150314,CDM,272,RC,,,Outpatient,,,8.29,8.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,7.04,84.88,,5.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.15,50,,3.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.22,75,,4.98,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.63,80,,5.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.39,65,,4.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,35,,2.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.46,90,,5.97,percent of total billed charges,90% of total billed charges for outpatient setting,1.06,7.46,
DRESSING SILVERLON ISLAND / ID-46,69169116,CDM,272,RC,,,Outpatient,,,132.57,132.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.8,70,,74.24,percent of total billed charges,70% of total billed charges for outpatient setting,112.53,84.88,,90.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.29,50,,53.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.43,75,,79.54,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,70,,74.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.02,12.84,,13.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.06,80,,84.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.02,12.84,,13.62,percent of total billed charges,12.84% of total billed charges,17.02,12.84,,13.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.17,65,,68.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.4,35,,37.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,119.31,90,,95.45,percent of total billed charges,90% of total billed charges for outpatient setting,17.02,119.31,
DRESSING WOUND VAC PICO / 66800953,70000336,CDM,272,RC,,,Outpatient,,,999.31,999.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.52,70,,559.62,percent of total billed charges,70% of total billed charges for outpatient setting,848.21,84.88,,678.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.66,50,,399.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.48,75,,599.58,percent of total billed charges,75% of total billed charges for outpatient setting,699.52,70,,559.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.31,12.84,,102.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.45,80,,639.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.31,12.84,,102.65,percent of total billed charges,12.84% of total billed charges,128.31,12.84,,102.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.55,65,,519.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.76,35,,279.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.38,90,,719.5,percent of total billed charges,90% of total billed charges for outpatient setting,128.31,899.38,
DRGS HELIX COMP 4.5X10 IN / ABS-4052,69162455,CDM,272,RC,,,Outpatient,,,227.12,227.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,192.78,84.88,,154.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.56,50,,90.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.34,75,,136.27,percent of total billed charges,75% of total billed charges for outpatient setting,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.7,80,,145.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.63,65,,118.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.49,35,,63.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.41,90,,163.53,percent of total billed charges,90% of total billed charges for outpatient setting,29.16,204.41,
DRGS HELIX COMP 5x6IN/ ABS-4051,69162536,CDM,272,RC,,,Outpatient,,,227.12,227.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,192.78,84.88,,154.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.56,50,,90.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.34,75,,136.27,percent of total billed charges,75% of total billed charges for outpatient setting,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.7,80,,145.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.63,65,,118.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.49,35,,63.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.41,90,,163.53,percent of total billed charges,90% of total billed charges for outpatient setting,29.16,204.41,
DRILL 1.5MM WIRE PASSG / 1608-002-059,6151043,CDM,272,RC,,,Outpatient,,,151.95,151.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.37,70,,85.1,percent of total billed charges,70% of total billed charges for outpatient setting,128.98,84.88,,103.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.98,50,,60.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.96,75,,91.17,percent of total billed charges,75% of total billed charges for outpatient setting,106.37,70,,85.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.51,12.84,,15.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.56,80,,97.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.51,12.84,,15.61,percent of total billed charges,12.84% of total billed charges,19.51,12.84,,15.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.77,65,,79.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.18,35,,42.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.76,90,,109.41,percent of total billed charges,90% of total billed charges for outpatient setting,19.51,136.76,
DRILL 1/8 IN QUICK RELEASE / 32-486265,69162552,CDM,272,RC,,,Outpatient,,,384,384,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.8,70,,215.04,percent of total billed charges,70% of total billed charges for outpatient setting,325.94,84.88,,260.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,192,50,,153.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288,75,,230.4,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,70,,215.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.31,12.84,,39.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.2,80,,245.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.31,12.84,,39.45,percent of total billed charges,12.84% of total billed charges,49.31,12.84,,39.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,249.6,65,,199.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,35,,107.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,345.6,90,,276.48,percent of total billed charges,90% of total billed charges for outpatient setting,49.31,345.6,
DRILL 2.0MM SPEEDGUIDE AO / 703891,70000314,CDM,272,RC,,,Outpatient,,,601.6,601.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.12,70,,336.9,percent of total billed charges,70% of total billed charges for outpatient setting,510.64,84.88,,408.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,300.8,50,,240.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.2,75,,360.96,percent of total billed charges,75% of total billed charges for outpatient setting,421.12,70,,336.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.28,80,,385.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,391.04,65,,312.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.56,35,,168.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,541.44,90,,433.15,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,541.44,
DRILL 2.6MM SPEEDGUIDE AO / 703894,70000261,CDM,272,RC,,,Outpatient,,,601.6,601.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.12,70,,336.9,percent of total billed charges,70% of total billed charges for outpatient setting,510.64,84.88,,408.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,300.8,50,,240.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.2,75,,360.96,percent of total billed charges,75% of total billed charges for outpatient setting,421.12,70,,336.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.28,80,,385.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,77.25,12.84,,61.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,391.04,65,,312.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.56,35,,168.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,541.44,90,,433.15,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,541.44,
DRILL 2.6X122MM AO-SHAFT / 45.35010,70000315,CDM,272,RC,,,Outpatient,,,639.17,639.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.42,70,,357.94,percent of total billed charges,70% of total billed charges for outpatient setting,542.53,84.88,,434.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,319.59,50,,255.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479.38,75,,383.5,percent of total billed charges,75% of total billed charges for outpatient setting,447.42,70,,357.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,12.84,,65.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.34,80,,409.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,12.84,,65.66,percent of total billed charges,12.84% of total billed charges,82.07,12.84,,65.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.46,65,,332.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.71,35,,178.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,575.25,90,,460.2,percent of total billed charges,90% of total billed charges for outpatient setting,82.07,575.25,
DRILL 2.7MM DISPOSABLE / 110040202,2419554,CDM,272,RC,,,Outpatient,,,468,468,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,70,,262.08,percent of total billed charges,70% of total billed charges for outpatient setting,397.24,84.88,,317.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,234,50,,187.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351,75,,280.8,percent of total billed charges,75% of total billed charges for outpatient setting,327.6,70,,262.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,80,,299.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,304.2,65,,243.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,35,,131.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,421.2,90,,336.96,percent of total billed charges,90% of total billed charges for outpatient setting,60.09,421.2,
DRILL 6.5MM CANN TWIST / 702601,70000435,CDM,272,RC,,,Outpatient,,,1961.7,1961.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1373.19,70,,1098.55,percent of total billed charges,70% of total billed charges for outpatient setting,1665.09,84.88,,1332.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,980.85,50,,784.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1471.28,75,,1177.02,percent of total billed charges,75% of total billed charges for outpatient setting,1373.19,70,,1098.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.88,12.84,,201.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1569.36,80,,1255.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.88,12.84,,201.5,percent of total billed charges,12.84% of total billed charges,251.88,12.84,,201.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1275.11,65,,1020.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.6,35,,549.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1765.53,90,,1412.42,percent of total billed charges,90% of total billed charges for outpatient setting,251.88,1765.53,
DRILL BIOUNI DISP KIT / ABS-4080D,69169822,CDM,272,RC,,,Outpatient,,,1200,1200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,70,,672,percent of total billed charges,70% of total billed charges for outpatient setting,1018.56,84.88,,814.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,600,50,,480,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,900,75,,720,percent of total billed charges,75% of total billed charges for outpatient setting,840,70,,672,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.08,12.84,,123.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,80,,768,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.08,12.84,,123.26,percent of total billed charges,12.84% of total billed charges,154.08,12.84,,123.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,780,65,,624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,35,,336,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,90,,864,percent of total billed charges,90% of total billed charges for outpatient setting,154.08,1080,
DRILL BIT 1.1X65MM / 03.130.201,69169252,CDM,272,RC,,,Outpatient,,,478.3,478.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.81,70,,267.85,percent of total billed charges,70% of total billed charges for outpatient setting,405.98,84.88,,324.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,239.15,50,,191.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.73,75,,286.98,percent of total billed charges,75% of total billed charges for outpatient setting,334.81,70,,267.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.41,12.84,,49.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.64,80,,306.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.41,12.84,,49.13,percent of total billed charges,12.84% of total billed charges,61.41,12.84,,49.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,310.9,65,,248.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.41,35,,133.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,430.47,90,,344.38,percent of total billed charges,90% of total billed charges for outpatient setting,61.41,430.47,
DRILL BIT 1.5X85MM / 310.15,69162708,CDM,272,RC,,,Outpatient,,,374.52,374.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.16,70,,209.73,percent of total billed charges,70% of total billed charges for outpatient setting,317.89,84.88,,254.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,187.26,50,,149.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.89,75,,224.71,percent of total billed charges,75% of total billed charges for outpatient setting,262.16,70,,209.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.09,12.84,,38.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.62,80,,239.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.09,12.84,,38.47,percent of total billed charges,12.84% of total billed charges,48.09,12.84,,38.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,243.44,65,,194.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.08,35,,104.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.07,90,,269.66,percent of total billed charges,90% of total billed charges for outpatient setting,48.09,337.07,
DRILL BIT 1.5X96MM / 310.507,9169657,CDM,272,RC,,,Outpatient,,,718.24,718.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.77,70,,402.22,percent of total billed charges,70% of total billed charges for outpatient setting,609.64,84.88,,487.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,359.12,50,,287.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,538.68,75,,430.94,percent of total billed charges,75% of total billed charges for outpatient setting,502.77,70,,402.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,12.84,,73.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.59,80,,459.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,12.84,,73.78,percent of total billed charges,12.84% of total billed charges,92.22,12.84,,73.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,466.86,65,,373.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.38,35,,201.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,646.42,90,,517.14,percent of total billed charges,90% of total billed charges for outpatient setting,92.22,646.42,
DRILL BIT 1.5X96MM / 310.507,69169657,CDM,272,RC,,,Outpatient,,,718.24,718.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.77,70,,402.22,percent of total billed charges,70% of total billed charges for outpatient setting,609.64,84.88,,487.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,359.12,50,,287.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,538.68,75,,430.94,percent of total billed charges,75% of total billed charges for outpatient setting,502.77,70,,402.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,12.84,,73.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.59,80,,459.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,12.84,,73.78,percent of total billed charges,12.84% of total billed charges,92.22,12.84,,73.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,466.86,65,,373.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.38,35,,201.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,646.42,90,,517.14,percent of total billed charges,90% of total billed charges for outpatient setting,92.22,646.42,
DRILL BIT 1.7 STRYKER / 60-14326,69161969,CDM,272,RC,,,Outpatient,,,595.26,595.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.68,70,,333.34,percent of total billed charges,70% of total billed charges for outpatient setting,505.26,84.88,,404.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,297.63,50,,238.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446.45,75,,357.16,percent of total billed charges,75% of total billed charges for outpatient setting,416.68,70,,333.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.43,12.84,,61.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.21,80,,380.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.43,12.84,,61.14,percent of total billed charges,12.84% of total billed charges,76.43,12.84,,61.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,386.92,65,,309.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.34,35,,166.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,535.73,90,,428.58,percent of total billed charges,90% of total billed charges for outpatient setting,76.43,535.73,
DRILL BIT 1.9 STRYKER / 60-19340,69162499,CDM,272,RC,,,Outpatient,,,558.05,558.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,473.67,84.88,,378.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,279.03,50,,223.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.54,75,,334.83,percent of total billed charges,75% of total billed charges for outpatient setting,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.44,80,,357.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,362.73,65,,290.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.32,35,,156.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,502.25,90,,401.8,percent of total billed charges,90% of total billed charges for outpatient setting,71.65,502.25,
DRILL BIT 12MM / 13-90-015-12,69169319,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,712.99,84.88,,570.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,420,50,,336,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630,75,,504,percent of total billed charges,75% of total billed charges for outpatient setting,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672,80,,537.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,546,65,,436.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,35,,235.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,756,90,,604.8,percent of total billed charges,90% of total billed charges for outpatient setting,107.86,756,
DRILL BIT 14MM / 13-90-015-14,69169303,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,712.99,84.88,,570.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,420,50,,336,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630,75,,504,percent of total billed charges,75% of total billed charges for outpatient setting,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672,80,,537.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,546,65,,436.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,35,,235.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,756,90,,604.8,percent of total billed charges,90% of total billed charges for outpatient setting,107.86,756,
DRILL BIT 2.0 / 45-27010,69162882,CDM,272,RC,,,Outpatient,,,218.03,218.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.62,70,,122.1,percent of total billed charges,70% of total billed charges for outpatient setting,185.06,84.88,,148.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.02,50,,87.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.52,75,,130.82,percent of total billed charges,75% of total billed charges for outpatient setting,152.62,70,,122.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,12.84,,22.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.42,80,,139.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,12.84,,22.4,percent of total billed charges,12.84% of total billed charges,28,12.84,,22.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.72,65,,113.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,35,,61.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.23,90,,156.98,percent of total billed charges,90% of total billed charges for outpatient setting,28,196.23,
DRILL BIT 2.0 / 703933,69161626,CDM,272,RC,,,Outpatient,,,348.35,348.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.85,70,,195.08,percent of total billed charges,70% of total billed charges for outpatient setting,295.68,84.88,,236.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,174.18,50,,139.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.26,75,,209.01,percent of total billed charges,75% of total billed charges for outpatient setting,243.85,70,,195.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,12.84,,35.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.68,80,,222.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,12.84,,35.78,percent of total billed charges,12.84% of total billed charges,44.73,12.84,,35.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,226.43,65,,181.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.92,35,,97.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.52,90,,250.82,percent of total billed charges,90% of total billed charges for outpatient setting,44.73,313.52,
DRILL BIT 2.0 STRYKER  XF0012002,69161631,CDM,272,RC,,,Outpatient,,,948.19,948.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.73,70,,530.98,percent of total billed charges,70% of total billed charges for outpatient setting,804.82,84.88,,643.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,474.1,50,,379.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,711.14,75,,568.91,percent of total billed charges,75% of total billed charges for outpatient setting,663.73,70,,530.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.75,12.84,,97.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.55,80,,606.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.75,12.84,,97.4,percent of total billed charges,12.84% of total billed charges,121.75,12.84,,97.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,616.32,65,,493.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.87,35,,265.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,853.37,90,,682.7,percent of total billed charges,90% of total billed charges for outpatient setting,121.75,853.37,
DRILL BIT 2.0 STRYKER / 60-20385,69162500,CDM,272,RC,,,Outpatient,,,249.48,249.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.64,70,,139.71,percent of total billed charges,70% of total billed charges for outpatient setting,211.76,84.88,,169.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.74,50,,99.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.11,75,,149.69,percent of total billed charges,75% of total billed charges for outpatient setting,174.64,70,,139.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.03,12.84,,25.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,80,,159.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.03,12.84,,25.62,percent of total billed charges,12.84% of total billed charges,32.03,12.84,,25.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.16,65,,129.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.32,35,,69.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,224.53,90,,179.62,percent of total billed charges,90% of total billed charges for outpatient setting,32.03,224.53,
DRILL BIT 2.0 X 40MM WRIST / A-3733,69169712,CDM,272,RC,,,Outpatient,,,885.78,885.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.05,70,,496.04,percent of total billed charges,70% of total billed charges for outpatient setting,751.85,84.88,,601.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,442.89,50,,354.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.34,75,,531.47,percent of total billed charges,75% of total billed charges for outpatient setting,620.05,70,,496.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.73,12.84,,90.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.62,80,,566.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.73,12.84,,90.98,percent of total billed charges,12.84% of total billed charges,113.73,12.84,,90.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,575.76,65,,460.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.02,35,,248.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,797.2,90,,637.76,percent of total billed charges,90% of total billed charges for outpatient setting,113.73,797.2,
DRILL BIT 2.0/1.6X25MM WRIST / A-3430,69169700,CDM,272,RC,,,Outpatient,,,885.78,885.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.05,70,,496.04,percent of total billed charges,70% of total billed charges for outpatient setting,751.85,84.88,,601.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,442.89,50,,354.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.34,75,,531.47,percent of total billed charges,75% of total billed charges for outpatient setting,620.05,70,,496.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.73,12.84,,90.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.62,80,,566.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.73,12.84,,90.98,percent of total billed charges,12.84% of total billed charges,113.73,12.84,,90.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,575.76,65,,460.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.02,35,,248.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,797.2,90,,637.76,percent of total billed charges,90% of total billed charges for outpatient setting,113.73,797.2,
DRILL BIT 2.0MM CANNULA  / AR-8956C-35PD,70000090,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
DRILL BIT 2.0MM CANNULATED  AR-8933-20C,69162353,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
DRILL BIT 2.0MM CANNULATED / AR-8005D-20,69162568,CDM,272,RC,,,Outpatient,,,601.31,601.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.92,70,,336.74,percent of total billed charges,70% of total billed charges for outpatient setting,510.39,84.88,,408.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,300.66,50,,240.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450.98,75,,360.78,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,70,,336.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.21,12.84,,61.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.05,80,,384.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.21,12.84,,61.77,percent of total billed charges,12.84% of total billed charges,77.21,12.84,,61.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390.85,65,,312.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.46,35,,168.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,541.18,90,,432.94,percent of total billed charges,90% of total billed charges for outpatient setting,77.21,541.18,
DRILL BIT 2.0MM J LATCH /310.201,6152736,CDM,270,RC,,,Outpatient,,,185.7,185.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.99,70,,103.99,percent of total billed charges,70% of total billed charges for outpatient setting,157.62,84.88,,126.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.85,50,,74.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.28,75,,111.42,percent of total billed charges,75% of total billed charges for outpatient setting,129.99,70,,103.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.56,80,,118.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.71,65,,96.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65,35,,52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.13,90,,133.7,percent of total billed charges,90% of total billed charges for outpatient setting,23.84,167.13,
DRILL BIT 2.0X100MM / 310.19,6152913,CDM,272,RC,,,Outpatient,,,425.25,425.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.68,70,,238.14,percent of total billed charges,70% of total billed charges for outpatient setting,360.95,84.88,,288.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.63,50,,170.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.94,75,,255.15,percent of total billed charges,75% of total billed charges for outpatient setting,297.68,70,,238.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.6,12.84,,43.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.2,80,,272.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.6,12.84,,43.68,percent of total billed charges,12.84% of total billed charges,54.6,12.84,,43.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,276.41,65,,221.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.84,35,,119.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,382.73,90,,306.18,percent of total billed charges,90% of total billed charges for outpatient setting,54.6,382.73,
DRILL BIT 2.0X125MM / 310.21,6152172,CDM,270,RC,,,Outpatient,,,345.73,345.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.01,70,,193.61,percent of total billed charges,70% of total billed charges for outpatient setting,293.46,84.88,,234.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,172.87,50,,138.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.3,75,,207.44,percent of total billed charges,75% of total billed charges for outpatient setting,242.01,70,,193.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.39,12.84,,35.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.58,80,,221.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.39,12.84,,35.51,percent of total billed charges,12.84% of total billed charges,44.39,12.84,,35.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.72,65,,179.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.01,35,,96.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.16,90,,248.93,percent of total billed charges,90% of total billed charges for outpatient setting,44.39,311.16,
DRILL BIT 2.0X135MM / 703896,70000605,CDM,272,RC,C1713,HCPCS,Outpatient,,,318.02,318.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.61,70,,178.09,percent of total billed charges,70% of total billed charges for outpatient setting,269.94,84.88,,215.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.52,75,,190.82,percent of total billed charges,75% of total billed charges for outpatient setting,222.61,70,,178.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.83,12.84,,32.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.42,80,,203.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.83,12.84,,32.66,percent of total billed charges,12.84% of total billed charges,40.83,12.84,,32.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,206.71,65,,165.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.31,35,,89.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.22,90,,228.98,percent of total billed charges,90% of total billed charges for outpatient setting,40.83,286.22,
DRILL BIT 2.2MM / 231200200,69169566,CDM,272,RC,,,Outpatient,,,394.8,394.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.36,70,,221.09,percent of total billed charges,70% of total billed charges for outpatient setting,335.11,84.88,,268.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,197.4,50,,157.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.1,75,,236.88,percent of total billed charges,75% of total billed charges for outpatient setting,276.36,70,,221.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,12.84,,40.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.84,80,,252.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,12.84,,40.55,percent of total billed charges,12.84% of total billed charges,50.69,12.84,,40.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,256.62,65,,205.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.18,35,,110.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,355.32,90,,284.26,percent of total billed charges,90% of total billed charges for outpatient setting,50.69,355.32,
DRILL BIT 2.4X100MM / 310.530,69161504,CDM,272,RC,,,Outpatient,,,899.81,899.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.87,70,,503.9,percent of total billed charges,70% of total billed charges for outpatient setting,763.76,84.88,,611.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,449.91,50,,359.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,674.86,75,,539.89,percent of total billed charges,75% of total billed charges for outpatient setting,629.87,70,,503.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.54,12.84,,92.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.85,80,,575.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.54,12.84,,92.43,percent of total billed charges,12.84% of total billed charges,115.54,12.84,,92.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,584.88,65,,467.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.93,35,,251.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,809.83,90,,647.86,percent of total billed charges,90% of total billed charges for outpatient setting,115.54,809.83,
DRILL BIT 2.5MM,69161658,CDM,272,RC,,,Outpatient,,,766.4,766.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.48,70,,429.18,percent of total billed charges,70% of total billed charges for outpatient setting,650.52,84.88,,520.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,383.2,50,,306.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,574.8,75,,459.84,percent of total billed charges,75% of total billed charges for outpatient setting,536.48,70,,429.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.41,12.84,,78.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.12,80,,490.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.41,12.84,,78.73,percent of total billed charges,12.84% of total billed charges,98.41,12.84,,78.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,498.16,65,,398.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.24,35,,214.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,689.76,90,,551.81,percent of total billed charges,90% of total billed charges for outpatient setting,98.41,689.76,
DRILL BIT 2.5MM / 310.25,6152173,CDM,270,RC,,,Outpatient,,,289.48,289.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.64,70,,162.11,percent of total billed charges,70% of total billed charges for outpatient setting,245.71,84.88,,196.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,144.74,50,,115.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.11,75,,173.69,percent of total billed charges,75% of total billed charges for outpatient setting,202.64,70,,162.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.17,12.84,,29.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.58,80,,185.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.17,12.84,,29.74,percent of total billed charges,12.84% of total billed charges,37.17,12.84,,29.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,188.16,65,,150.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.32,35,,81.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,260.53,90,,208.42,percent of total billed charges,90% of total billed charges for outpatient setting,37.17,260.53,
DRILL BIT 2.5MM CLBRTED / AR-8943-13,69169805,CDM,272,RC,,,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.5,50,,142.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
DRILL BIT 2.5X12MM / UM180-00-12,69169458,CDM,272,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390,65,,312,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540,90,,432,percent of total billed charges,90% of total billed charges for outpatient setting,77.04,540,
DRILL BIT 2.5X14MM / UM180-00-14,69169381,CDM,272,RC,,,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,70,,73.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.31,65,,68.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.13,90,,94.5,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,118.13,
DRILL BIT 2.6 / 703934,69161552,CDM,272,RC,,,Outpatient,,,350.41,350.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.29,70,,196.23,percent of total billed charges,70% of total billed charges for outpatient setting,297.43,84.88,,237.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,175.21,50,,140.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.81,75,,210.25,percent of total billed charges,75% of total billed charges for outpatient setting,245.29,70,,196.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.99,12.84,,35.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.33,80,,224.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.99,12.84,,35.99,percent of total billed charges,12.84% of total billed charges,44.99,12.84,,35.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,227.77,65,,182.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.64,35,,98.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,315.37,90,,252.3,percent of total billed charges,90% of total billed charges for outpatient setting,44.99,315.37,
DRILL BIT 2.6 LOCKING / 703896,69169454,CDM,272,RC,,,Outpatient,,,513.92,513.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.74,70,,287.79,percent of total billed charges,70% of total billed charges for outpatient setting,436.22,84.88,,348.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.96,50,,205.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.44,75,,308.35,percent of total billed charges,75% of total billed charges for outpatient setting,359.74,70,,287.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,12.84,,52.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.14,80,,328.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,12.84,,52.79,percent of total billed charges,12.84% of total billed charges,65.99,12.84,,52.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,334.05,65,,267.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,35,,143.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,462.53,90,,370.02,percent of total billed charges,90% of total billed charges for outpatient setting,65.99,462.53,
DRILL BIT 2.6X70 AO SHAFT / 45-35010,70000125,CDM,272,RC,,,Outpatient,,,255.66,255.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.96,70,,143.17,percent of total billed charges,70% of total billed charges for outpatient setting,217,84.88,,173.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.83,50,,102.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.75,75,,153.4,percent of total billed charges,75% of total billed charges for outpatient setting,178.96,70,,143.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.53,80,,163.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.18,65,,132.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.48,35,,71.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.09,90,,184.07,percent of total billed charges,90% of total billed charges for outpatient setting,32.83,230.09,
DRILL BIT 2.7MM CANNULATED /310.221,69160756,CDM,270,RC,,,Outpatient,,,2070.88,2070.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449.62,70,,1159.7,percent of total billed charges,70% of total billed charges for outpatient setting,1757.76,84.88,,1406.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,1035.44,50,,828.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1553.16,75,,1242.53,percent of total billed charges,75% of total billed charges for outpatient setting,1449.62,70,,1159.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.9,12.84,,212.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1656.7,80,,1325.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.9,12.84,,212.72,percent of total billed charges,12.84% of total billed charges,265.9,12.84,,212.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1346.07,65,,1076.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.81,35,,579.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1863.79,90,,1491.03,percent of total billed charges,90% of total billed charges for outpatient setting,265.9,1863.79,
"DRILL BIT 2.7MM, CALIBRATED",69161651,CDM,272,RC,,,Outpatient,,,655,655,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.5,70,,366.8,percent of total billed charges,70% of total billed charges for outpatient setting,555.96,84.88,,444.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,327.5,50,,262,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,491.25,75,,393,percent of total billed charges,75% of total billed charges for outpatient setting,458.5,70,,366.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524,80,,419.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,425.75,65,,340.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.25,35,,183.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,589.5,90,,471.6,percent of total billed charges,90% of total billed charges for outpatient setting,84.1,589.5,
DRILL BIT 2.7MMx85MM/310.27,69169138,CDM,270,RC,,,Outpatient,,,396.9,396.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.83,70,,222.26,percent of total billed charges,70% of total billed charges for outpatient setting,336.89,84.88,,269.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,198.45,50,,158.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.68,75,,238.14,percent of total billed charges,75% of total billed charges for outpatient setting,277.83,70,,222.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.96,12.84,,40.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.52,80,,254.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.96,12.84,,40.77,percent of total billed charges,12.84% of total billed charges,50.96,12.84,,40.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.99,65,,206.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.92,35,,111.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,357.21,90,,285.77,percent of total billed charges,90% of total billed charges for outpatient setting,50.96,357.21,
DRILL BIT 2.8MM   170X80MM /03.133.107,69169696,CDM,272,RC,,,Outpatient,,,716.14,716.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.3,70,,401.04,percent of total billed charges,70% of total billed charges for outpatient setting,607.86,84.88,,486.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,358.07,50,,286.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,537.11,75,,429.69,percent of total billed charges,75% of total billed charges for outpatient setting,501.3,70,,401.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.95,12.84,,73.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.91,80,,458.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.95,12.84,,73.56,percent of total billed charges,12.84% of total billed charges,91.95,12.84,,73.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,465.49,65,,372.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.65,35,,200.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,644.53,90,,515.62,percent of total billed charges,90% of total billed charges for outpatient setting,91.95,644.53,
DRILL BIT 2.8MM 200X110MM / 03.133.108,69169792,CDM,272,RC,,,Outpatient,,,765.7,765.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.99,70,,428.79,percent of total billed charges,70% of total billed charges for outpatient setting,649.93,84.88,,519.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,382.85,50,,306.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,574.28,75,,459.42,percent of total billed charges,75% of total billed charges for outpatient setting,535.99,70,,428.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.32,12.84,,78.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.56,80,,490.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.32,12.84,,78.66,percent of total billed charges,12.84% of total billed charges,98.32,12.84,,78.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.71,65,,398.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268,35,,214.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,689.13,90,,551.3,percent of total billed charges,90% of total billed charges for outpatient setting,98.32,689.13,
DRILL BIT 2.8MM PERCUTANEOUS/  324.211,69169306,CDM,270,RC,,,Outpatient,,,1023.75,1023.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.63,70,,573.3,percent of total billed charges,70% of total billed charges for outpatient setting,868.96,84.88,,695.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,511.88,50,,409.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,767.81,75,,614.25,percent of total billed charges,75% of total billed charges for outpatient setting,716.63,70,,573.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.45,12.84,,105.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,80,,655.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.45,12.84,,105.16,percent of total billed charges,12.84% of total billed charges,131.45,12.84,,105.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,665.44,65,,532.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.31,35,,286.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,921.38,90,,737.1,percent of total billed charges,90% of total billed charges for outpatient setting,131.45,921.38,
DRILL BIT 2.9MM   8290-30-070,69161592,CDM,272,RC,,,Outpatient,,,1314.45,1314.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,920.12,70,,736.1,percent of total billed charges,70% of total billed charges for outpatient setting,1115.71,84.88,,892.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,657.23,50,,525.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,985.84,75,,788.67,percent of total billed charges,75% of total billed charges for outpatient setting,920.12,70,,736.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.78,12.84,,135.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1051.56,80,,841.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.78,12.84,,135.02,percent of total billed charges,12.84% of total billed charges,168.78,12.84,,135.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,854.39,65,,683.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.06,35,,368.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1183.01,90,,946.41,percent of total billed charges,90% of total billed charges for outpatient setting,168.78,1183.01,
DRILL BIT 2.9MM CANNULATED 829030070,69161865,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
DRILL BIT 3.0MM / 9020013,69169125,CDM,272,RC,,,Outpatient,,,496.41,496.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.49,70,,277.99,percent of total billed charges,70% of total billed charges for outpatient setting,421.35,84.88,,337.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,248.21,50,,198.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.31,75,,297.85,percent of total billed charges,75% of total billed charges for outpatient setting,347.49,70,,277.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.74,12.84,,50.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,80,,317.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.74,12.84,,50.99,percent of total billed charges,12.84% of total billed charges,63.74,12.84,,50.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,322.67,65,,258.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.74,35,,138.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.77,90,,357.42,percent of total billed charges,90% of total billed charges for outpatient setting,63.74,446.77,
DRILL BIT 3.2MM / 03.010.060,69162059,CDM,272,RC,,,Outpatient,,,1014.79,1014.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.35,70,,568.28,percent of total billed charges,70% of total billed charges for outpatient setting,861.35,84.88,,689.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,507.4,50,,405.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,761.09,75,,608.87,percent of total billed charges,75% of total billed charges for outpatient setting,710.35,70,,568.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.3,12.84,,104.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.83,80,,649.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.3,12.84,,104.24,percent of total billed charges,12.84% of total billed charges,130.3,12.84,,104.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,659.61,65,,527.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.18,35,,284.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,913.31,90,,730.65,percent of total billed charges,90% of total billed charges for outpatient setting,130.3,913.31,
DRILL BIT 3.2MM CANNULATED/03.226.039,69169422,CDM,272,RC,,,Outpatient,,,1923.86,1923.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1346.7,70,,1077.36,percent of total billed charges,70% of total billed charges for outpatient setting,1632.97,84.88,,1306.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,961.93,50,,769.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1442.9,75,,1154.32,percent of total billed charges,75% of total billed charges for outpatient setting,1346.7,70,,1077.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.02,12.84,,197.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1539.09,80,,1231.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.02,12.84,,197.62,percent of total billed charges,12.84% of total billed charges,247.02,12.84,,197.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1250.51,65,,1000.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.35,35,,538.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1731.47,90,,1385.18,percent of total billed charges,90% of total billed charges for outpatient setting,247.02,1731.47,
DRILL BIT 3.2MM FLTD NDL / 03.010.103S,695803,CDM,272,RC,,,Outpatient,,,1000.24,1000.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.17,70,,560.14,percent of total billed charges,70% of total billed charges for outpatient setting,849,84.88,,679.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,500.12,50,,400.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,750.18,75,,600.14,percent of total billed charges,75% of total billed charges for outpatient setting,700.17,70,,560.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.43,12.84,,102.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.19,80,,640.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.43,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.43,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,650.16,65,,520.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.08,35,,280.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,900.22,90,,720.18,percent of total billed charges,90% of total billed charges for outpatient setting,128.43,900.22,
DRILL BIT 3.2MM FLUTE CLBR / 03.010.060S,692346,CDM,272,RC,,,Outpatient,,,1313.04,1313.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.13,70,,735.3,percent of total billed charges,70% of total billed charges for outpatient setting,1114.51,84.88,,891.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,656.52,50,,525.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,984.78,75,,787.82,percent of total billed charges,75% of total billed charges for outpatient setting,919.13,70,,735.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.59,12.84,,134.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.43,80,,840.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.59,12.84,,134.87,percent of total billed charges,12.84% of total billed charges,168.59,12.84,,134.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,853.48,65,,682.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.56,35,,367.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1181.74,90,,945.39,percent of total billed charges,90% of total billed charges for outpatient setting,168.59,1181.74,
DRILL BIT 3.2MM NDL POINT / 03.010.103,70000406,CDM,272,RC,,,Outpatient,,,723.48,723.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.44,70,,405.15,percent of total billed charges,70% of total billed charges for outpatient setting,614.09,84.88,,491.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,361.74,50,,289.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,542.61,75,,434.09,percent of total billed charges,75% of total billed charges for outpatient setting,506.44,70,,405.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.89,12.84,,74.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.78,80,,463.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.89,12.84,,74.31,percent of total billed charges,12.84% of total billed charges,92.89,12.84,,74.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,470.26,65,,376.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.22,35,,202.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,651.13,90,,520.9,percent of total billed charges,90% of total billed charges for outpatient setting,92.89,651.13,
DRILL BIT 3.5  702450,69162174,CDM,272,RC,,,Outpatient,,,1511.94,1511.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.36,70,,846.69,percent of total billed charges,70% of total billed charges for outpatient setting,1283.33,84.88,,1026.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,755.97,50,,604.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1133.96,75,,907.17,percent of total billed charges,75% of total billed charges for outpatient setting,1058.36,70,,846.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.13,12.84,,155.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.55,80,,967.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.13,12.84,,155.3,percent of total billed charges,12.84% of total billed charges,194.13,12.84,,155.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,982.76,65,,786.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.18,35,,423.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.75,90,,1088.6,percent of total billed charges,90% of total billed charges for outpatient setting,194.13,1360.75,
DRILL BIT 3.5 STRYKER / 45-35020,70000085,CDM,272,RC,,,Outpatient,,,603.48,603.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.44,70,,337.95,percent of total billed charges,70% of total billed charges for outpatient setting,512.23,84.88,,409.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,301.74,50,,241.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,452.61,75,,362.09,percent of total billed charges,75% of total billed charges for outpatient setting,422.44,70,,337.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.49,12.84,,61.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.78,80,,386.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.49,12.84,,61.99,percent of total billed charges,12.84% of total billed charges,77.49,12.84,,61.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,392.26,65,,313.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.22,35,,168.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,543.13,90,,434.5,percent of total billed charges,90% of total billed charges for outpatient setting,77.49,543.13,
DRILL BIT 3.5mm   310.35,69161268,CDM,270,RC,,,Outpatient,,,429.59,429.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.71,70,,240.57,percent of total billed charges,70% of total billed charges for outpatient setting,364.64,84.88,,291.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,214.8,50,,171.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.19,75,,257.75,percent of total billed charges,75% of total billed charges for outpatient setting,300.71,70,,240.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.16,12.84,,44.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.67,80,,274.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.16,12.84,,44.13,percent of total billed charges,12.84% of total billed charges,55.16,12.84,,44.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,279.23,65,,223.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.36,35,,120.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,386.63,90,,309.3,percent of total billed charges,90% of total billed charges for outpatient setting,55.16,386.63,
DRILL BIT 3.5MM   682.106,69162616,CDM,272,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,90,,622.94,percent of total billed charges,90% of total billed charges for outpatient setting,111.09,778.68,
DRILL BIT 3.5MM / AR-4160-35,69162323,CDM,272,RC,,,Outpatient,,,341.75,341.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.23,70,,191.38,percent of total billed charges,70% of total billed charges for outpatient setting,290.08,84.88,,232.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.88,50,,136.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.31,75,,205.05,percent of total billed charges,75% of total billed charges for outpatient setting,239.23,70,,191.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,12.84,,35.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.4,80,,218.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,12.84,,35.1,percent of total billed charges,12.84% of total billed charges,43.88,12.84,,35.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,222.14,65,,177.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.61,35,,95.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,307.58,90,,246.06,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,307.58,
DRILL BIT 3.5MM SHORT / 6149.1037,69162658,CDM,272,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,90,,622.94,percent of total billed charges,90% of total billed charges for outpatient setting,111.09,778.68,
DRILL BIT 3.5X230MM / 1806-3540S,31180,CDM,272,RC,,,Outpatient,,,553.6,553.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.52,70,,310.02,percent of total billed charges,70% of total billed charges for outpatient setting,469.9,84.88,,375.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,276.8,50,,221.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,415.2,75,,332.16,percent of total billed charges,75% of total billed charges for outpatient setting,387.52,70,,310.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.08,12.84,,56.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.88,80,,354.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.08,12.84,,56.86,percent of total billed charges,12.84% of total billed charges,71.08,12.84,,56.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,359.84,65,,287.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.76,35,,155.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,498.24,90,,398.59,percent of total billed charges,90% of total billed charges for outpatient setting,71.08,498.24,
DRILL BIT 4.0MM / 829033070,69161862,CDM,272,RC,,,Outpatient,,,655,655,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.5,70,,366.8,percent of total billed charges,70% of total billed charges for outpatient setting,555.96,84.88,,444.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,327.5,50,,262,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,491.25,75,,393,percent of total billed charges,75% of total billed charges for outpatient setting,458.5,70,,366.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524,80,,419.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,84.1,12.84,,67.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,425.75,65,,340.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.25,35,,183.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,589.5,90,,471.6,percent of total billed charges,90% of total billed charges for outpatient setting,84.1,589.5,
DRILL BIT 4.0MM / AR-4160-40,69162478,CDM,272,RC,,,Outpatient,,,540.75,540.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,70,,302.82,percent of total billed charges,70% of total billed charges for outpatient setting,458.99,84.88,,367.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,270.38,50,,216.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.56,75,,324.45,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,70,,302.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.43,12.84,,55.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.6,80,,346.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.43,12.84,,55.54,percent of total billed charges,12.84% of total billed charges,69.43,12.84,,55.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.49,65,,281.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.26,35,,151.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,486.68,90,,389.34,percent of total billed charges,90% of total billed charges for outpatient setting,69.43,486.68,
DRILL BIT 4.0MM CANLTED / 702446,70000446,CDM,272,RC,,,Outpatient,,,1674.16,1674.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1171.91,70,,937.53,percent of total billed charges,70% of total billed charges for outpatient setting,1421.03,84.88,,1136.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,837.08,50,,669.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1255.62,75,,1004.5,percent of total billed charges,75% of total billed charges for outpatient setting,1171.91,70,,937.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.96,12.84,,171.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1339.33,80,,1071.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.96,12.84,,171.97,percent of total billed charges,12.84% of total billed charges,214.96,12.84,,171.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1088.2,65,,870.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.96,35,,468.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1506.74,90,,1205.39,percent of total billed charges,90% of total billed charges for outpatient setting,214.96,1506.74,
DRILL BIT 4.2MM FLTD NDL / 03.010.104S,695807,CDM,272,RC,,,Outpatient,,,1000.24,1000.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.17,70,,560.14,percent of total billed charges,70% of total billed charges for outpatient setting,849,84.88,,679.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,500.12,50,,400.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,750.18,75,,600.14,percent of total billed charges,75% of total billed charges for outpatient setting,700.17,70,,560.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.43,12.84,,102.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.19,80,,640.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.43,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.43,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,650.16,65,,520.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.08,35,,280.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,900.22,90,,720.18,percent of total billed charges,90% of total billed charges for outpatient setting,128.43,900.22,
DRILL BIT 4.2MM FLUTE CLBR / 03.010.061S,695761,CDM,272,RC,,,Outpatient,,,1313.04,1313.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.13,70,,735.3,percent of total billed charges,70% of total billed charges for outpatient setting,1114.51,84.88,,891.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,656.52,50,,525.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,984.78,75,,787.82,percent of total billed charges,75% of total billed charges for outpatient setting,919.13,70,,735.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.59,12.84,,134.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.43,80,,840.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.59,12.84,,134.87,percent of total billed charges,12.84% of total billed charges,168.59,12.84,,134.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,853.48,65,,682.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.56,35,,367.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1181.74,90,,945.39,percent of total billed charges,90% of total billed charges for outpatient setting,168.59,1181.74,
DRILL BIT 4.2X340MM / 1806-4260S,31184,CDM,272,RC,,,Outpatient,,,534.4,534.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.08,70,,299.26,percent of total billed charges,70% of total billed charges for outpatient setting,453.6,84.88,,362.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.2,50,,213.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.8,75,,320.64,percent of total billed charges,75% of total billed charges for outpatient setting,374.08,70,,299.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.62,12.84,,54.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.52,80,,342.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.62,12.84,,54.9,percent of total billed charges,12.84% of total billed charges,68.62,12.84,,54.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,347.36,65,,277.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.04,35,,149.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480.96,90,,384.77,percent of total billed charges,90% of total billed charges for outpatient setting,68.62,480.96,
DRILL BIT 4.5MM CANNULATED / 03.010.089,70000411,CDM,272,RC,,,Outpatient,,,1520.59,1520.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.41,70,,851.53,percent of total billed charges,70% of total billed charges for outpatient setting,1290.68,84.88,,1032.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,760.3,50,,608.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1140.44,75,,912.35,percent of total billed charges,75% of total billed charges for outpatient setting,1064.41,70,,851.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.24,12.84,,156.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.47,80,,973.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.24,12.84,,156.19,percent of total billed charges,12.84% of total billed charges,195.24,12.84,,156.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,988.38,65,,790.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.21,35,,425.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1368.53,90,,1094.82,percent of total billed charges,90% of total billed charges for outpatient setting,195.24,1368.53,
DRILL BIT 4.5MM INTEGRA / DRL-890-00,69162131,CDM,272,RC,,,Outpatient,,,1410.28,1410.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.2,70,,789.76,percent of total billed charges,70% of total billed charges for outpatient setting,1197.05,84.88,,957.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,705.14,50,,564.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1057.71,75,,846.17,percent of total billed charges,75% of total billed charges for outpatient setting,987.2,70,,789.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.08,12.84,,144.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.22,80,,902.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.08,12.84,,144.86,percent of total billed charges,12.84% of total billed charges,181.08,12.84,,144.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,916.68,65,,733.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.6,35,,394.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1269.25,90,,1015.4,percent of total billed charges,90% of total billed charges for outpatient setting,181.08,1269.25,
DRILL BIT 5.0X230MM / 1806-5000S,70000685,CDM,272,RC,,,Outpatient,,,371.18,371.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.83,70,,207.86,percent of total billed charges,70% of total billed charges for outpatient setting,315.06,84.88,,252.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,185.59,50,,148.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.39,75,,222.71,percent of total billed charges,75% of total billed charges for outpatient setting,259.83,70,,207.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,12.84,,38.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.94,80,,237.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,12.84,,38.13,percent of total billed charges,12.84% of total billed charges,47.66,12.84,,38.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,241.27,65,,193.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.91,35,,103.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,334.06,90,,267.25,percent of total billed charges,90% of total billed charges for outpatient setting,47.66,334.06,
DRILL BIT AO 2.0X122MM / 703701,69161553,CDM,272,RC,,,Outpatient,,,922.35,922.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.65,70,,516.52,percent of total billed charges,70% of total billed charges for outpatient setting,782.89,84.88,,626.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,461.18,50,,368.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,691.76,75,,553.41,percent of total billed charges,75% of total billed charges for outpatient setting,645.65,70,,516.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.43,12.84,,94.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,737.88,80,,590.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.43,12.84,,94.74,percent of total billed charges,12.84% of total billed charges,118.43,12.84,,94.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,599.53,65,,479.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.82,35,,258.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,830.12,90,,664.1,percent of total billed charges,90% of total billed charges for outpatient setting,118.43,830.12,
DRILL BIT AO 3.5X122MM / 703694,70000343,CDM,272,RC,,,Outpatient,,,513.92,513.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.74,70,,287.79,percent of total billed charges,70% of total billed charges for outpatient setting,436.22,84.88,,348.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.96,50,,205.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.44,75,,308.35,percent of total billed charges,75% of total billed charges for outpatient setting,359.74,70,,287.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,12.84,,52.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.14,80,,328.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,12.84,,52.79,percent of total billed charges,12.84% of total billed charges,65.99,12.84,,52.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,334.05,65,,267.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,35,,143.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,462.53,90,,370.02,percent of total billed charges,90% of total billed charges for outpatient setting,65.99,462.53,
DRILL BIT ELLIPSE  682.104,69162380,CDM,272,RC,,,Outpatient,,,1734.73,1734.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1214.31,70,,971.45,percent of total billed charges,70% of total billed charges for outpatient setting,1472.44,84.88,,1177.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,867.37,50,,693.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1301.05,75,,1040.84,percent of total billed charges,75% of total billed charges for outpatient setting,1214.31,70,,971.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.74,12.84,,178.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.78,80,,1110.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.74,12.84,,178.19,percent of total billed charges,12.84% of total billed charges,222.74,12.84,,178.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1127.57,65,,902.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,607.16,35,,485.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1561.26,90,,1249.01,percent of total billed charges,90% of total billed charges for outpatient setting,222.74,1561.26,
DRILL BIT FOR 3.5MM / 6149.1035,69162655,CDM,272,RC,,,Outpatient,,,1268,1268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.6,70,,710.08,percent of total billed charges,70% of total billed charges for outpatient setting,1076.28,84.88,,861.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,634,50,,507.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,951,75,,760.8,percent of total billed charges,75% of total billed charges for outpatient setting,887.6,70,,710.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.81,12.84,,130.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.4,80,,811.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.81,12.84,,130.25,percent of total billed charges,12.84% of total billed charges,162.81,12.84,,130.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,824.2,65,,659.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.8,35,,355.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1141.2,90,,912.96,percent of total billed charges,90% of total billed charges for outpatient setting,162.81,1141.2,
DRILL BIT SLEEVE / 703930,69162259,CDM,272,RC,,,Outpatient,,,776.09,776.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.26,70,,434.61,percent of total billed charges,70% of total billed charges for outpatient setting,658.75,84.88,,527,percent of total billed charges,84.88% of total billed charges for outpatient setting,388.05,50,,310.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,582.07,75,,465.66,percent of total billed charges,75% of total billed charges for outpatient setting,543.26,70,,434.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.87,80,,496.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,504.46,65,,403.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.63,35,,217.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,698.48,90,,558.78,percent of total billed charges,90% of total billed charges for outpatient setting,99.65,698.48,
"DRILL BIT, 3.2MM CANNULATED   310.65",69162038,CDM,272,RC,,,Outpatient,,,2080.42,2080.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456.29,70,,1165.03,percent of total billed charges,70% of total billed charges for outpatient setting,1765.86,84.88,,1412.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,1040.21,50,,832.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1560.32,75,,1248.26,percent of total billed charges,75% of total billed charges for outpatient setting,1456.29,70,,1165.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.13,12.84,,213.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1664.34,80,,1331.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.13,12.84,,213.7,percent of total billed charges,12.84% of total billed charges,267.13,12.84,,213.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1352.27,65,,1081.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.15,35,,582.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1872.38,90,,1497.9,percent of total billed charges,90% of total billed charges for outpatient setting,267.13,1872.38,
"DRILL BIT, CANNULATED 5.0MM 310.63",69160649,CDM,270,RC,,,Outpatient,,,2158.77,2158.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1511.14,70,,1208.91,percent of total billed charges,70% of total billed charges for outpatient setting,1832.36,84.88,,1465.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1079.39,50,,863.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1619.08,75,,1295.26,percent of total billed charges,75% of total billed charges for outpatient setting,1511.14,70,,1208.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.19,12.84,,221.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.02,80,,1381.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.19,12.84,,221.75,percent of total billed charges,12.84% of total billed charges,277.19,12.84,,221.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1403.2,65,,1122.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.57,35,,604.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1942.89,90,,1554.31,percent of total billed charges,90% of total billed charges for outpatient setting,277.19,1942.89,
DRILL BIT-COMPRESSION SCREW-STRYKER,69161442,CDM,272,RC,C1769,HCPCS,Outpatient,,,1238.71,1238.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.1,70,,693.68,percent of total billed charges,70% of total billed charges for outpatient setting,1051.42,84.88,,841.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.03,75,,743.22,percent of total billed charges,75% of total billed charges for outpatient setting,867.1,70,,693.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.05,12.84,,127.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,990.97,80,,792.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.05,12.84,,127.24,percent of total billed charges,12.84% of total billed charges,159.05,12.84,,127.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,805.16,65,,644.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.55,35,,346.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1114.84,90,,891.87,percent of total billed charges,90% of total billed charges for outpatient setting,159.05,1114.84,
DRILL D2.8 / 1910-1270S,70000530,CDM,272,RC,,,Outpatient,,,2271.15,2271.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,70,,1271.85,percent of total billed charges,70% of total billed charges for outpatient setting,1927.75,84.88,,1542.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1135.58,50,,908.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1703.36,75,,1362.69,percent of total billed charges,75% of total billed charges for outpatient setting,1589.81,70,,1271.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,80,,1453.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1476.25,65,,1181,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.9,35,,635.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,90,,1635.23,percent of total billed charges,90% of total billed charges for outpatient setting,291.62,2044.04,
DRILL FLIPCUTTER III / AR-1204FF,71000619,CDM,272,RC,,,Outpatient,,,1743,1743,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1220.1,70,,976.08,percent of total billed charges,70% of total billed charges for outpatient setting,1479.46,84.88,,1183.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,871.5,50,,697.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1307.25,75,,1045.8,percent of total billed charges,75% of total billed charges for outpatient setting,1220.1,70,,976.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.8,12.84,,179.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1394.4,80,,1115.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.8,12.84,,179.04,percent of total billed charges,12.84% of total billed charges,223.8,12.84,,179.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1132.95,65,,906.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.05,35,,488.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1568.7,90,,1254.96,percent of total billed charges,90% of total billed charges for outpatient setting,223.8,1568.7,
DRILL GRAY PT 3.2X200MM / 5085-2-032,70000786,CDM,278,RC,,,Outpatient,,,259.56,259.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.74,60,,124.59,percent of total billed charges,60% of total Billed charges for outpatient setting,220.31,84.88,,176.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.67,75,,155.74,percent of total billed charges,75% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,80,,166.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.56,65,,207.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,35,,72.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,60,,124.59,percent of total billed charges,60% of total billed charges for outpatient setting,33.33,259.56,
DRILL GUIDE 1.8MM THRDED LCP / 323.029,657274,CDM,270,RC,,,Outpatient,,,1395.56,1395.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,976.89,70,,781.51,percent of total billed charges,70% of total billed charges for outpatient setting,1184.55,84.88,,947.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,697.78,50,,558.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1046.67,75,,837.34,percent of total billed charges,75% of total billed charges for outpatient setting,976.89,70,,781.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,12.84,,143.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.45,80,,893.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,12.84,,143.35,percent of total billed charges,12.84% of total billed charges,179.19,12.84,,143.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,907.11,65,,725.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.45,35,,390.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1256,90,,1004.8,percent of total billed charges,90% of total billed charges for outpatient setting,179.19,1256,
DRILL GUIDE 1.8MM THRDED SHORT / 323.035,69162211,CDM,270,RC,,,Outpatient,,,460.72,460.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.5,70,,258,percent of total billed charges,70% of total billed charges for outpatient setting,391.06,84.88,,312.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,230.36,50,,184.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.54,75,,276.43,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,70,,258,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.16,12.84,,47.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.58,80,,294.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.16,12.84,,47.33,percent of total billed charges,12.84% of total billed charges,59.16,12.84,,47.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,299.47,65,,239.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.25,35,,129,percent of total billed charges,35% of total Billed charges for Outpatient Setting,414.65,90,,331.72,percent of total billed charges,90% of total billed charges for outpatient setting,59.16,414.65,
DRILL GUIDE 2.0 / 703931,69162498,CDM,272,RC,,,Outpatient,,,776.09,776.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.26,70,,434.61,percent of total billed charges,70% of total billed charges for outpatient setting,658.75,84.88,,527,percent of total billed charges,84.88% of total billed charges for outpatient setting,388.05,50,,310.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,582.07,75,,465.66,percent of total billed charges,75% of total billed charges for outpatient setting,543.26,70,,434.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.87,80,,496.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,99.65,12.84,,79.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,504.46,65,,403.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.63,35,,217.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,698.48,90,,558.78,percent of total billed charges,90% of total billed charges for outpatient setting,99.65,698.48,
DRILL LINDEMANN 2.2MM/1608-002-043,6151042,CDM,272,RC,,,Outpatient,,,233.15,233.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.21,70,,130.57,percent of total billed charges,70% of total billed charges for outpatient setting,197.9,84.88,,158.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.58,50,,93.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.86,75,,139.89,percent of total billed charges,75% of total billed charges for outpatient setting,163.21,70,,130.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.94,12.84,,23.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.52,80,,149.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.94,12.84,,23.95,percent of total billed charges,12.84% of total billed charges,29.94,12.84,,23.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.55,65,,121.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,35,,65.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,209.84,90,,167.87,percent of total billed charges,90% of total billed charges for outpatient setting,29.94,209.84,
DRILL PIN 3.2X75MM / 00-5901-020-00,69169372,CDM,272,RC,C1776,HCPCS,Outpatient,,,1684.2,1684.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1178.94,70,,943.15,percent of total billed charges,70% of total billed charges for outpatient setting,1429.55,84.88,,1143.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1263.15,75,,1010.52,percent of total billed charges,75% of total billed charges for outpatient setting,1178.94,70,,943.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.25,12.84,,173,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.36,80,,1077.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.25,12.84,,173,percent of total billed charges,12.84% of total billed charges,216.25,12.84,,173,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1094.73,65,,875.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.47,35,,471.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1515.78,90,,1212.62,percent of total billed charges,90% of total billed charges for outpatient setting,216.25,1515.78,
DRILL PROFILE MICRO CMP / AR-8737-46,71000810,CDM,272,RC,,,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,409.5,65,,327.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,567,90,,453.6,percent of total billed charges,90% of total billed charges for outpatient setting,80.89,567,
DRILL PROFILE MINI CMP / AR-8737-47,69169821,CDM,272,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390,65,,312,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540,90,,432,percent of total billed charges,90% of total billed charges for outpatient setting,77.04,540,
DRILL SPEEDGUIDE AO 2.0MM / 703892,69169784,CDM,272,RC,,,Outpatient,,,694.85,694.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.4,70,,389.12,percent of total billed charges,70% of total billed charges for outpatient setting,589.79,84.88,,471.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,347.43,50,,277.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,521.14,75,,416.91,percent of total billed charges,75% of total billed charges for outpatient setting,486.4,70,,389.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.22,12.84,,71.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.88,80,,444.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.22,12.84,,71.38,percent of total billed charges,12.84% of total billed charges,89.22,12.84,,71.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,451.65,65,,361.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.2,35,,194.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,625.37,90,,500.3,percent of total billed charges,90% of total billed charges for outpatient setting,89.22,625.37,
DRILL SPEEDGUIDE VARIAX 2.7MM / 703890,1627329,CDM,272,RC,,,Outpatient,,,1253.12,1253.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.18,70,,701.74,percent of total billed charges,70% of total billed charges for outpatient setting,1063.65,84.88,,850.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,626.56,50,,501.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,939.84,75,,751.87,percent of total billed charges,75% of total billed charges for outpatient setting,877.18,70,,701.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.5,80,,802,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,814.53,65,,651.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.59,35,,350.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1127.81,90,,902.25,percent of total billed charges,90% of total billed charges for outpatient setting,160.9,1127.81,
DRILL TWIST 1.1MMX50MM / 25-452-05-91,69162226,CDM,272,RC,,,Outpatient,,,661.66,661.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.16,70,,370.53,percent of total billed charges,70% of total billed charges for outpatient setting,561.62,84.88,,449.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,330.83,50,,264.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.25,75,,397,percent of total billed charges,75% of total billed charges for outpatient setting,463.16,70,,370.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.96,12.84,,67.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.33,80,,423.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.96,12.84,,67.97,percent of total billed charges,12.84% of total billed charges,84.96,12.84,,67.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,430.08,65,,344.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.58,35,,185.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,595.49,90,,476.39,percent of total billed charges,90% of total billed charges for outpatient setting,84.96,595.49,
DRILL TWIST 1.9MM DIA / 60-19326,70000104,CDM,272,RC,,,Outpatient,,,558.05,558.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,473.67,84.88,,378.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,279.03,50,,223.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.54,75,,334.83,percent of total billed charges,75% of total billed charges for outpatient setting,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.44,80,,357.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,362.73,65,,290.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.32,35,,156.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,502.25,90,,401.8,percent of total billed charges,90% of total billed charges for outpatient setting,71.65,502.25,
DRILL TWIST 2.5MM DIA / 60-25326,70000105,CDM,272,RC,,,Outpatient,,,558.05,558.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,473.67,84.88,,378.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,279.03,50,,223.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.54,75,,334.83,percent of total billed charges,75% of total billed charges for outpatient setting,390.64,70,,312.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.44,80,,357.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,362.73,65,,290.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.32,35,,156.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,502.25,90,,401.8,percent of total billed charges,90% of total billed charges for outpatient setting,71.65,502.25,
DRIVER BLADE DENTAL T6 / 705506,7053226,CDM,272,RC,,,Outpatient,,,630.08,630.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.06,70,,352.85,percent of total billed charges,70% of total billed charges for outpatient setting,534.81,84.88,,427.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,315.04,50,,252.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.56,75,,378.05,percent of total billed charges,75% of total billed charges for outpatient setting,441.06,70,,352.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.9,12.84,,64.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.06,80,,403.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.9,12.84,,64.72,percent of total billed charges,12.84% of total billed charges,80.9,12.84,,64.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,409.55,65,,327.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.53,35,,176.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,567.07,90,,453.66,percent of total billed charges,90% of total billed charges for outpatient setting,80.9,567.07,
DROPERIDOL (INAPSINE) 2ML AMP : 2.5MG/ML,3300993,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
DROPERIDOL (INAPSINE) AMP 5MG: 2ML,3300994,CDM,636,RC,J1790,HCPCS,Outpatient,,,32.96,32.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,70,,18.46,percent of total billed charges,70% of total billed charges for outpatient setting,27.98,84.88,,22.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.72,75,,19.78,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,70,,18.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,80,,21.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,4.23,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.42,65,,17.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.66,90,,23.73,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,29.66,
DROPERIDOL (INAPSINE) INJ 2.5MG/ML: 1ML,3300992,CDM,250,RC,,,Outpatient,,,12.39,12.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.67,70,,6.94,percent of total billed charges,70% of total billed charges for outpatient setting,10.52,84.88,,8.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.2,50,,4.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.29,75,,7.43,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,70,,6.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,80,,7.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.05,65,,6.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.34,35,,3.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.15,90,,8.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,11.15,
DROPERIDOL (INAPSINE) SOL 2.5ML: 2ML,3300995,CDM,250,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
DROPERIDOL (INAPSINE):2.5 MG/ML,3303182,CDM,250,RC,,,Outpatient,,,89.72,89.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.8,70,,50.24,percent of total billed charges,70% of total billed charges for outpatient setting,76.15,84.88,,60.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.86,50,,35.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.29,75,,53.83,percent of total billed charges,75% of total billed charges for outpatient setting,62.8,70,,50.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,12.84,,9.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.78,80,,57.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,11.52,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.32,65,,46.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.4,35,,25.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.75,90,,64.6,percent of total billed charges,90% of total billed charges for outpatient setting,11.52,80.75,
DRSG NASAL 5.5CM RAPID RHINO /PR500,69169168,CDM,272,RC,,,Outpatient,,,164.39,164.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.07,70,,92.06,percent of total billed charges,70% of total billed charges for outpatient setting,139.53,84.88,,111.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.2,50,,65.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.29,75,,98.63,percent of total billed charges,75% of total billed charges for outpatient setting,115.07,70,,92.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,12.84,,16.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.51,80,,105.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,12.84,,16.89,percent of total billed charges,12.84% of total billed charges,21.11,12.84,,16.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.85,65,,85.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.54,35,,46.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,147.95,90,,118.36,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,147.95,
DRSNG HEMOPORE HEMOSTATIC / 5400020208,69169266,CDM,272,RC,,,Outpatient,,,1386,1386,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.2,70,,776.16,percent of total billed charges,70% of total billed charges for outpatient setting,1176.44,84.88,,941.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,693,50,,554.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1039.5,75,,831.6,percent of total billed charges,75% of total billed charges for outpatient setting,970.2,70,,776.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.8,80,,887.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900.9,65,,720.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.1,35,,388.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1247.4,90,,997.92,percent of total billed charges,90% of total billed charges for outpatient setting,177.96,1247.4,
DRSNG NASAPORE 4CM /5400020004,69169547,CDM,272,RC,,,Outpatient,,,827.86,827.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.5,70,,463.6,percent of total billed charges,70% of total billed charges for outpatient setting,702.69,84.88,,562.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,413.93,50,,331.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,620.9,75,,496.72,percent of total billed charges,75% of total billed charges for outpatient setting,579.5,70,,463.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.3,12.84,,85.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.29,80,,529.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.3,12.84,,85.04,percent of total billed charges,12.84% of total billed charges,106.3,12.84,,85.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,538.11,65,,430.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.75,35,,231.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,745.07,90,,596.06,percent of total billed charges,90% of total billed charges for outpatient setting,106.3,745.07,
DRUG SCREEN 9 PANEL URINE,220347,CDM,300,RC,80307,HCPCS,Outpatient,,,279.63,251.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,237.35,84.88,,189.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.72,75,,167.78,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.7,80,,178.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,79.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of Custom Fee Schedule,251.67,90,,201.34,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,251.67,
"DRUG SCREEN, BLOOD",220921,CDM,300,RC,80307,HCPCS,Outpatient,,,279.63,251.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,237.35,84.88,,189.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.72,75,,167.78,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,70,,156.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.7,80,,178.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,79.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of Custom Fee Schedule,251.67,90,,201.34,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,251.67,
DRY SKIN CREAM:454 G,3303117,CDM,259,RC,,,Outpatient,,,35,35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,29.71,84.88,,23.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.5,50,,14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.25,75,,21,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,80,,22.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.75,65,,18.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,35,,9.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.5,
DULOXETIN (genCYMBALTA) 30MG CAP,3303059,CDM,259,RC,,,Outpatient,,,15.62,15.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.93,70,,8.74,percent of total billed charges,70% of total billed charges for outpatient setting,13.26,84.88,,10.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.81,50,,6.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.72,75,,9.38,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,70,,8.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,80,,10,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.15,65,,8.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,35,,4.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.06,90,,11.25,percent of total billed charges,90% of total billed charges for outpatient setting,2.01,14.06,
DULOXETINE (genericCYMBALTA) 20MG CAP,3303069,CDM,259,RC,,,Outpatient,,,15.62,15.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.93,70,,8.74,percent of total billed charges,70% of total billed charges for outpatient setting,13.26,84.88,,10.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.81,50,,6.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.72,75,,9.38,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,70,,8.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,80,,10,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.15,65,,8.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,35,,4.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.06,90,,11.25,percent of total billed charges,90% of total billed charges for outpatient setting,2.01,14.06,
DULOXETINE (genericCYMBALTA) 30MG CAP,3313608,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
DULOXETINE (genericCYMBALTA) 60MG CAP,3303253,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
DUODERM THIN 4X4 /1879-55,5150243,CDM,272,RC,,,Outpatient,,,12.57,12.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,70,,7.04,percent of total billed charges,70% of total billed charges for outpatient setting,10.67,84.88,,8.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.29,50,,5.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.43,75,,7.54,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,70,,7.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.06,80,,8.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.17,65,,6.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,35,,3.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.31,90,,9.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.61,11.31,
DUOVISC  /PROVISC 0.85ML/ 8065199907,69169841,CDM,270,RC,,,Outpatient,,,268.32,268.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.82,70,,150.26,percent of total billed charges,70% of total billed charges for outpatient setting,227.75,84.88,,182.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.16,50,,107.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.24,75,,160.99,percent of total billed charges,75% of total billed charges for outpatient setting,187.82,70,,150.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,12.84,,27.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.66,80,,171.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,12.84,,27.56,percent of total billed charges,12.84% of total billed charges,34.45,12.84,,27.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174.41,65,,139.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.91,35,,75.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,241.49,90,,193.19,percent of total billed charges,90% of total billed charges for outpatient setting,34.45,241.49,
DUOVISC  KIT:,3302547,CDM,259,RC,,,Outpatient,,,521.84,521.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.29,70,,292.23,percent of total billed charges,70% of total billed charges for outpatient setting,442.94,84.88,,354.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,260.92,50,,208.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.38,75,,313.1,percent of total billed charges,75% of total billed charges for outpatient setting,365.29,70,,292.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.47,80,,333.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,67,12.84,,53.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,339.2,65,,271.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.64,35,,146.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,469.66,90,,375.73,percent of total billed charges,90% of total billed charges for outpatient setting,67,469.66,
DUOVISC 0.5ML PROVISC / 8065183150,6152096,CDM,270,RC,,,Outpatient,,,246.52,246.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.56,70,,138.05,percent of total billed charges,70% of total billed charges for outpatient setting,209.25,84.88,,167.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.26,50,,98.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.89,75,,147.91,percent of total billed charges,75% of total billed charges for outpatient setting,172.56,70,,138.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.65,12.84,,25.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.22,80,,157.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.65,12.84,,25.32,percent of total billed charges,12.84% of total billed charges,31.65,12.84,,25.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,160.24,65,,128.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,35,,69.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.87,90,,177.5,percent of total billed charges,90% of total billed charges for outpatient setting,31.65,221.87,
DUP SCAN EXTRACRANIAL ARTERIES COMP BILA,2600042,CDM,921,RC,93880,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
DUPLEX SCAN ABD/PELVIC/SCROTAL LIMITED,2600007,CDM,921,RC,93976,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
DUPLEX SCAN AORTA/INF VC/ILIAC COMPLETE,2600008,CDM,921,RC,93978,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
DUPLEX SCAN AORTA/INF VC/ILIAC UNILAT/LI,2600009,CDM,921,RC,93979,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
DURAFORM 2  x 2  /   801475,69161794,CDM,278,RC,,,Outpatient,,,892.94,892.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.76,60,,428.61,percent of total billed charges,60% of total Billed charges for outpatient setting,757.93,84.88,,606.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,446.47,50,,357.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,669.71,75,,535.77,percent of total billed charges,75% of total billed charges for outpatient setting,446.47,50,,357.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.65,12.84,,91.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.35,80,,571.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.65,12.84,,91.72,percent of total billed charges,12.84% of total billed charges,114.65,12.84,,91.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,892.94,65,,714.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.53,35,,250.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,535.76,60,,428.61,percent of total billed charges,60% of total billed charges for outpatient setting,114.65,892.94,
DURAGEN 3X3 PLUS / DP1033,69169539,CDM,278,RC,C1769,HCPCS,Outpatient,,,3300.67,3300.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980.4,60,,1584.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.61,84.88,,2241.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475.5,75,,1980.4,percent of total billed charges,75% of total billed charges for outpatient setting,1650.34,50,,1320.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.81,12.84,,339.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640.54,80,,2112.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.81,12.84,,339.05,percent of total billed charges,12.84% of total billed charges,423.81,12.84,,339.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465.7,105,,2772.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155.23,35,,924.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980.4,60,,1584.32,percent of total billed charges,60% of total billed charges for outpatient setting,423.81,3465.7,
DURAPREP 26 ML / 8630,69169220,CDM,272,RC,,,Outpatient,,,29.36,29.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,70,,16.44,percent of total billed charges,70% of total billed charges for outpatient setting,24.92,84.88,,19.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.68,50,,11.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.02,75,,17.62,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,70,,16.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,12.84,,3.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.49,80,,18.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,3.77,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.08,65,,15.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,35,,8.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.42,90,,21.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.77,26.42,
DUTASTERIDE (AVODART) 0.5MG CAP,3303259,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
E HISTOLYTICA AG,220071,CDM,302,RC,86753,HCPCS,Outpatient,,,55.76,50.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.03,70,,31.22,percent of total billed charges,70% of total billed charges for outpatient setting,47.33,84.88,,37.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.82,75,,33.46,percent of total billed charges,75% of total billed charges for outpatient setting,39.03,70,,31.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.61,80,,35.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.09,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.49,100,,,Fee Schedule,100% of Custom Fee Schedule,50.18,90,,40.14,percent of total billed charges,90% of total billed charges for outpatient setting,12.39,50.18,
E1 ESTRONE,220116,CDM,300,RC,82679,HCPCS,Outpatient,,,112.28,101.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.6,70,,62.88,percent of total billed charges,70% of total billed charges for outpatient setting,95.3,84.88,,76.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,84.21,75,,67.37,percent of total billed charges,75% of total billed charges for outpatient setting,78.6,70,,62.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.82,80,,71.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.33,100,,,Fee Schedule,100% of Custom Fee Schedule,101.05,90,,80.84,percent of total billed charges,90% of total billed charges for outpatient setting,24.95,101.05,
EBV EARLY ANTIGEN,220860,CDM,302,RC,86663,HCPCS,Outpatient,,,59.04,53.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.33,70,,33.06,percent of total billed charges,70% of total billed charges for outpatient setting,50.11,84.88,,40.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.28,75,,35.42,percent of total billed charges,75% of total billed charges for outpatient setting,41.33,70,,33.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.23,80,,37.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.16,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.88,100,,,Fee Schedule,100% of Custom Fee Schedule,53.14,90,,42.51,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,53.14,
EBV NUCLEAR ANTIGEN,220861,CDM,302,RC,86664,HCPCS,Outpatient,,,68.81,61.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,58.41,84.88,,46.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.61,75,,41.29,percent of total billed charges,75% of total billed charges for outpatient setting,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.05,80,,44.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.01,100,,,Fee Schedule,100% of Custom Fee Schedule,61.93,90,,49.54,percent of total billed charges,90% of total billed charges for outpatient setting,15.29,61.93,
EBV VCA  IgG,220858,CDM,302,RC,86665,HCPCS,Outpatient,,,81.63,73.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,69.29,84.88,,55.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,61.22,75,,48.98,percent of total billed charges,75% of total billed charges for outpatient setting,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,80,,52.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.8,100,,,Fee Schedule,100% of Custom Fee Schedule,73.47,90,,58.78,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,73.47,
EBV VCA  IgM,220859,CDM,302,RC,86665,HCPCS,Outpatient,,,81.63,73.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,69.29,84.88,,55.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,61.22,75,,48.98,percent of total billed charges,75% of total billed charges for outpatient setting,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,80,,52.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.8,100,,,Fee Schedule,100% of Custom Fee Schedule,73.47,90,,58.78,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,73.47,
ECHELON 35MM VASCLR SATPLER / PVE35A,69169727,CDM,272,RC,,,Outpatient,,,1169.96,1169.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.97,70,,655.18,percent of total billed charges,70% of total billed charges for outpatient setting,993.06,84.88,,794.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,584.98,50,,467.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877.47,75,,701.98,percent of total billed charges,75% of total billed charges for outpatient setting,818.97,70,,655.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.22,12.84,,120.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.97,80,,748.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.22,12.84,,120.18,percent of total billed charges,12.84% of total billed charges,150.22,12.84,,120.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,760.47,65,,608.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.49,35,,327.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1052.96,90,,842.37,percent of total billed charges,90% of total billed charges for outpatient setting,150.22,1052.96,
ECHELON 35MM WHITE / VASECR35,69169728,CDM,272,RC,,,Outpatient,,,573.56,573.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.49,70,,321.19,percent of total billed charges,70% of total billed charges for outpatient setting,486.84,84.88,,389.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,286.78,50,,229.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,430.17,75,,344.14,percent of total billed charges,75% of total billed charges for outpatient setting,401.49,70,,321.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.65,12.84,,58.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.85,80,,367.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.65,12.84,,58.92,percent of total billed charges,12.84% of total billed charges,73.65,12.84,,58.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.81,65,,298.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.75,35,,160.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,516.2,90,,412.96,percent of total billed charges,90% of total billed charges for outpatient setting,73.65,516.2,
ECHELON 60MM BLUE / GST60B,69162129,CDM,272,RC,,,Outpatient,,,476,476,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.2,70,,266.56,percent of total billed charges,70% of total billed charges for outpatient setting,404.03,84.88,,323.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,238,50,,190.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357,75,,285.6,percent of total billed charges,75% of total billed charges for outpatient setting,333.2,70,,266.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.12,12.84,,48.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.8,80,,304.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.12,12.84,,48.9,percent of total billed charges,12.84% of total billed charges,61.12,12.84,,48.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,309.4,65,,247.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.6,35,,133.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.4,90,,342.72,percent of total billed charges,90% of total billed charges for outpatient setting,61.12,428.4,
ECHELON 60MM BLUE RELOADS / ECR60B,69161850,CDM,272,RC,,,Outpatient,,,713.33,713.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.33,70,,399.46,percent of total billed charges,70% of total billed charges for outpatient setting,605.47,84.88,,484.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,356.67,50,,285.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535,75,,428,percent of total billed charges,75% of total billed charges for outpatient setting,499.33,70,,399.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.59,12.84,,73.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.66,80,,456.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.59,12.84,,73.27,percent of total billed charges,12.84% of total billed charges,91.59,12.84,,73.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,463.66,65,,370.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.67,35,,199.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642,90,,513.6,percent of total billed charges,90% of total billed charges for outpatient setting,91.59,642,
ECHELON 60MM GREEN / GST60G,69162143,CDM,272,RC,,,Outpatient,,,460,460,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322,70,,257.6,percent of total billed charges,70% of total billed charges for outpatient setting,390.45,84.88,,312.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,230,50,,184,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345,75,,276,percent of total billed charges,75% of total billed charges for outpatient setting,322,70,,257.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.06,12.84,,47.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368,80,,294.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.06,12.84,,47.25,percent of total billed charges,12.84% of total billed charges,59.06,12.84,,47.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,299,65,,239.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,35,,128.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,414,90,,331.2,percent of total billed charges,90% of total billed charges for outpatient setting,59.06,414,
ECHELON 60MM GREEN RELOADS / GTS60G,69162102,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
ECHELON 60MM WHITE / GST60W,69162717,CDM,272,RC,,,Outpatient,,,490.2,490.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.14,70,,274.51,percent of total billed charges,70% of total billed charges for outpatient setting,416.08,84.88,,332.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,245.1,50,,196.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,75,,294.12,percent of total billed charges,75% of total billed charges for outpatient setting,343.14,70,,274.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.94,12.84,,50.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.16,80,,313.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.94,12.84,,50.35,percent of total billed charges,12.84% of total billed charges,62.94,12.84,,50.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,318.63,65,,254.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.57,35,,137.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,441.18,90,,352.94,percent of total billed charges,90% of total billed charges for outpatient setting,62.94,441.18,
ECHINOCOCCUS AB,220073,CDM,302,RC,86682,HCPCS,Outpatient,,,58.55,52.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,49.7,84.88,,39.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.91,75,,35.13,percent of total billed charges,75% of total billed charges for outpatient setting,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.84,80,,37.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.67,100,,,Fee Schedule,100% of Custom Fee Schedule,52.7,90,,42.16,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,52.7,
ECHO - TEE,2600325,CDM,483,RC,93312,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,707.1,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
ECHO COMPLETE W/DOPPLER & COLOR FLOW,2600005,CDM,483,RC,93306,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
ECHO COMPLETE W/O COLOR FLOW/DOPPLER,2610019,CDM,483,RC,93307,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,676.89,
ECHO FOLLOW UP OR LIMITED STUDY,2600010,CDM,483,RC,93308,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.19,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,642.14,
ECHOCARDIOGRAM,1300030,CDM,483,RC,93307,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,676.89,
ECHOCARDIOGRAM - STRESS TEST,1300050,CDM,482,RC,93350,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
ECHOCARDIOGRAM STRESS TEST,2600320,CDM,483,RC,93350,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
ECO2 REAGENT / DF137,200605,CDM,300,RC,82374,HCPCS,Outpatient,,,38.22,34.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.75,70,,21.4,percent of total billed charges,70% of total billed charges for outpatient setting,32.44,84.88,,25.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.67,75,,22.94,percent of total billed charges,75% of total billed charges for outpatient setting,26.75,70,,21.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.58,80,,24.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,34.4,90,,27.52,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,34.4,
ECTRA II PROCEDURE KIT / 4116,69162703,CDM,272,RC,,,Outpatient,,,1051.22,1051.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.85,70,,588.68,percent of total billed charges,70% of total billed charges for outpatient setting,892.28,84.88,,713.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,525.61,50,,420.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,788.42,75,,630.74,percent of total billed charges,75% of total billed charges for outpatient setting,735.85,70,,588.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.98,12.84,,107.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.98,80,,672.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.98,12.84,,107.98,percent of total billed charges,12.84% of total billed charges,134.98,12.84,,107.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,683.29,65,,546.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.93,35,,294.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,946.1,90,,756.88,percent of total billed charges,90% of total billed charges for outpatient setting,134.98,946.1,
EDROPHONIUM (ENLON) INJ 10MG/ML 15 ML,3300997,CDM,250,RC,,,Outpatient,,,38.5,38.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,32.68,84.88,,26.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.25,50,,15.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,75,,23.1,percent of total billed charges,75% of total billed charges for outpatient setting,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,80,,24.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.03,65,,20.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,35,,10.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.65,
EEA ORVIL 25MM / EEAORVIL25,69161209,CDM,272,RC,,,Outpatient,,,477.21,477.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.05,70,,267.24,percent of total billed charges,70% of total billed charges for outpatient setting,405.06,84.88,,324.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,238.61,50,,190.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.91,75,,286.33,percent of total billed charges,75% of total billed charges for outpatient setting,334.05,70,,267.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.27,12.84,,49.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.77,80,,305.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.27,12.84,,49.02,percent of total billed charges,12.84% of total billed charges,61.27,12.84,,49.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,310.19,65,,248.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.02,35,,133.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,429.49,90,,343.59,percent of total billed charges,90% of total billed charges for outpatient setting,61.27,429.49,
EEG,2600110,CDM,402,RC,95819,HCPCS,Outpatient,,,860.06,860.06,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,730.02,84.88,,584.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,645.05,75,,516.04,percent of total billed charges,75% of total billed charges for outpatient setting,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,110.43,12.84,,88.344,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,688.05,80,,550.44,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,216.03,100,,,Fee Schedule,100% of Custom Fee Schedule,774.05,90,,619.24,percent of total billed charges,90% of total billed charges for outpatient setting,110.43,774.05,
EEG 1 HOUR,2600115,CDM,402,RC,95812,HCPCS,Outpatient,,,860.06,860.06,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,730.02,84.88,,584.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,645.05,75,,516.04,percent of total billed charges,75% of total billed charges for outpatient setting,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,110.43,12.84,,88.344,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,688.05,80,,550.44,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,216.03,100,,,Fee Schedule,100% of Custom Fee Schedule,774.05,90,,619.24,percent of total billed charges,90% of total billed charges for outpatient setting,110.43,774.05,
EEG B-SCAN AND/OR REAL TIME W/IMAGE,2600125,CDM,402,RC,76506,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
EEG EXTENDED,2600120,CDM,402,RC,95813,HCPCS,Outpatient,,,860.06,860.06,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,730.02,84.88,,584.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,645.05,75,,516.04,percent of total billed charges,75% of total billed charges for outpatient setting,602.04,70,,481.63,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,110.43,12.84,,88.344,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,688.05,80,,550.44,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.43,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,216.03,100,,,Fee Schedule,100% of Custom Fee Schedule,774.05,90,,619.24,percent of total billed charges,90% of total billed charges for outpatient setting,110.43,774.05,
EHL PROBE 1.9FR / E4-2F,6152286,CDM,270,RC,,,Outpatient,,,866.71,866.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.7,70,,485.36,percent of total billed charges,70% of total billed charges for outpatient setting,735.66,84.88,,588.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,433.36,50,,346.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650.03,75,,520.02,percent of total billed charges,75% of total billed charges for outpatient setting,606.7,70,,485.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.29,12.84,,89.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.37,80,,554.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.29,12.84,,89.03,percent of total billed charges,12.84% of total billed charges,111.29,12.84,,89.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,563.36,65,,450.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.35,35,,242.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,780.04,90,,624.03,percent of total billed charges,90% of total billed charges for outpatient setting,111.29,780.04,
EHL PROBE 9FR / E4-9F,69161628,CDM,272,RC,,,Outpatient,,,892.71,892.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.9,70,,499.92,percent of total billed charges,70% of total billed charges for outpatient setting,757.73,84.88,,606.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,446.36,50,,357.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,669.53,75,,535.62,percent of total billed charges,75% of total billed charges for outpatient setting,624.9,70,,499.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.62,12.84,,91.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.17,80,,571.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.62,12.84,,91.7,percent of total billed charges,12.84% of total billed charges,114.62,12.84,,91.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580.26,65,,464.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.45,35,,249.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,803.44,90,,642.75,percent of total billed charges,90% of total billed charges for outpatient setting,114.62,803.44,
EHRLICHIOSIS TEST,201559,CDM,302,RC,86666,HCPCS,Outpatient,,,45.81,41.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,84.88,,31.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.36,75,,27.49,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,80,,29.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,100,,,Fee Schedule,100% of Custom Fee Schedule,41.23,90,,32.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,41.23,
EJECTORS SALIVA,6150681,CDM,270,RC,,,Outpatient,,,0.48,0.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,70,,0.27,percent of total billed charges,70% of total billed charges for outpatient setting,0.41,84.88,,0.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.24,50,,0.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.36,75,,0.29,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,70,,0.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,12.84,,0.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,80,,0.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,12.84,,0.05,percent of total billed charges,12.84% of total billed charges,0.06,12.84,,0.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.31,65,,0.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,35,,0.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.43,90,,0.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.06,0.43,
EKG INTERP DR ELMALAH,1300044,CDM,985,RC,93010,HCPCS,Outpatient,,,32.64,32.64,,7.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,84.88,,26.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.64,75,,26.11,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,70,,9,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,26.112,percent of total billed charges,100% of total billed charges for outpatient setting,7.92,215,,,Fee Schedule,215% of Medicare OPPS rate,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.92,175,,,Fee Schedule,175% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.64,65,,26.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,32.64,
EKG INTERP DR ROSS SMITH,1300047,CDM,985,RC,93010,HCPCS,Outpatient,,,32.64,32.64,,7.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,84.88,,26.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.64,75,,26.11,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,70,,9,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,26.112,percent of total billed charges,100% of total billed charges for outpatient setting,7.92,215,,,Fee Schedule,215% of Medicare OPPS rate,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.92,175,,,Fee Schedule,175% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.64,65,,26.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,32.64,
EKG INTERP M SAMPOGNARO,1300032,CDM,985,RC,93010,HCPCS,Outpatient,,,32.64,32.64,,7.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,84.88,,26.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.64,75,,26.11,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,70,,9,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,26.112,percent of total billed charges,100% of total billed charges for outpatient setting,7.92,215,,,Fee Schedule,215% of Medicare OPPS rate,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.92,175,,,Fee Schedule,175% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.64,65,,26.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,32.64,
EKG PADS (3M RED DOT) ADULT,7650060,CDM,272,RC,,,Outpatient,,,1.72,1.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,70,,0.96,percent of total billed charges,70% of total billed charges for outpatient setting,1.46,84.88,,1.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.86,50,,0.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.29,75,,1.03,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,70,,0.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.22,12.84,,0.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,80,,1.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.22,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,0.22,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.12,65,,0.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.6,35,,0.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.55,90,,1.24,percent of total billed charges,90% of total billed charges for outpatient setting,0.22,1.55,
EKG TRACING DR ELMALAH,1300014,CDM,730,RC,93005,HCPCS,Outpatient,,,358.5,358.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,304.29,84.88,,243.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,268.88,75,,215.1,percent of total billed charges,75% of total billed charges for outpatient setting,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.03,12.84,,36.824,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,286.8,80,,229.44,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.26,100,,,Fee Schedule,100% of Custom Fee Schedule,322.65,90,,258.12,percent of total billed charges,90% of total billed charges for outpatient setting,32.26,322.65,
EKG TRACING DR M SAMPOGNARO,1300027,CDM,730,RC,93005,HCPCS,Outpatient,,,358.5,358.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,304.29,84.88,,243.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,268.88,75,,215.1,percent of total billed charges,75% of total billed charges for outpatient setting,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.03,12.84,,36.824,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,286.8,80,,229.44,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.26,100,,,Fee Schedule,100% of Custom Fee Schedule,322.65,90,,258.12,percent of total billed charges,90% of total billed charges for outpatient setting,32.26,322.65,
EKG TRACING DR ROSS SMITH,1300012,CDM,730,RC,93005,HCPCS,Outpatient,,,358.5,358.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,304.29,84.88,,243.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,268.88,75,,215.1,percent of total billed charges,75% of total billed charges for outpatient setting,250.95,70,,200.76,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.03,12.84,,36.824,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,286.8,80,,229.44,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,46.03,12.84,,36.82,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.26,100,,,Fee Schedule,100% of Custom Fee Schedule,322.65,90,,258.12,percent of total billed charges,90% of total billed charges for outpatient setting,32.26,322.65,
ELASTASE  STOOL,220011,CDM,301,RC,82656,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
ELBOW 2 VWS BILATERAL,2400507,CDM,320,RC,73070,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
ELBOW 2 VWS LEFT,2400506,CDM,320,RC,73070,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ELBOW 2 VWS RIGHT,2400505,CDM,320,RC,73070,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ELBOW 3+ VWS BILATERAL,2400512,CDM,320,RC,73080,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
ELBOW 3+ VWS LEFT,2400511,CDM,320,RC,73080,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ELBOW 3+ VWS RIGHT,2400510,CDM,320,RC,73080,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
ELBOW ARTHROGRAPHY LEFT,2400516,CDM,322,RC,73085,HCPCS,Outpatient,,,1141.31,855.98,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
ELBOW ARTHROGRAPHY RIGHT,2400515,CDM,322,RC,73085,HCPCS,Outpatient,,,1141.31,855.98,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
ELBOW FLEX ANEST / 5157EU,69161961,CDM,270,RC,,,Outpatient,,,14.13,14.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,11.99,84.88,,9.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.07,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.6,75,,8.48,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,70,,7.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,80,,9.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.18,65,,7.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,35,,3.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.72,90,,10.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.72,
ELECTRO LUBE / EL-101,69161341,CDM,272,RC,,,Outpatient,,,148,148,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.6,70,,82.88,percent of total billed charges,70% of total billed charges for outpatient setting,125.62,84.88,,100.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,74,50,,59.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111,75,,88.8,percent of total billed charges,75% of total billed charges for outpatient setting,103.6,70,,82.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.4,80,,94.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,19,12.84,,15.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.2,65,,76.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.8,35,,41.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.2,90,,106.56,percent of total billed charges,90% of total billed charges for outpatient setting,19,133.2,
ELECTROD ADULT MONITORING / 31078135,6050071,CDM,272,RC,,,Outpatient,,,0.57,0.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,70,,0.32,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,84.88,,0.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.29,50,,0.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.43,75,,0.34,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,70,,0.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,80,,0.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.37,65,,0.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.2,35,,0.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.51,90,,0.41,percent of total billed charges,90% of total billed charges for outpatient setting,0.07,0.51,
ELECTRODE 10CM RF / RFDE-10,69169625,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
ELECTRODE 15CM RF / RFDE-15,69169626,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
ELECTRODE 24FR BALL BIPOLAR / 27040NB-S,69169104,CDM,272,RC,,,Outpatient,,,1490.92,1490.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1043.64,70,,834.91,percent of total billed charges,70% of total billed charges for outpatient setting,1265.49,84.88,,1012.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,745.46,50,,596.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1118.19,75,,894.55,percent of total billed charges,75% of total billed charges for outpatient setting,1043.64,70,,834.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.43,12.84,,153.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.74,80,,954.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.43,12.84,,153.14,percent of total billed charges,12.84% of total billed charges,191.43,12.84,,153.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,969.1,65,,775.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.82,35,,417.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1341.83,90,,1073.46,percent of total billed charges,90% of total billed charges for outpatient setting,191.43,1341.83,
ELECTRODE 24FR POINTED BIPLR /27040BL1-S,69169356,CDM,272,RC,,,Outpatient,,,1520.86,1520.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.6,70,,851.68,percent of total billed charges,70% of total billed charges for outpatient setting,1290.91,84.88,,1032.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,760.43,50,,608.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1140.65,75,,912.52,percent of total billed charges,75% of total billed charges for outpatient setting,1064.6,70,,851.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.28,12.84,,156.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.69,80,,973.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.28,12.84,,156.22,percent of total billed charges,12.84% of total billed charges,195.28,12.84,,156.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,988.56,65,,790.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.3,35,,425.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1368.77,90,,1095.02,percent of total billed charges,90% of total billed charges for outpatient setting,195.28,1368.77,
ELECTRODE 5IN BALL / 0009,6150427,CDM,270,RC,,,Outpatient,,,62.84,62.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.99,70,,35.19,percent of total billed charges,70% of total billed charges for outpatient setting,53.34,84.88,,42.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.42,50,,25.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.13,75,,37.7,percent of total billed charges,75% of total billed charges for outpatient setting,43.99,70,,35.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,12.84,,6.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.27,80,,40.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,12.84,,6.46,percent of total billed charges,12.84% of total billed charges,8.07,12.84,,6.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.85,65,,32.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,35,,17.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.56,90,,45.25,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,56.56,
ELECTRODE ADHESIVE TAB / 31447793,163525,CDM,271,RC,,,Outpatient,,,15.48,15.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,70,,8.67,percent of total billed charges,70% of total billed charges for outpatient setting,13.14,84.88,,10.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.74,50,,6.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.61,75,,9.29,percent of total billed charges,75% of total billed charges for outpatient setting,10.84,70,,8.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,80,,9.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,1.99,12.84,,1.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.06,65,,8.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.42,35,,4.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.93,90,,11.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.99,13.93,
ELECTRODE ADULT SINGLE FOIL / 400-2100,6050023,CDM,272,RC,,,Outpatient,,,24.16,24.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,70,,13.53,percent of total billed charges,70% of total billed charges for outpatient setting,20.51,84.88,,16.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.08,50,,9.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.12,75,,14.5,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,70,,13.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.33,80,,15.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.7,65,,12.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,35,,6.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.74,90,,17.39,percent of total billed charges,90% of total billed charges for outpatient setting,3.1,21.74,
ELECTRODE LOOP 10X5MM PURPLE / 0420,6150428,CDM,272,RC,,,Outpatient,,,75.63,75.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.94,70,,42.35,percent of total billed charges,70% of total billed charges for outpatient setting,64.19,84.88,,51.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.82,50,,30.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.72,75,,45.38,percent of total billed charges,75% of total billed charges for outpatient setting,52.94,70,,42.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.5,80,,48.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.16,65,,39.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,35,,21.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.07,90,,54.46,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,68.07,
ELECTRODE LOOP 15X6MM GRAY/0430,6151033,CDM,272,RC,,,Outpatient,,,95.41,95.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.79,70,,53.43,percent of total billed charges,70% of total billed charges for outpatient setting,80.98,84.88,,64.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.71,50,,38.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.56,75,,57.25,percent of total billed charges,75% of total billed charges for outpatient setting,66.79,70,,53.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,12.84,,9.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.33,80,,61.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,12.84,,9.8,percent of total billed charges,12.84% of total billed charges,12.25,12.84,,9.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.02,65,,49.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,35,,26.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.87,90,,68.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,85.87,
ELECTRODE LOOP BIPOLR 24/26FR/27040GP1-S,69162799,CDM,272,RC,,,Outpatient,,,1483.3,1483.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.31,70,,830.65,percent of total billed charges,70% of total billed charges for outpatient setting,1259.03,84.88,,1007.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,741.65,50,,593.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1112.48,75,,889.98,percent of total billed charges,75% of total billed charges for outpatient setting,1038.31,70,,830.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.46,12.84,,152.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.64,80,,949.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.46,12.84,,152.37,percent of total billed charges,12.84% of total billed charges,190.46,12.84,,152.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,964.15,65,,771.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.16,35,,415.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1334.97,90,,1067.98,percent of total billed charges,90% of total billed charges for outpatient setting,190.46,1334.97,
ELECTRODE ROUND LOOP WHITE 20X12MM/0470,6152673,CDM,270,RC,,,Outpatient,,,77.42,77.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.19,70,,43.35,percent of total billed charges,70% of total billed charges for outpatient setting,65.71,84.88,,52.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.71,50,,30.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.07,75,,46.46,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,70,,43.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,12.84,,7.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.94,80,,49.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,12.84,,7.95,percent of total billed charges,12.84% of total billed charges,9.94,12.84,,7.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.32,65,,40.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,35,,21.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.68,90,,55.74,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,69.68,
ELECTRODE RT REPOSITIONABLE / E301RASR,7223694,CDM,272,RC,,,Outpatient,,,3.1,3.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,2.63,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.33,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.02,65,,1.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,35,,0.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.79,90,,2.23,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.79,
ELECTRODE SNAP RED DOT / 2670-5,70000338,CDM,272,RC,,,Outpatient,,,1.58,1.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,70,,0.89,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,84.88,,1.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,50,,0.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.19,75,,0.95,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,70,,0.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,80,,1.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.03,65,,0.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,35,,0.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.42,90,,1.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.2,1.42,
ELECTRODES 5CM RF / RFDE-5,69169288,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
"ELECTRODES SUBDERMAL, STIM RET (FACIAL)",69162156,CDM,272,RC,,,Outpatient,,,423.95,423.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,359.85,84.88,,287.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,211.98,50,,169.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.96,75,,254.37,percent of total billed charges,75% of total billed charges for outpatient setting,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.16,80,,271.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.57,65,,220.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.38,35,,118.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.56,90,,305.25,percent of total billed charges,90% of total billed charges for outpatient setting,54.44,381.56,
ELECTROLYTE (LYPHOLYTE II) SOL INJ :20ML,3300999,CDM,250,RC,,,Outpatient,,,13.82,13.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,70,,7.74,percent of total billed charges,70% of total billed charges for outpatient setting,11.73,84.88,,9.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.91,50,,5.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.37,75,,8.3,percent of total billed charges,75% of total billed charges for outpatient setting,9.67,70,,7.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,80,,8.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.98,65,,7.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,35,,3.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.44,90,,9.95,percent of total billed charges,90% of total billed charges for outpatient setting,1.77,12.44,
ELECTROLYTE (NUTRILYTE II) INJ : 20 ML,3300998,CDM,250,RC,,,Outpatient,,,10.11,10.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.08,70,,5.66,percent of total billed charges,70% of total billed charges for outpatient setting,8.58,84.88,,6.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.06,50,,4.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.58,75,,6.06,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,70,,5.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,80,,6.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.57,65,,5.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,35,,2.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.1,90,,7.28,percent of total billed charges,90% of total billed charges for outpatient setting,1.3,9.1,
ELECTROLYTE PANEL LYTES,200011,CDM,300,RC,80051,HCPCS,Outpatient,,,31.55,28.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.09,70,,17.67,percent of total billed charges,70% of total billed charges for outpatient setting,26.78,84.88,,21.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.66,75,,18.93,percent of total billed charges,75% of total billed charges for outpatient setting,22.09,70,,17.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.24,80,,20.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,100,,,Fee Schedule,100% of Custom Fee Schedule,28.4,90,,22.72,percent of total billed charges,90% of total billed charges for outpatient setting,7.01,28.4,
ELECTROPHORECTIC TECHNIQUE,201457,CDM,301,RC,82664,HCPCS,Outpatient,,,276.75,249.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.73,70,,154.98,percent of total billed charges,70% of total billed charges for outpatient setting,234.91,84.88,,187.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,207.56,75,,166.05,percent of total billed charges,75% of total billed charges for outpatient setting,193.73,70,,154.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.4,80,,177.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.15,100,,,Fee Schedule,100% of Custom Fee Schedule,249.08,90,,199.26,percent of total billed charges,90% of total billed charges for outpatient setting,13.56,249.08,
ELECTROPHYSIOLOGIC EVAL;SING/DUAL PACING,6157024,CDM,360,RC,93640,HCPCS,Outpatient,,,2394.83,2394.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,2032.73,84.88,,1626.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1796.12,75,,1436.9,percent of total billed charges,75% of total billed charges for outpatient setting,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.86,80,,1532.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2155.35,90,,1724.28,percent of total billed charges,90% of total billed charges for outpatient setting,307.5,2155.35,
ELETRIPTAN HBR(RELPAX)): 40 MG TAB,3304991,CDM,259,RC,,,Outpatient,,,262.79,262.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.95,70,,147.16,percent of total billed charges,70% of total billed charges for outpatient setting,223.06,84.88,,178.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.4,50,,105.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.09,75,,157.67,percent of total billed charges,75% of total billed charges for outpatient setting,183.95,70,,147.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.74,12.84,,26.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.23,80,,168.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.74,12.84,,26.99,percent of total billed charges,12.84% of total billed charges,33.74,12.84,,26.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,170.81,65,,136.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.98,35,,73.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,236.51,90,,189.21,percent of total billed charges,90% of total billed charges for outpatient setting,33.74,236.51,
ELEVATE ANTERIOR SYST / 720093-01,69161283,CDM,278,RC,C1781,HCPCS,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
ELEVATE POSTERIOR SYST / 720127-01,69161396,CDM,278,RC,C1781,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
ELEVATOR PASSING / SC-4230,71000614,CDM,272,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,169.76,84.88,,135.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,100,50,,80,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,75,,120,percent of total billed charges,75% of total billed charges for outpatient setting,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,80,,128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130,65,,104,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,35,,56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,90,,144,percent of total billed charges,90% of total billed charges for outpatient setting,25.68,180,
ELUCIREM  7.5ML INJ / 423604US,7786508,CDM,636,RC,A9575,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,70,,50.4,percent of total billed charges,70% of total billed charges for outpatient setting,76.39,84.88,,61.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.5,75,,54,percent of total billed charges,75% of total billed charges for outpatient setting,63,70,,50.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,80,,57.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.5,65,,46.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,100,,,Fee Schedule,100% of Custom Fee Schedule,81,90,,64.8,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,81,
ELUCIREM 10ML INJ / 423607US,7786507,CDM,636,RC,A9575,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,101.86,84.88,,81.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,90,75,,72,percent of total billed charges,75% of total billed charges for outpatient setting,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,80,,76.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78,65,,62.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,100,,,Fee Schedule,100% of Custom Fee Schedule,108,90,,86.4,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,108,
EMG CRANIAL  BILATERAL,6000605,CDM,922,RC,95868,HCPCS,Outpatient,,,246.18,246.18,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.33,70,,137.86,percent of total billed charges,70% of total billed charges for outpatient setting,208.96,84.88,,167.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,184.64,75,,147.71,percent of total billed charges,75% of total billed charges for outpatient setting,172.33,70,,137.86,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,31.61,12.84,,25.288,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,196.94,80,,157.55,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,31.61,12.84,,25.29,percent of total billed charges,12.84% of total billed charges,31.61,12.84,,25.29,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,221.56,90,,177.25,percent of total billed charges,90% of total billed charges for outpatient setting,31.61,509.88,
"EMG CRANIAL, BILATERAL",60000605,CDM,922,RC,95868,HCPCS,Outpatient,,,182.35,182.35,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,127.65,70,,102.12,percent of total billed charges,70% of total billed charges for outpatient setting,154.78,84.88,,123.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,136.76,75,,109.41,percent of total billed charges,75% of total billed charges for outpatient setting,127.65,70,,102.12,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.41,12.84,,18.728,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,145.88,80,,116.7,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.41,12.84,,18.73,percent of total billed charges,12.84% of total billed charges,23.41,12.84,,18.73,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,164.12,90,,131.3,percent of total billed charges,90% of total billed charges for outpatient setting,23.41,509.88,
"EMG CRANIAL, UNILATERAL",6000604,CDM,922,RC,95867,HCPCS,Outpatient,,,246.18,246.18,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,172.33,70,,137.86,percent of total billed charges,70% of total billed charges for outpatient setting,208.96,84.88,,167.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,184.64,75,,147.71,percent of total billed charges,75% of total billed charges for outpatient setting,172.33,70,,137.86,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,31.61,12.84,,25.288,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,196.94,80,,157.55,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,31.61,12.84,,25.29,percent of total billed charges,12.84% of total billed charges,31.61,12.84,,25.29,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,221.56,90,,177.25,percent of total billed charges,90% of total billed charges for outpatient setting,31.61,509.88,
EMG LARYNX,6000601,CDM,922,RC,95865,HCPCS,Outpatient,,,92.47,92.47,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,64.73,70,,51.78,percent of total billed charges,70% of total billed charges for outpatient setting,78.49,84.88,,62.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,69.35,75,,55.48,percent of total billed charges,75% of total billed charges for outpatient setting,64.73,70,,51.78,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.87,12.84,,9.496,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.98,80,,59.18,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.87,12.84,,9.5,percent of total billed charges,12.84% of total billed charges,11.87,12.84,,9.5,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.84,100,,,Fee Schedule,100% of Custom Fee Schedule,83.22,90,,66.58,percent of total billed charges,90% of total billed charges for outpatient setting,11.87,323,
EMG THORACIC PARASPINAL,6000606,CDM,922,RC,95869,HCPCS,Outpatient,,,156.24,156.24,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,109.37,70,,87.5,percent of total billed charges,70% of total billed charges for outpatient setting,132.62,84.88,,106.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,117.18,75,,93.74,percent of total billed charges,75% of total billed charges for outpatient setting,109.37,70,,87.5,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,20.06,12.84,,16.048,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,124.99,80,,99.99,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,20.06,12.84,,16.05,percent of total billed charges,12.84% of total billed charges,20.06,12.84,,16.05,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.84,100,,,Fee Schedule,100% of Custom Fee Schedule,140.62,90,,112.5,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,323,
EMOLLIENT (HYDROCERIN) CRM : 120GM,3301000,CDM,259,RC,,,Outpatient,,,13.62,13.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,84.88,,9.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.81,50,,5.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.22,75,,8.18,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,80,,8.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.85,65,,7.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,35,,3.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.26,90,,9.81,percent of total billed charges,90% of total billed charges for outpatient setting,1.75,12.26,
ENALAPRIL (VASOTEC) : 20 MG,3302993,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ENALAPRIL (VASOTEC) TAB : 10 MG,3301002,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ENALAPRIL (VASOTEC) TAB : 5 MG,3301001,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ENALAPRIL (VASOTEC) TAB: 10 MG,3301004,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ENALAPRIL (VASOTEC) TAB: 5 MG,3301003,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ENALAPRILAT (VASOTEC) INJ 1.25 MG,3301006,CDM,250,RC,,,Outpatient,,,32.76,32.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.93,70,,18.34,percent of total billed charges,70% of total billed charges for outpatient setting,27.81,84.88,,22.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.38,50,,13.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.57,75,,19.66,percent of total billed charges,75% of total billed charges for outpatient setting,22.93,70,,18.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.21,80,,20.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.29,65,,17.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,35,,9.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.48,90,,23.58,percent of total billed charges,90% of total billed charges for outpatient setting,4.21,29.48,
ENALAPRILAT (VASOTEC) INJ 1.25MG/ML: 1ML,3301005,CDM,250,RC,,,Outpatient,,,9.92,9.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.94,70,,5.55,percent of total billed charges,70% of total billed charges for outpatient setting,8.42,84.88,,6.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.96,50,,3.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.44,75,,5.95,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,70,,5.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.27,12.84,,1.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,80,,6.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.27,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,1.27,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.45,65,,5.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,35,,2.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.93,90,,7.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.27,8.93,
"ENCEPHALITIS, CALIFORNIA LA CROSSE",200163,CDM,302,RC,86651,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"ENCEPHALITIS, EASTERN EQUINE",200112,CDM,302,RC,86652,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"ENCEPHALITIS, ST. LOUIS",200113,CDM,302,RC,86653,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"ENCEPHALITIS, WESTERN EQUINE",200114,CDM,302,RC,86654,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
END CAP HMRL NAIL 0MM EXT / 04.001.000,70000410,CDM,278,RC,C1776,HCPCS,Outpatient,,,646.65,646.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.99,60,,310.39,percent of total billed charges,60% of total Billed charges for outpatient setting,548.88,84.88,,439.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.99,75,,387.99,percent of total billed charges,75% of total billed charges for outpatient setting,323.33,50,,258.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,12.84,,66.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.32,80,,413.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,12.84,,66.42,percent of total billed charges,12.84% of total billed charges,83.03,12.84,,66.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.65,65,,517.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.33,35,,181.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,387.99,60,,310.39,percent of total billed charges,60% of total billed charges for outpatient setting,83.03,646.65,
END CAP HMRL NAIL 0MM EXT / 04.001.000S,69162060,CDM,278,RC,C1776,HCPCS,Outpatient,,,1038.02,1038.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.81,60,,498.25,percent of total billed charges,60% of total Billed charges for outpatient setting,881.07,84.88,,704.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.52,75,,622.82,percent of total billed charges,75% of total billed charges for outpatient setting,519.01,50,,415.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.28,12.84,,106.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,830.42,80,,664.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.28,12.84,,106.62,percent of total billed charges,12.84% of total billed charges,133.28,12.84,,106.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1038.02,65,,830.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.31,35,,290.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,622.81,60,,498.25,percent of total billed charges,60% of total billed charges for outpatient setting,133.28,1038.02,
END CAP TIB NAIL 0MM EXT / 04.004.000S,705033,CDM,278,RC,C1776,HCPCS,Outpatient,,,976.2,976.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.72,60,,468.58,percent of total billed charges,60% of total Billed charges for outpatient setting,828.6,84.88,,662.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.15,75,,585.72,percent of total billed charges,75% of total billed charges for outpatient setting,488.1,50,,390.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.34,12.84,,100.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.96,80,,624.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.34,12.84,,100.27,percent of total billed charges,12.84% of total billed charges,125.34,12.84,,100.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,976.2,65,,780.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.67,35,,273.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,585.72,60,,468.58,percent of total billed charges,60% of total billed charges for outpatient setting,125.34,976.2,
ENDO ABORT/CANCEL PRIOR TO PROCEDURE,6000091,CDM,750,RC,,,Outpatient,,,179.67,179.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.77,70,,100.62,percent of total billed charges,70% of total billed charges for outpatient setting,152.5,84.88,,122,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.84,50,,71.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.75,75,,107.8,percent of total billed charges,75% of total billed charges for outpatient setting,125.77,70,,100.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,12.84,,18.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.74,80,,114.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,12.84,,18.46,percent of total billed charges,12.84% of total billed charges,23.07,12.84,,18.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.88,35,,50.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,161.7,90,,129.36,percent of total billed charges,90% of total billed charges for outpatient setting,23.07,161.7,
ENDO ABORTED PROCEDURE,6000090,CDM,750,RC,,,Outpatient,,,1382.37,1382.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.66,70,,774.13,percent of total billed charges,70% of total billed charges for outpatient setting,1173.36,84.88,,938.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,691.19,50,,552.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1036.78,75,,829.42,percent of total billed charges,75% of total billed charges for outpatient setting,967.66,70,,774.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,12.84,,142,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1105.9,80,,884.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,12.84,,142,percent of total billed charges,12.84% of total billed charges,177.5,12.84,,142,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.83,35,,387.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1244.13,90,,995.3,percent of total billed charges,90% of total billed charges for outpatient setting,177.5,1244.13,
ENDO BEDSIDE PROCEDURE,6000074,CDM,360,RC,,,Outpatient,,,494.46,494.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.12,70,,276.9,percent of total billed charges,70% of total billed charges for outpatient setting,419.7,84.88,,335.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,247.23,50,,197.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.85,75,,296.68,percent of total billed charges,75% of total billed charges for outpatient setting,346.12,70,,276.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.49,12.84,,50.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.57,80,,316.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.49,12.84,,50.79,percent of total billed charges,12.84% of total billed charges,63.49,12.84,,50.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.06,35,,138.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,445.01,90,,356.01,percent of total billed charges,90% of total billed charges for outpatient setting,63.49,445.01,
ENDO BUTTON W/LOOP 45MM,6152171,CDM,270,RC,,,Outpatient,,,600.3,600.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.21,70,,336.17,percent of total billed charges,70% of total billed charges for outpatient setting,509.53,84.88,,407.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,300.15,50,,240.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450.23,75,,360.18,percent of total billed charges,75% of total billed charges for outpatient setting,420.21,70,,336.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.08,12.84,,61.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.24,80,,384.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.08,12.84,,61.66,percent of total billed charges,12.84% of total billed charges,77.08,12.84,,61.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390.2,65,,312.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.11,35,,168.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540.27,90,,432.22,percent of total billed charges,90% of total billed charges for outpatient setting,77.08,540.27,
ENDO CATCH 15MM / 173049,69160635,CDM,272,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.19,65,,224.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.55,389.34,
ENDO CLOSE / 173022,6150033,CDM,272,RC,,,Outpatient,,,137.9,137.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,117.05,84.88,,93.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.95,50,,55.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.43,75,,82.74,percent of total billed charges,75% of total billed charges for outpatient setting,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.32,80,,88.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.64,65,,71.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.27,35,,38.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.11,90,,99.29,percent of total billed charges,90% of total billed charges for outpatient setting,17.71,124.11,
ENDO EXCHNG TUBES STRAIGHT,69159182,CDM,272,RC,,,Outpatient,,,81.88,81.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.32,70,,45.86,percent of total billed charges,70% of total billed charges for outpatient setting,69.5,84.88,,55.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.94,50,,32.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.41,75,,49.13,percent of total billed charges,75% of total billed charges for outpatient setting,57.32,70,,45.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.51,12.84,,8.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,80,,52.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.51,12.84,,8.41,percent of total billed charges,12.84% of total billed charges,10.51,12.84,,8.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.22,65,,42.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.66,35,,22.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.69,90,,58.95,percent of total billed charges,90% of total billed charges for outpatient setting,10.51,73.69,
"ENDO FAN RETRACT 10MM, 176647",69159835,CDM,272,RC,,,Outpatient,,,443.42,443.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.39,70,,248.31,percent of total billed charges,70% of total billed charges for outpatient setting,376.37,84.88,,301.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,221.71,50,,177.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,332.57,75,,266.06,percent of total billed charges,75% of total billed charges for outpatient setting,310.39,70,,248.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.94,12.84,,45.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.74,80,,283.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.94,12.84,,45.55,percent of total billed charges,12.84% of total billed charges,56.94,12.84,,45.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,288.22,65,,230.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.2,35,,124.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,399.08,90,,319.26,percent of total billed charges,90% of total billed charges for outpatient setting,56.94,399.08,
ENDO LEVEL I PROCEDURE,6000075,CDM,750,RC,,,Outpatient,,,3374.58,3374.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2362.21,70,,1889.77,percent of total billed charges,70% of total billed charges for outpatient setting,2864.34,84.88,,2291.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,1687.29,50,,1349.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2530.94,75,,2024.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.3,12.84,,346.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2699.66,80,,2159.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.3,12.84,,346.64,percent of total billed charges,12.84% of total billed charges,433.3,12.84,,346.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.1,35,,944.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3037.12,90,,2429.7,percent of total billed charges,90% of total billed charges for outpatient setting,433.3,3037.12,
ENDO LEVEL II PROCEDURE,6000080,CDM,750,RC,,,Outpatient,,,2699.68,2699.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1889.78,70,,1511.82,percent of total billed charges,70% of total billed charges for outpatient setting,2291.49,84.88,,1833.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349.84,50,,1079.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2024.76,75,,1619.81,percent of total billed charges,75% of total billed charges for outpatient setting,1889.78,70,,1511.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.64,12.84,,277.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2159.74,80,,1727.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.64,12.84,,277.31,percent of total billed charges,12.84% of total billed charges,346.64,12.84,,277.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.89,35,,755.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2429.71,90,,1943.77,percent of total billed charges,90% of total billed charges for outpatient setting,346.64,2429.71,
ENDO LEVEL III PROCEDURE,6000085,CDM,750,RC,,,Outpatient,,,2728.78,2728.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1910.15,70,,1528.12,percent of total billed charges,70% of total billed charges for outpatient setting,2316.19,84.88,,1852.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,1364.39,50,,1091.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2046.59,75,,1637.27,percent of total billed charges,75% of total billed charges for outpatient setting,1910.15,70,,1528.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.38,12.84,,280.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2183.02,80,,1746.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.38,12.84,,280.3,percent of total billed charges,12.84% of total billed charges,350.38,12.84,,280.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.07,35,,764.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2455.9,90,,1964.72,percent of total billed charges,90% of total billed charges for outpatient setting,350.38,2455.9,
ENDO POUCH 10MM / POUCH,69159865,CDM,272,RC,,,Outpatient,,,188.15,188.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.71,70,,105.37,percent of total billed charges,70% of total billed charges for outpatient setting,159.7,84.88,,127.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.08,50,,75.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.11,75,,112.89,percent of total billed charges,75% of total billed charges for outpatient setting,131.71,70,,105.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.16,12.84,,19.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.52,80,,120.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.16,12.84,,19.33,percent of total billed charges,12.84% of total billed charges,24.16,12.84,,19.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122.3,65,,97.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.85,35,,52.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.34,90,,135.47,percent of total billed charges,90% of total billed charges for outpatient setting,24.16,169.34,
ENDO SCRUB 2 TUBING SET / 1912030,69161855,CDM,272,RC,,,Outpatient,,,220.25,220.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.18,70,,123.34,percent of total billed charges,70% of total billed charges for outpatient setting,186.95,84.88,,149.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.13,50,,88.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.19,75,,132.15,percent of total billed charges,75% of total billed charges for outpatient setting,154.18,70,,123.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,12.84,,22.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.2,80,,140.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,12.84,,22.62,percent of total billed charges,12.84% of total billed charges,28.28,12.84,,22.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.16,65,,114.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.09,35,,61.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198.23,90,,158.58,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,198.23,
ENDO SMART SOURCE TUBE LUER 210 / 100551,70000657,CDM,270,RC,,,Outpatient,,,49.21,49.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,70,,27.56,percent of total billed charges,70% of total billed charges for outpatient setting,41.77,84.88,,33.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.61,50,,19.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.91,75,,29.53,percent of total billed charges,75% of total billed charges for outpatient setting,34.45,70,,27.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.32,12.84,,5.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.37,80,,31.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.32,12.84,,5.06,percent of total billed charges,12.84% of total billed charges,6.32,12.84,,5.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.99,65,,25.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,35,,13.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.29,90,,35.43,percent of total billed charges,90% of total billed charges for outpatient setting,6.32,44.29,
ENDO SMARTCAP FUJI / 100165CO2,70000656,CDM,272,RC,,,Outpatient,,,73.5,73.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,62.39,84.88,,49.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.75,50,,29.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.13,75,,44.1,percent of total billed charges,75% of total billed charges for outpatient setting,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,80,,47.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.78,65,,38.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,35,,20.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.15,90,,52.92,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,66.15,
ENDO SUTURE ASST 5.16MMX38CM / SW100,6150262,CDM,270,RC,,,Outpatient,,,484.72,484.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.3,70,,271.44,percent of total billed charges,70% of total billed charges for outpatient setting,411.43,84.88,,329.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,242.36,50,,193.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,363.54,75,,290.83,percent of total billed charges,75% of total billed charges for outpatient setting,339.3,70,,271.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,12.84,,49.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.78,80,,310.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,12.84,,49.79,percent of total billed charges,12.84% of total billed charges,62.24,12.84,,49.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.07,65,,252.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.65,35,,135.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,436.25,90,,349,percent of total billed charges,90% of total billed charges for outpatient setting,62.24,436.25,
ENDOBUTTO CL ULTRA 20MM / 72200147,69169263,CDM,278,RC,,,Outpatient,,,1213.8,1213.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.28,60,,582.62,percent of total billed charges,60% of total Billed charges for outpatient setting,1030.27,84.88,,824.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,606.9,50,,485.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,910.35,75,,728.28,percent of total billed charges,75% of total billed charges for outpatient setting,606.9,50,,485.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.85,12.84,,124.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,971.04,80,,776.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.85,12.84,,124.68,percent of total billed charges,12.84% of total billed charges,155.85,12.84,,124.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1213.8,65,,971.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.83,35,,339.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,728.28,60,,582.62,percent of total billed charges,60% of total billed charges for outpatient setting,155.85,1213.8,
ENDOBUTTON CL PAC / 7209216,69162933,CDM,278,RC,C1713,HCPCS,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.68,60,,622.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1297.8,65,,1038.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,60,,622.94,percent of total billed charges,60% of total billed charges for outpatient setting,166.64,1297.8,
ENDOBUTTON KIT / 014893,69169262,CDM,272,RC,,,Outpatient,,,1898.4,1898.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1328.88,70,,1063.1,percent of total billed charges,70% of total billed charges for outpatient setting,1611.36,84.88,,1289.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,949.2,50,,759.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1423.8,75,,1139.04,percent of total billed charges,75% of total billed charges for outpatient setting,1328.88,70,,1063.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.75,12.84,,195,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.72,80,,1214.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.75,12.84,,195,percent of total billed charges,12.84% of total billed charges,243.75,12.84,,195,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1233.96,65,,987.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,664.44,35,,531.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1708.56,90,,1366.85,percent of total billed charges,90% of total billed charges for outpatient setting,243.75,1708.56,
ENDOCLIP 3 5MM COVIDIEN / 176630,70000191,CDM,272,RC,,,Outpatient,,,529.59,529.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.71,70,,296.57,percent of total billed charges,70% of total billed charges for outpatient setting,449.52,84.88,,359.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,264.8,50,,211.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.19,75,,317.75,percent of total billed charges,75% of total billed charges for outpatient setting,370.71,70,,296.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,12.84,,54.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.67,80,,338.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,12.84,,54.4,percent of total billed charges,12.84% of total billed charges,68,12.84,,54.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344.23,65,,275.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.36,35,,148.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,476.63,90,,381.3,percent of total billed charges,90% of total billed charges for outpatient setting,68,476.63,
ENDOCLIP 3 5MM ETHICON / EL5ML,69160533,CDM,272,RC,,,Outpatient,,,501.48,501.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.04,70,,280.83,percent of total billed charges,70% of total billed charges for outpatient setting,425.66,84.88,,340.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,250.74,50,,200.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.11,75,,300.89,percent of total billed charges,75% of total billed charges for outpatient setting,351.04,70,,280.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.39,12.84,,51.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.18,80,,320.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.39,12.84,,51.51,percent of total billed charges,12.84% of total billed charges,64.39,12.84,,51.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,325.96,65,,260.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.52,35,,140.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,451.33,90,,361.06,percent of total billed charges,90% of total billed charges for outpatient setting,64.39,451.33,
ENDOGATOR CO2 KIT FUJINON / 100629,70000599,CDM,272,RC,,,Outpatient,,,144.38,144.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.07,70,,80.86,percent of total billed charges,70% of total billed charges for outpatient setting,122.55,84.88,,98.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.19,50,,57.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.29,75,,86.63,percent of total billed charges,75% of total billed charges for outpatient setting,101.07,70,,80.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,12.84,,14.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.5,80,,92.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,12.84,,14.83,percent of total billed charges,12.84% of total billed charges,18.54,12.84,,14.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.85,65,,75.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.53,35,,40.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.94,90,,103.95,percent of total billed charges,90% of total billed charges for outpatient setting,18.54,129.94,
ENDOGATOR KIT FUJINON / 100618,69169076,CDM,270,RC,,,Outpatient,,,126.92,126.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.84,70,,71.07,percent of total billed charges,70% of total billed charges for outpatient setting,107.73,84.88,,86.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.46,50,,50.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.19,75,,76.15,percent of total billed charges,75% of total billed charges for outpatient setting,88.84,70,,71.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,12.84,,13.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.54,80,,81.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,12.84,,13.04,percent of total billed charges,12.84% of total billed charges,16.3,12.84,,13.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.5,65,,66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,35,,35.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.23,90,,91.38,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,114.23,
ENDOLOOP 0-VICRYL / EJ10G,6150346,CDM,272,RC,,,Outpatient,,,153.35,153.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,70,,85.88,percent of total billed charges,70% of total billed charges for outpatient setting,130.16,84.88,,104.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.68,50,,61.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.01,75,,92.01,percent of total billed charges,75% of total billed charges for outpatient setting,107.35,70,,85.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,12.84,,15.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.68,80,,98.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.69,12.84,,15.75,percent of total billed charges,12.84% of total billed charges,19.69,12.84,,15.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.68,65,,79.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.67,35,,42.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.02,90,,110.42,percent of total billed charges,90% of total billed charges for outpatient setting,19.69,138.02,
ENDOMETRIAL ABLATION SYS / MIN9770,69169707,CDM,272,RC,,,Outpatient,,,3150,3150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,70,,1764,percent of total billed charges,70% of total billed charges for outpatient setting,2673.72,84.88,,2138.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,1575,50,,1260,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2362.5,75,,1890,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,80,,2016,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2047.5,65,,1638,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,35,,882,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2835,90,,2268,percent of total billed charges,90% of total billed charges for outpatient setting,404.46,2835,
"ENDOMYSIAL ANTIBODY (EMA), EA IG CLASS",201097,CDM,302,RC,86231,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.81,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,35,,15.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,9.07,48.97,
ENDOPATH 10MM ANVIL GRASPER / 10AG,6153101,CDM,270,RC,,,Outpatient,,,325.88,325.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.12,70,,182.5,percent of total billed charges,70% of total billed charges for outpatient setting,276.61,84.88,,221.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,162.94,50,,130.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.41,75,,195.53,percent of total billed charges,75% of total billed charges for outpatient setting,228.12,70,,182.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.84,12.84,,33.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.7,80,,208.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.84,12.84,,33.47,percent of total billed charges,12.84% of total billed charges,41.84,12.84,,33.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,211.82,65,,169.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.06,35,,91.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,293.29,90,,234.63,percent of total billed charges,90% of total billed charges for outpatient setting,41.84,293.29,
ENDOSCOPIC APPLICATOR -SURGIFLO / MS1995,69162140,CDM,272,RC,,,Outpatient,,,282.8,282.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.96,70,,158.37,percent of total billed charges,70% of total billed charges for outpatient setting,240.04,84.88,,192.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,141.4,50,,113.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.1,75,,169.68,percent of total billed charges,75% of total billed charges for outpatient setting,197.96,70,,158.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.31,12.84,,29.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.24,80,,180.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.31,12.84,,29.05,percent of total billed charges,12.84% of total billed charges,36.31,12.84,,29.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.82,65,,147.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.98,35,,79.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,254.52,90,,203.62,percent of total billed charges,90% of total billed charges for outpatient setting,36.31,254.52,
ENDOSCOPIC CATHERIZATION OF THE BILIARY,2400695,CDM,320,RC,74328,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
ENDOSHEARS LONG 5X45CM / 174601,69162419,CDM,272,RC,,,Outpatient,,,962.1,962.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.47,70,,538.78,percent of total billed charges,70% of total billed charges for outpatient setting,816.63,84.88,,653.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,481.05,50,,384.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,721.58,75,,577.26,percent of total billed charges,75% of total billed charges for outpatient setting,673.47,70,,538.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.53,12.84,,98.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.68,80,,615.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.53,12.84,,98.82,percent of total billed charges,12.84% of total billed charges,123.53,12.84,,98.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,625.37,65,,500.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.74,35,,269.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,865.89,90,,692.71,percent of total billed charges,90% of total billed charges for outpatient setting,123.53,865.89,
ENDOSTITCH 10MM DEVICE / 173016,6153064,CDM,272,RC,,,Outpatient,,,1871.76,1871.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1310.23,70,,1048.18,percent of total billed charges,70% of total billed charges for outpatient setting,1588.75,84.88,,1271,percent of total billed charges,84.88% of total billed charges for outpatient setting,935.88,50,,748.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1403.82,75,,1123.06,percent of total billed charges,75% of total billed charges for outpatient setting,1310.23,70,,1048.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.33,12.84,,192.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.41,80,,1197.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.33,12.84,,192.26,percent of total billed charges,12.84% of total billed charges,240.33,12.84,,192.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1216.64,65,,973.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.12,35,,524.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1684.58,90,,1347.66,percent of total billed charges,90% of total billed charges for outpatient setting,240.33,1684.58,
ENDOSTITCH 2-0 SURGIDAC 7 / 173021,6153065,CDM,272,RC,,,Outpatient,,,105.91,105.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.14,70,,59.31,percent of total billed charges,70% of total billed charges for outpatient setting,89.9,84.88,,71.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.96,50,,42.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.43,75,,63.54,percent of total billed charges,75% of total billed charges for outpatient setting,74.14,70,,59.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.73,80,,67.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.84,65,,55.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.07,35,,29.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.32,90,,76.26,percent of total billed charges,90% of total billed charges for outpatient setting,13.6,95.32,
ENDOSTITCH 3-0 POLYSORB ES-9 / 170071,69169688,CDM,272,RC,,,Outpatient,,,27.2,27.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,23.09,84.88,,18.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.6,50,,10.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.4,75,,16.32,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,80,,17.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,65,,14.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,35,,7.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.48,90,,19.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,24.48,
ENDPLATE 11X12 6 DEG / 714.106S,69162488,CDM,278,RC,C1713,HCPCS,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,60,,3840,percent of total billed charges,60% of total Billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8400,105,,6720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4800,60,,3840,percent of total billed charges,60% of total billed charges for outpatient setting,1027.2,8400,
ENDPLATE 11X12 6DEG / 714.166S,70000109,CDM,278,RC,C1713,HCPCS,Outpatient,,,10000,10000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,60,,4800,percent of total billed charges,60% of total Billed charges for outpatient setting,8488,84.88,,6790.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7500,75,,6000,percent of total billed charges,75% of total billed charges for outpatient setting,5000,50,,4000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8000,80,,6400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10500,105,,8400,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,35,,2800,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6000,60,,4800,percent of total billed charges,60% of total billed charges for outpatient setting,1284,10500,
ENDPLATE 13X14 6DEG / 714.206S,69162164,CDM,278,RC,,,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,60,,3840,percent of total billed charges,60% of total Billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8400,105,,6720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4800,60,,3840,percent of total billed charges,60% of total billed charges for outpatient setting,1027.2,8400,
"ENDPLATE 13X14, 6mm, 6 deg  714.266S",69162089,CDM,278,RC,,,Outpatient,,,14000,14000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8400,60,,6720,percent of total billed charges,60% of total Billed charges for outpatient setting,11883.2,84.88,,9506.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,7000,50,,5600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10500,75,,8400,percent of total billed charges,75% of total billed charges for outpatient setting,7000,50,,5600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.6,12.84,,1438.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11200,80,,8960,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.6,12.84,,1438.08,percent of total billed charges,12.84% of total billed charges,1797.6,12.84,,1438.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14700,105,,11760,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4900,35,,3920,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8400,60,,6720,percent of total billed charges,60% of total billed charges for outpatient setting,1797.6,14700,
ENDPLATE 14MM LOWER / 351.351,69162629,CDM,278,RC,,,Outpatient,,,2384.71,2384.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.83,60,,1144.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2024.14,84.88,,1619.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1788.53,75,,1430.82,percent of total billed charges,75% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.77,80,,1526.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2503.95,105,,2003.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.65,35,,667.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1430.83,60,,1144.66,percent of total billed charges,60% of total billed charges for outpatient setting,306.2,2503.95,
ENDPLATE 14MM LOWER 3.5/ 351.353,69162939,CDM,278,RC,,,Outpatient,,,2384.71,2384.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.83,60,,1144.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2024.14,84.88,,1619.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1788.53,75,,1430.82,percent of total billed charges,75% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.77,80,,1526.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2503.95,105,,2003.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.65,35,,667.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1430.83,60,,1144.66,percent of total billed charges,60% of total billed charges for outpatient setting,306.2,2503.95,
ENDPLATE 14MM UPPER / 351.301,69162628,CDM,278,RC,,,Outpatient,,,2384.71,2384.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.83,60,,1144.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2024.14,84.88,,1619.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1788.53,75,,1430.82,percent of total billed charges,75% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.77,80,,1526.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2503.95,105,,2003.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.65,35,,667.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1430.83,60,,1144.66,percent of total billed charges,60% of total billed charges for outpatient setting,306.2,2503.95,
ENDPLATE 14MM UPPER/ 351.303,69162938,CDM,278,RC,,,Outpatient,,,2384.71,2384.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.83,60,,1144.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2024.14,84.88,,1619.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1788.53,75,,1430.82,percent of total billed charges,75% of total billed charges for outpatient setting,1192.36,50,,953.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.77,80,,1526.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,306.2,12.84,,244.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2503.95,105,,2003.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.65,35,,667.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1430.83,60,,1144.66,percent of total billed charges,60% of total billed charges for outpatient setting,306.2,2503.95,
ENDPLATE 14MM/25-30MM / 337.301,69169593,CDM,278,RC,C1821,HCPCS,Outpatient,,,2360,2360,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1416,60,,1132.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2003.17,84.88,,1602.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1770,75,,1416,percent of total billed charges,75% of total billed charges for outpatient setting,1180,50,,944,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.02,12.84,,242.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1888,80,,1510.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.02,12.84,,242.42,percent of total billed charges,12.84% of total billed charges,303.02,12.84,,242.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2478,105,,1982.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826,35,,660.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1416,60,,1132.8,percent of total billed charges,60% of total billed charges for outpatient setting,303.02,2478,
ENDPLATE 14x16  6 DEG / 714.306S,69162945,CDM,278,RC,,,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,60,,3840,percent of total billed charges,60% of total Billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8400,105,,6720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4800,60,,3840,percent of total billed charges,60% of total billed charges for outpatient setting,1027.2,8400,
ENOXAPARIN (genLOVENOX) 100MG/ML INJ,3302982,CDM,636,RC,J1650,HCPCS,Outpatient,,,104.74,104.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.32,70,,58.66,percent of total billed charges,70% of total billed charges for outpatient setting,88.9,84.88,,71.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.56,75,,62.85,percent of total billed charges,75% of total billed charges for outpatient setting,73.32,70,,58.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,12.84,,10.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.79,80,,67.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,12.84,,10.76,percent of total billed charges,12.84% of total billed charges,13.45,12.84,,10.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.08,65,,54.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,94.27,90,,75.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,94.27,
ENOXAPARIN (genLOVENOX) 120MG/0.8 ML INJ,3305845,CDM,636,RC,J1650,HCPCS,Outpatient,,,74.53,74.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.17,70,,41.74,percent of total billed charges,70% of total billed charges for outpatient setting,63.26,84.88,,50.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.9,75,,44.72,percent of total billed charges,75% of total billed charges for outpatient setting,52.17,70,,41.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.62,80,,47.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.44,65,,38.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,67.08,90,,53.66,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,67.08,
ENOXAPARIN (genLOVENOX)30MG/0.3ML INJ,3301007,CDM,636,RC,J1650,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
ENOXAPARIN (genLOVENOX)40MG/0.4ML INJ,3301008,CDM,636,RC,J1650,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
ENOXAPARIN (genLOVENOX)60MG/0.6ML INJ,3301009,CDM,636,RC,J1650,HCPCS,Outpatient,,,147.14,147.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103,70,,82.4,percent of total billed charges,70% of total billed charges for outpatient setting,124.89,84.88,,99.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,110.36,75,,88.29,percent of total billed charges,75% of total billed charges for outpatient setting,103,70,,82.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.71,80,,94.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.64,65,,76.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,132.43,90,,105.94,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,132.43,
ENOXAPARIN (genLOVENOX)80MG/0.8ML INJ,3303309,CDM,250,RC,J1650,HCPCS,Outpatient,,,83.79,83.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.65,70,,46.92,percent of total billed charges,70% of total billed charges for outpatient setting,71.12,84.88,,56.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.84,75,,50.27,percent of total billed charges,75% of total billed charges for outpatient setting,58.65,70,,46.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,12.84,,8.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.03,80,,53.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,12.84,,8.61,percent of total billed charges,12.84% of total billed charges,10.76,12.84,,8.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.46,65,,43.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,100,,,Fee Schedule,100% of Custom Fee Schedule,75.41,90,,60.33,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,75.41,
ENOXAPARIN (LOVENOX 100MG INJ):100MG/1ML,3302695,CDM,250,RC,,,Outpatient,,,236.27,236.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.39,70,,132.31,percent of total billed charges,70% of total billed charges for outpatient setting,200.55,84.88,,160.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.14,50,,94.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.2,75,,141.76,percent of total billed charges,75% of total billed charges for outpatient setting,165.39,70,,132.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.34,12.84,,24.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,80,,151.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.34,12.84,,24.27,percent of total billed charges,12.84% of total billed charges,30.34,12.84,,24.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.58,65,,122.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,212.64,90,,170.11,percent of total billed charges,90% of total billed charges for outpatient setting,30.34,212.64,
ENT 1 BILATERAL PROCEDURE,6100061,CDM,360,RC,,,Outpatient,,,2757.83,2757.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.48,70,,1544.38,percent of total billed charges,70% of total billed charges for outpatient setting,2340.85,84.88,,1872.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.92,50,,1103.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2068.37,75,,1654.7,percent of total billed charges,75% of total billed charges for outpatient setting,1930.48,70,,1544.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.11,12.84,,283.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2206.26,80,,1765.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.11,12.84,,283.29,percent of total billed charges,12.84% of total billed charges,354.11,12.84,,283.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,965.24,35,,772.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2482.05,90,,1985.64,percent of total billed charges,90% of total billed charges for outpatient setting,354.11,2482.05,
ENT 2 BILATERAL PROCEDURES,6100055,CDM,360,RC,,,Outpatient,,,4136.74,4136.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2895.72,70,,2316.58,percent of total billed charges,70% of total billed charges for outpatient setting,3511.26,84.88,,2809.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,2068.37,50,,1654.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3102.56,75,,2482.05,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.16,12.84,,424.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3309.39,80,,2647.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.16,12.84,,424.93,percent of total billed charges,12.84% of total billed charges,531.16,12.84,,424.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1447.86,35,,1158.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3723.07,90,,2978.46,percent of total billed charges,90% of total billed charges for outpatient setting,531.16,3723.07,
ENT 2 SURGICAL PROCEDURES,6100052,CDM,360,RC,,,Outpatient,,,2757.83,2757.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.48,70,,1544.38,percent of total billed charges,70% of total billed charges for outpatient setting,2340.85,84.88,,1872.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.92,50,,1103.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2068.37,75,,1654.7,percent of total billed charges,75% of total billed charges for outpatient setting,1930.48,70,,1544.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.11,12.84,,283.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2206.26,80,,1765.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.11,12.84,,283.29,percent of total billed charges,12.84% of total billed charges,354.11,12.84,,283.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,965.24,35,,772.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2482.05,90,,1985.64,percent of total billed charges,90% of total billed charges for outpatient setting,354.11,2482.05,
ENT 3 OR 4 BILAT PROCEDURES,6100056,CDM,360,RC,,,Outpatient,,,8111.25,8111.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5677.88,70,,4542.3,percent of total billed charges,70% of total billed charges for outpatient setting,6884.83,84.88,,5507.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,4055.63,50,,3244.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6083.44,75,,4866.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.48,12.84,,833.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489,80,,5191.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.48,12.84,,833.18,percent of total billed charges,12.84% of total billed charges,1041.48,12.84,,833.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2838.94,35,,2271.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7300.13,90,,5840.1,percent of total billed charges,90% of total billed charges for outpatient setting,1041.48,7300.13,
ENT 3 OR 4 PROCEDURES,6100053,CDM,360,RC,,,Outpatient,,,5407.5,5407.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3785.25,70,,3028.2,percent of total billed charges,70% of total billed charges for outpatient setting,4589.89,84.88,,3671.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,2703.75,50,,2163,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4055.63,75,,3244.5,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.32,12.84,,555.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4326,80,,3460.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.32,12.84,,555.46,percent of total billed charges,12.84% of total billed charges,694.32,12.84,,555.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1892.63,35,,1514.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4866.75,90,,3893.4,percent of total billed charges,90% of total billed charges for outpatient setting,694.32,4866.75,
ENT 5 OR MORE BILAT PROCEDURES,6100057,CDM,360,RC,,,Outpatient,,,12166.88,12166.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.82,70,,6813.46,percent of total billed charges,70% of total billed charges for outpatient setting,10327.25,84.88,,8261.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,6083.44,50,,4866.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9125.16,75,,7300.13,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.23,12.84,,1249.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9733.5,80,,7786.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.23,12.84,,1249.78,percent of total billed charges,12.84% of total billed charges,1562.23,12.84,,1249.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4258.41,35,,3406.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10950.19,90,,8760.15,percent of total billed charges,90% of total billed charges for outpatient setting,1562.23,10950.19,
ENT 5 OR MORE PROCEDURES,6100054,CDM,360,RC,,,Outpatient,,,8111.25,8111.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5677.88,70,,4542.3,percent of total billed charges,70% of total billed charges for outpatient setting,6884.83,84.88,,5507.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,4055.63,50,,3244.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6083.44,75,,4866.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.48,12.84,,833.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489,80,,5191.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.48,12.84,,833.18,percent of total billed charges,12.84% of total billed charges,1041.48,12.84,,833.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2838.94,35,,2271.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7300.13,90,,5840.1,percent of total billed charges,90% of total billed charges for outpatient setting,1041.48,7300.13,
ENT MICRODEBRIDER AGRESSIVE/290-638-000,6152910,CDM,272,RC,,,Outpatient,,,454.21,454.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.95,70,,254.36,percent of total billed charges,70% of total billed charges for outpatient setting,385.53,84.88,,308.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,227.11,50,,181.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.66,75,,272.53,percent of total billed charges,75% of total billed charges for outpatient setting,317.95,70,,254.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.37,80,,290.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,295.24,65,,236.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.97,35,,127.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,408.79,90,,327.03,percent of total billed charges,90% of total billed charges for outpatient setting,58.32,408.79,
ENT MICROSCOPE BULB ZEISS S21/8380079-90,6152606,CDM,270,RC,,,Outpatient,,,67.69,67.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.38,70,,37.9,percent of total billed charges,70% of total billed charges for outpatient setting,57.46,84.88,,45.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.85,50,,27.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.77,75,,40.62,percent of total billed charges,75% of total billed charges for outpatient setting,47.38,70,,37.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,12.84,,6.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.15,80,,43.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,12.84,,6.95,percent of total billed charges,12.84% of total billed charges,8.69,12.84,,6.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44,65,,35.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.69,35,,18.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.92,90,,48.74,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,60.92,
ENT TIER 1 OR TIME,6100111,CDM,360,RC,,,Outpatient,,,5000,5000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,70,,2800,percent of total billed charges,70% of total billed charges for outpatient setting,4244,84.88,,3395.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750,75,,3000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4000,80,,3200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,35,,1400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4500,90,,3600,percent of total billed charges,90% of total billed charges for outpatient setting,642,4500,
ENT TIER 2 OR TIME,6100112,CDM,360,RC,,,Outpatient,,,7500,7500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,70,,4200,percent of total billed charges,70% of total billed charges for outpatient setting,6366,84.88,,5092.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,3750,50,,3000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5625,75,,4500,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963,12.84,,770.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,80,,4800,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963,12.84,,770.4,percent of total billed charges,12.84% of total billed charges,963,12.84,,770.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625,35,,2100,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6750,90,,5400,percent of total billed charges,90% of total billed charges for outpatient setting,963,6750,
ENT TIER 3 OR TIME,6100113,CDM,360,RC,,,Outpatient,,,10000,10000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7000,70,,5600,percent of total billed charges,70% of total billed charges for outpatient setting,8488,84.88,,6790.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,5000,50,,4000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7500,75,,6000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8000,80,,6400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,35,,2800,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9000,90,,7200,percent of total billed charges,90% of total billed charges for outpatient setting,1284,9000,
ENTEROCLYSIS,2400635,CDM,320,RC,74251,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
ENTEROVIRUS PANEL II,201428,CDM,302,RC,86658,HCPCS,Outpatient,,,58.64,52.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,49.77,84.88,,39.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.98,75,,35.18,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.91,80,,37.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,100,,,Fee Schedule,100% of Custom Fee Schedule,52.78,90,,42.22,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,52.78,
ENVELOPE 2.7X2.5IN MED / NMRM6122,1857222,CDM,278,RC,C1820,HCPCS,Outpatient,,,2990,2990,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794,60,,1435.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.91,84.88,,2030.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.5,75,,1794,percent of total billed charges,75% of total billed charges for outpatient setting,1495,50,,1196,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392,80,,1913.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.5,105,,2511.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.5,35,,837.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794,60,,1435.2,percent of total billed charges,60% of total billed charges for outpatient setting,383.92,3139.5,
"ENZM ACTIVITY NONRADIOACT, EA SPCIMEN",201490,CDM,301,RC,82657,HCPCS,Outpatient,,,99.77,89.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.84,70,,55.87,percent of total billed charges,70% of total billed charges for outpatient setting,84.68,84.88,,67.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,74.83,75,,59.86,percent of total billed charges,75% of total billed charges for outpatient setting,69.84,70,,55.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.82,80,,63.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,89.79,90,,71.83,percent of total billed charges,90% of total billed charges for outpatient setting,22.17,89.79,
ENZYMATIC CARBONATE (CO2),200475,CDM,300,RC,82374,HCPCS,Outpatient,,,21.96,19.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,84.88,,14.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.47,75,,13.18,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.57,80,,14.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,19.76,90,,15.81,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,19.76,
ENZYMATIC CARBONATE CO2,201155,CDM,300,RC,82374,HCPCS,Outpatient,,,21.96,19.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,84.88,,14.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.47,75,,13.18,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.57,80,,14.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,19.76,90,,15.81,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,19.76,
"EOSINOPHIL COUNT,NASAL",202152,CDM,310,RC,89190,HCPCS,Outpatient,,,26.06,23.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,70,,14.59,percent of total billed charges,70% of total billed charges for outpatient setting,22.12,84.88,,17.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.55,75,,15.64,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,70,,14.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.85,80,,16.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,100,,,Fee Schedule,100% of Custom Fee Schedule,23.45,90,,18.76,percent of total billed charges,90% of total billed charges for outpatient setting,5.79,23.45,
"EOSINOPHIL SMEAR, URINE",201138,CDM,300,RC,89050,HCPCS,Outpatient,,,21.24,19.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.87,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,18.03,84.88,,14.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.93,75,,12.74,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,70,,11.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.99,80,,13.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.9,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,100,,,Fee Schedule,100% of Custom Fee Schedule,19.12,90,,15.3,percent of total billed charges,90% of total billed charges for outpatient setting,4.72,19.12,
EP EVAL WITH TESTING OF SING/DUAL AICD,6100098,CDM,480,RC,93641,HCPCS,Outpatient,,,2394.83,2394.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,2032.73,84.88,,1626.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1796.12,75,,1436.9,percent of total billed charges,75% of total billed charges for outpatient setting,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.86,80,,1532.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2155.35,90,,1724.28,percent of total billed charges,90% of total billed charges for outpatient setting,307.5,2155.35,
EPHEDRINE 50MG/5ML SYRINGE,3309723,CDM,250,RC,,,Outpatient,,,105,105,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,58.8,percent of total billed charges,70% of total billed charges for outpatient setting,89.12,84.88,,71.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.5,50,,42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.75,75,,63,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,70,,58.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,12.84,,10.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,80,,67.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,12.84,,10.78,percent of total billed charges,12.84% of total billed charges,13.48,12.84,,10.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.25,65,,54.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,35,,29.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.5,90,,75.6,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,94.5,
EPHEDRINE 50MG/ML 1 ML VIAL,3302674,CDM,250,RC,,,Outpatient,,,78.79,78.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,70,,44.12,percent of total billed charges,70% of total billed charges for outpatient setting,66.88,84.88,,53.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.4,50,,31.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.09,75,,47.27,percent of total billed charges,75% of total billed charges for outpatient setting,55.15,70,,44.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,12.84,,8.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.03,80,,50.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,10.12,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.21,65,,40.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.58,35,,22.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.91,90,,56.73,percent of total billed charges,90% of total billed charges for outpatient setting,10.12,70.91,
EPI DISC  DUAL PK / 1417100,69162049,CDM,270,RC,,,Outpatient,,,339.88,339.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.92,70,,190.34,percent of total billed charges,70% of total billed charges for outpatient setting,288.49,84.88,,230.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,169.94,50,,135.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.91,75,,203.93,percent of total billed charges,75% of total billed charges for outpatient setting,237.92,70,,190.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,12.84,,34.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.9,80,,217.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,12.84,,34.91,percent of total billed charges,12.84% of total billed charges,43.64,12.84,,34.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,220.92,65,,176.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,35,,95.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,305.89,90,,244.71,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,305.89,
EPI DISC TM PERFORATD PTCH / 1417151,6152962,CDM,270,RC,,,Outpatient,,,654.09,654.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.86,70,,366.29,percent of total billed charges,70% of total billed charges for outpatient setting,555.19,84.88,,444.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,327.05,50,,261.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,490.57,75,,392.46,percent of total billed charges,75% of total billed charges for outpatient setting,457.86,70,,366.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.99,12.84,,67.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.27,80,,418.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.99,12.84,,67.19,percent of total billed charges,12.84% of total billed charges,83.99,12.84,,67.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,425.16,65,,340.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.93,35,,183.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,588.68,90,,470.94,percent of total billed charges,90% of total billed charges for outpatient setting,83.99,588.68,
EPI-FILM / 1417000,6150692,CDM,270,RC,,,Outpatient,,,863.44,863.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.41,70,,483.53,percent of total billed charges,70% of total billed charges for outpatient setting,732.89,84.88,,586.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,431.72,50,,345.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.58,75,,518.06,percent of total billed charges,75% of total billed charges for outpatient setting,604.41,70,,483.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.87,12.84,,88.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,690.75,80,,552.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.87,12.84,,88.7,percent of total billed charges,12.84% of total billed charges,110.87,12.84,,88.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,561.24,65,,448.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.2,35,,241.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,777.1,90,,621.68,percent of total billed charges,90% of total billed charges for outpatient setting,110.87,777.1,
EPINEPHRIN (ADRENALIN)  VIAL1MG/ML : 1ML,3301013,CDM,250,RC,,,Outpatient,,,110.45,110.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,93.75,84.88,,75,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.23,50,,44.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.84,75,,66.27,percent of total billed charges,75% of total billed charges for outpatient setting,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.36,80,,70.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.79,65,,57.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,35,,30.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.41,90,,79.53,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,99.41,
EPINEPHRINE  INJ 1MG/ML  30ML 5ml ud/chg,3301011,CDM,250,RC,,,Outpatient,,,169,169,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.3,70,,94.64,percent of total billed charges,70% of total billed charges for outpatient setting,143.45,84.88,,114.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.5,50,,67.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.75,75,,101.4,percent of total billed charges,75% of total billed charges for outpatient setting,118.3,70,,94.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,12.84,,17.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.2,80,,108.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,12.84,,17.36,percent of total billed charges,12.84% of total billed charges,21.7,12.84,,17.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.85,65,,87.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.15,35,,47.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.1,90,,121.68,percent of total billed charges,90% of total billed charges for outpatient setting,21.7,152.1,
EPINEPHRINE (ADRENALIN) NASAL 0.1%:30ML,3301015,CDM,259,RC,,,Outpatient,,,53.52,53.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.46,70,,29.97,percent of total billed charges,70% of total billed charges for outpatient setting,45.43,84.88,,36.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.76,50,,21.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.14,75,,32.11,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,70,,29.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.87,12.84,,5.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.82,80,,34.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.87,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,6.87,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.79,65,,27.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,35,,14.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.17,90,,38.54,percent of total billed charges,90% of total billed charges for outpatient setting,6.87,48.17,
EPINEPHRINE (ADRENALIN)1MG/1ML VIAL,3301014,CDM,250,RC,,,Outpatient,,,100.37,100.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.26,70,,56.21,percent of total billed charges,70% of total billed charges for outpatient setting,85.19,84.88,,68.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.19,50,,40.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.28,75,,60.22,percent of total billed charges,75% of total billed charges for outpatient setting,70.26,70,,56.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.3,80,,64.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.24,65,,52.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.13,35,,28.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.33,90,,72.26,percent of total billed charges,90% of total billed charges for outpatient setting,12.89,90.33,
EPINEPHRINE (ADRENALIN)INJ 0.1MG/ML 10ML,3301016,CDM,250,RC,,,Outpatient,,,42.62,42.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,84.88,,28.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.31,50,,17.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.97,75,,25.58,percent of total billed charges,75% of total billed charges for outpatient setting,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,80,,27.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.7,65,,22.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.92,35,,11.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.36,90,,30.69,percent of total billed charges,90% of total billed charges for outpatient setting,5.47,38.36,
EPINEPHRINE (EPINEPHRNE) INJ 50MG/ML:1ML,3301010,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
EPINEPHRINE (EPIPEN)INJ 0.15MG : JR,3301019,CDM,250,RC,,,Outpatient,,,137.62,137.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.33,70,,77.06,percent of total billed charges,70% of total billed charges for outpatient setting,116.81,84.88,,93.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.81,50,,55.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.22,75,,82.58,percent of total billed charges,75% of total billed charges for outpatient setting,96.33,70,,77.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,12.84,,14.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.1,80,,88.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,17.67,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.45,65,,71.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.17,35,,38.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.86,90,,99.09,percent of total billed charges,90% of total billed charges for outpatient setting,17.67,123.86,
EPINEPHRINE (genEPIPEN) 0.3MG INJECTOR,3301020,CDM,250,RC,,,Outpatient,,,540.94,540.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.66,70,,302.93,percent of total billed charges,70% of total billed charges for outpatient setting,459.15,84.88,,367.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,270.47,50,,216.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.71,75,,324.57,percent of total billed charges,75% of total billed charges for outpatient setting,378.66,70,,302.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.46,12.84,,55.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.75,80,,346.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.46,12.84,,55.57,percent of total billed charges,12.84% of total billed charges,69.46,12.84,,55.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.61,65,,281.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.33,35,,151.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,486.85,90,,389.48,percent of total billed charges,90% of total billed charges for outpatient setting,69.46,486.85,
EPINEPHRINE (GLAUCON) OPTH SOL : 10ML,3301017,CDM,259,RC,,,Outpatient,,,79.23,79.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.46,70,,44.37,percent of total billed charges,70% of total billed charges for outpatient setting,67.25,84.88,,53.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.62,50,,31.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.42,75,,47.54,percent of total billed charges,75% of total billed charges for outpatient setting,55.46,70,,44.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,12.84,,8.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.38,80,,50.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,12.84,,8.14,percent of total billed charges,12.84% of total billed charges,10.17,12.84,,8.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.5,65,,41.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.73,35,,22.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.31,90,,57.05,percent of total billed charges,90% of total billed charges for outpatient setting,10.17,71.31,
EPINEPHRINE 1:1000 SULFITE FREE 1ML:AMP,3303312,CDM,250,RC,,,Outpatient,,,41.54,41.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.08,70,,23.26,percent of total billed charges,70% of total billed charges for outpatient setting,35.26,84.88,,28.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.77,50,,16.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.16,75,,24.93,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,70,,23.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,12.84,,4.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.23,80,,26.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,12.84,,4.26,percent of total billed charges,12.84% of total billed charges,5.33,12.84,,4.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27,65,,21.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.54,35,,11.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.39,90,,29.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,37.39,
EPINEPHRINE INJ 1MG/ML : 30ML,3301012,CDM,250,RC,,,Outpatient,,,16.18,16.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.33,70,,9.06,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,84.88,,10.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.09,50,,6.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.14,75,,9.71,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,70,,9.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,80,,10.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.52,65,,8.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,35,,4.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.56,90,,11.65,percent of total billed charges,90% of total billed charges for outpatient setting,2.08,14.56,
EPINEPHRINE intraOCULAR 1MG/ML AMP,3313729,CDM,250,RC,,,Outpatient,,,79.75,79.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.83,70,,44.66,percent of total billed charges,70% of total billed charges for outpatient setting,67.69,84.88,,54.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.88,50,,31.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.81,75,,47.85,percent of total billed charges,75% of total billed charges for outpatient setting,55.83,70,,44.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.24,12.84,,8.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.8,80,,51.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.24,12.84,,8.19,percent of total billed charges,12.84% of total billed charges,10.24,12.84,,8.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.84,65,,41.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.91,35,,22.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.78,90,,57.42,percent of total billed charges,90% of total billed charges for outpatient setting,10.24,71.78,
EPOETIN (EPOGEN) 10000U INJ : 1 ML,3301028,CDM,250,RC,,,Outpatient,,,349.24,349.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.47,70,,195.58,percent of total billed charges,70% of total billed charges for outpatient setting,296.43,84.88,,237.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,174.62,50,,139.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.93,75,,209.54,percent of total billed charges,75% of total billed charges for outpatient setting,244.47,70,,195.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.84,12.84,,35.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.39,80,,223.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.84,12.84,,35.87,percent of total billed charges,12.84% of total billed charges,44.84,12.84,,35.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,227.01,65,,181.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,35,,97.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,314.32,90,,251.46,percent of total billed charges,90% of total billed charges for outpatient setting,44.84,314.32,
EPOETIN (EPOGEN) 20000U INJ: 1ML,3301030,CDM,250,RC,,,Outpatient,,,709.19,709.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.43,70,,397.14,percent of total billed charges,70% of total billed charges for outpatient setting,601.96,84.88,,481.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,354.6,50,,283.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.89,75,,425.51,percent of total billed charges,75% of total billed charges for outpatient setting,496.43,70,,397.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.06,12.84,,72.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.35,80,,453.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.06,12.84,,72.85,percent of total billed charges,12.84% of total billed charges,91.06,12.84,,72.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,460.97,65,,368.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.22,35,,198.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,638.27,90,,510.62,percent of total billed charges,90% of total billed charges for outpatient setting,91.06,638.27,
EPOETIN (EPOGEN) 2000U INJ : 1 ML,3301023,CDM,250,RC,,,Outpatient,,,67.26,67.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,57.09,84.88,,45.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.63,50,,26.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.45,75,,40.36,percent of total billed charges,75% of total billed charges for outpatient setting,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.81,80,,43.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.72,65,,34.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.54,35,,18.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.53,90,,48.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.64,60.53,
EPOETIN (EPOGEN) 3000U INJ : 1 ML,3301025,CDM,250,RC,,,Outpatient,,,104.8,104.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.36,70,,58.69,percent of total billed charges,70% of total billed charges for outpatient setting,88.95,84.88,,71.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.4,50,,41.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.6,75,,62.88,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,70,,58.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,12.84,,10.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.84,80,,67.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,12.84,,10.77,percent of total billed charges,12.84% of total billed charges,13.46,12.84,,10.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.12,65,,54.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.68,35,,29.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.32,90,,75.46,percent of total billed charges,90% of total billed charges for outpatient setting,13.46,94.32,
EPOETIN (EPOGEN) 4000U INJ : 1 ML,3301026,CDM,250,RC,,,Outpatient,,,134.45,134.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.12,70,,75.3,percent of total billed charges,70% of total billed charges for outpatient setting,114.12,84.88,,91.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.23,50,,53.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.84,75,,80.67,percent of total billed charges,75% of total billed charges for outpatient setting,94.12,70,,75.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.26,12.84,,13.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.56,80,,86.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.26,12.84,,13.81,percent of total billed charges,12.84% of total billed charges,17.26,12.84,,13.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.39,65,,69.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.06,35,,37.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.01,90,,96.81,percent of total billed charges,90% of total billed charges for outpatient setting,17.26,121.01,
EPOETIN (PROCRIT) 20000U INJ : 1 ML,3301029,CDM,250,RC,,,Outpatient,,,672.25,672.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.58,70,,376.46,percent of total billed charges,70% of total billed charges for outpatient setting,570.61,84.88,,456.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,336.13,50,,268.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504.19,75,,403.35,percent of total billed charges,75% of total billed charges for outpatient setting,470.58,70,,376.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.32,12.84,,69.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.8,80,,430.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.32,12.84,,69.06,percent of total billed charges,12.84% of total billed charges,86.32,12.84,,69.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.96,65,,349.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.29,35,,188.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,605.03,90,,484.02,percent of total billed charges,90% of total billed charges for outpatient setting,86.32,605.03,
EPOETIN (PROCRIT) INJ 10000U :1 ML,3301027,CDM,250,RC,,,Outpatient,,,336.15,336.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.31,70,,188.25,percent of total billed charges,70% of total billed charges for outpatient setting,285.32,84.88,,228.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,168.08,50,,134.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.11,75,,201.69,percent of total billed charges,75% of total billed charges for outpatient setting,235.31,70,,188.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.16,12.84,,34.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.92,80,,215.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.16,12.84,,34.53,percent of total billed charges,12.84% of total billed charges,43.16,12.84,,34.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,218.5,65,,174.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.65,35,,94.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.54,90,,242.03,percent of total billed charges,90% of total billed charges for outpatient setting,43.16,302.54,
EPOETIN (PROCRIT) INJ 2000U : 1 ML,3301021,CDM,250,RC,,,Outpatient,,,66.79,66.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.75,70,,37.4,percent of total billed charges,70% of total billed charges for outpatient setting,56.69,84.88,,45.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.4,50,,26.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.09,75,,40.07,percent of total billed charges,75% of total billed charges for outpatient setting,46.75,70,,37.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,12.84,,6.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,80,,42.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,8.58,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.41,65,,34.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.38,35,,18.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.11,90,,48.09,percent of total billed charges,90% of total billed charges for outpatient setting,8.58,60.11,
EPOETIN (PROCRIT) INJ 3000U : 1 ML,3301022,CDM,250,RC,,,Outpatient,,,108.05,108.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.64,70,,60.51,percent of total billed charges,70% of total billed charges for outpatient setting,91.71,84.88,,73.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.03,50,,43.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.04,75,,64.83,percent of total billed charges,75% of total billed charges for outpatient setting,75.64,70,,60.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.87,12.84,,11.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.44,80,,69.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.87,12.84,,11.1,percent of total billed charges,12.84% of total billed charges,13.87,12.84,,11.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.23,65,,56.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.82,35,,30.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.25,90,,77.8,percent of total billed charges,90% of total billed charges for outpatient setting,13.87,97.25,
EPOETIN (PROCRIT) INJ 4000U : 1 ML,3301024,CDM,250,RC,,,Outpatient,,,161.58,161.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.11,70,,90.49,percent of total billed charges,70% of total billed charges for outpatient setting,137.15,84.88,,109.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.79,50,,64.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.19,75,,96.95,percent of total billed charges,75% of total billed charges for outpatient setting,113.11,70,,90.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.75,12.84,,16.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.26,80,,103.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.75,12.84,,16.6,percent of total billed charges,12.84% of total billed charges,20.75,12.84,,16.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.03,65,,84.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.55,35,,45.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.42,90,,116.34,percent of total billed charges,90% of total billed charges for outpatient setting,20.75,145.42,
EPOETIN (RETACRIT) INJ 4000U  1ML,3302923,CDM,250,RC,Q5106,HCPCS,Outpatient,,,181.84,181.84,,13,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,127.29,70,,101.83,percent of total billed charges,70% of total billed charges for outpatient setting,154.35,84.88,,123.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,136.38,75,,109.1,percent of total billed charges,75% of total billed charges for outpatient setting,127.29,70,,101.83,percent of total billed charges,70% of total billed charges for outpatient setting,13.82,170,,,Fee Schedule,170% of Medicare OPPS rate,17.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.35,12.84,,18.68,percent of total billed charges,12.84% of total billed charges,14.22,175,,,Fee Schedule,175% of Medicare OPPS rate,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,145.47,80,,116.38,percent of total billed charges,80% of total billed charges for outpatient setting,11.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,10.16,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.35,12.84,,18.68,percent of total billed charges,12.84% of total billed charges,23.35,12.84,,18.68,percent of total billed charges,12.84% of total billed charges,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,118.2,65,,94.56,percent of total billed charges,65% of total billed charges for outpatient setting,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.27,100,,,Fee Schedule,100% of Custom Fee Schedule,163.66,90,,130.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.13,163.66,
"EPOETIN ALFA (PROCRIT): 10,000 U/ML",3303077,CDM,636,RC,J0885,HCPCS,Outpatient,,,446.66,446.66,,13.39,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,312.66,70,,250.13,percent of total billed charges,70% of total billed charges for outpatient setting,379.13,84.88,,303.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,335,75,,268,percent of total billed charges,75% of total billed charges for outpatient setting,312.66,70,,250.13,percent of total billed charges,70% of total billed charges for outpatient setting,14.22,170,,,Fee Schedule,170% of Medicare OPPS rate,17.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,57.35,12.84,,45.88,percent of total billed charges,12.84% of total billed charges,14.64,175,,,Fee Schedule,175% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,357.33,80,,285.86,percent of total billed charges,80% of total billed charges for outpatient setting,11.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,10.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,57.35,12.84,,45.88,percent of total billed charges,12.84% of total billed charges,57.35,12.84,,45.88,percent of total billed charges,12.84% of total billed charges,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,290.33,65,,232.26,percent of total billed charges,65% of total billed charges for outpatient setting,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.54,100,,,Fee Schedule,100% of Custom Fee Schedule,401.99,90,,321.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.36,401.99,
EPOETIN ALFA (PROCRIT): 2000 U/ML,3303011,CDM,636,RC,J0885,HCPCS,Outpatient,,,128.53,128.53,,13.39,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.97,70,,71.98,percent of total billed charges,70% of total billed charges for outpatient setting,109.1,84.88,,87.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,96.4,75,,77.12,percent of total billed charges,75% of total billed charges for outpatient setting,89.97,70,,71.98,percent of total billed charges,70% of total billed charges for outpatient setting,14.22,170,,,Fee Schedule,170% of Medicare OPPS rate,17.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,16.5,12.84,,13.2,percent of total billed charges,12.84% of total billed charges,14.64,175,,,Fee Schedule,175% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.82,80,,82.26,percent of total billed charges,80% of total billed charges for outpatient setting,11.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,10.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,16.5,12.84,,13.2,percent of total billed charges,12.84% of total billed charges,16.5,12.84,,13.2,percent of total billed charges,12.84% of total billed charges,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.54,65,,66.83,percent of total billed charges,65% of total billed charges for outpatient setting,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.54,100,,,Fee Schedule,100% of Custom Fee Schedule,115.68,90,,92.54,percent of total billed charges,90% of total billed charges for outpatient setting,8.36,115.68,
EPOETIN ALFA (PROCRIT): 3000 U/ML,3303012,CDM,636,RC,J0885,HCPCS,Outpatient,,,192.79,192.79,,13.39,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,163.64,84.88,,130.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144.59,75,,115.67,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,14.22,170,,,Fee Schedule,170% of Medicare OPPS rate,17.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,24.75,12.84,,19.8,percent of total billed charges,12.84% of total billed charges,14.64,175,,,Fee Schedule,175% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,154.23,80,,123.38,percent of total billed charges,80% of total billed charges for outpatient setting,11.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,10.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,24.75,12.84,,19.8,percent of total billed charges,12.84% of total billed charges,24.75,12.84,,19.8,percent of total billed charges,12.84% of total billed charges,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.31,65,,100.25,percent of total billed charges,65% of total billed charges for outpatient setting,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.54,100,,,Fee Schedule,100% of Custom Fee Schedule,173.51,90,,138.81,percent of total billed charges,90% of total billed charges for outpatient setting,8.36,173.51,
EPSTEIN BARR VIRUS VIRAL CAPSID IGG,201533,CDM,300,RC,86665,HCPCS,Outpatient,,,81.63,73.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,69.29,84.88,,55.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,61.22,75,,48.98,percent of total billed charges,75% of total billed charges for outpatient setting,57.14,70,,45.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,80,,52.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.8,100,,,Fee Schedule,100% of Custom Fee Schedule,73.47,90,,58.78,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,73.47,
EPSTEIN-BARR VIRUS EARLY ANTIGEN IGG,201530,CDM,300,RC,86663,HCPCS,Outpatient,,,59.04,53.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.33,70,,33.06,percent of total billed charges,70% of total billed charges for outpatient setting,50.11,84.88,,40.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.28,75,,35.42,percent of total billed charges,75% of total billed charges for outpatient setting,41.33,70,,33.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.23,80,,37.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.16,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.88,100,,,Fee Schedule,100% of Custom Fee Schedule,53.14,90,,42.51,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,53.14,
EPSTIEN BARR VIRUS NUCLEAR ANTIGEN IGG,201532,CDM,300,RC,86664,HCPCS,Outpatient,,,68.81,61.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,58.41,84.88,,46.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.61,75,,41.29,percent of total billed charges,75% of total billed charges for outpatient setting,48.17,70,,38.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.05,80,,44.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.01,100,,,Fee Schedule,100% of Custom Fee Schedule,61.93,90,,49.54,percent of total billed charges,90% of total billed charges for outpatient setting,15.29,61.93,
EPTIFIBATIDE (INTEGRILIN) INJ: 20 MG,3301031,CDM,636,RC,J1327,HCPCS,Outpatient,,,297.12,297.12,,2.99,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,207.98,70,,166.38,percent of total billed charges,70% of total billed charges for outpatient setting,252.2,84.88,,201.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,222.84,75,,178.27,percent of total billed charges,75% of total billed charges for outpatient setting,207.98,70,,166.38,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,170,,,Fee Schedule,170% of Medicare OPPS rate,4.01,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.15,12.84,,30.52,percent of total billed charges,12.84% of total billed charges,3.27,175,,,Fee Schedule,175% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.7,80,,190.16,percent of total billed charges,80% of total billed charges for outpatient setting,2.61,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,2.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.15,12.84,,30.52,percent of total billed charges,12.84% of total billed charges,38.15,12.84,,30.52,percent of total billed charges,12.84% of total billed charges,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193.13,65,,154.5,percent of total billed charges,65% of total billed charges for outpatient setting,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33,100,,,Fee Schedule,100% of Custom Fee Schedule,267.41,90,,213.93,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,267.41,
EPTIFIBATIDE (INTEGRILIN) INJ: 75 MG,3301032,CDM,636,RC,J1327,HCPCS,Outpatient,,,929.85,929.85,,2.99,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,650.9,70,,520.72,percent of total billed charges,70% of total billed charges for outpatient setting,789.26,84.88,,631.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,697.39,75,,557.91,percent of total billed charges,75% of total billed charges for outpatient setting,650.9,70,,520.72,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,170,,,Fee Schedule,170% of Medicare OPPS rate,4.01,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,119.39,12.84,,95.512,percent of total billed charges,12.84% of total billed charges,3.27,175,,,Fee Schedule,175% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,743.88,80,,595.1,percent of total billed charges,80% of total billed charges for outpatient setting,2.61,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,2.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,119.39,12.84,,95.51,percent of total billed charges,12.84% of total billed charges,119.39,12.84,,95.51,percent of total billed charges,12.84% of total billed charges,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,604.4,65,,483.52,percent of total billed charges,65% of total billed charges for outpatient setting,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33,100,,,Fee Schedule,100% of Custom Fee Schedule,836.87,90,,669.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,836.87,
ERTAPENEM (genericINVANZ) 1 GM VIAL,3302716,CDM,636,RC,J1335,HCPCS,Outpatient,,,144.1,144.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.87,70,,80.7,percent of total billed charges,70% of total billed charges for outpatient setting,122.31,84.88,,97.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,108.08,75,,86.46,percent of total billed charges,75% of total billed charges for outpatient setting,100.87,70,,80.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.28,80,,92.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.67,65,,74.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of Custom Fee Schedule,129.69,90,,103.75,percent of total billed charges,90% of total billed charges for outpatient setting,18.5,129.69,
ERYTHROMYCIN (E.E.S.)SUSP 200/5ML:100ML,3301036,CDM,259,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,9.34,84.88,,7.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.5,50,,4.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.25,75,,6.6,percent of total billed charges,75% of total billed charges for outpatient setting,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,80,,7.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.15,65,,5.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,35,,3.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.9,90,,7.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,9.9,
ERYTHROMYCIN (EMYCIN) OINT 5MG/ML:3.5GM,3301033,CDM,259,RC,,,Outpatient,,,11.99,11.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,70,,6.71,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,84.88,,8.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,6,50,,4.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.99,75,,7.19,percent of total billed charges,75% of total billed charges for outpatient setting,8.39,70,,6.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,80,,7.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.79,65,,6.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,35,,3.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.79,90,,8.63,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.79,
ERYTHROMYCIN (ERY-TAB) TAB: 250 MG,3301034,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ERYTHROMYCIN BASE TAB:250MG UD,3301035,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ERYTHROMYCIN ETHYSUCCINATE 400MG/5ML:SUS,3303156,CDM,259,RC,,,Outpatient,,,29.2,29.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.44,70,,16.35,percent of total billed charges,70% of total billed charges for outpatient setting,24.78,84.88,,19.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.6,50,,11.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.9,75,,17.52,percent of total billed charges,75% of total billed charges for outpatient setting,20.44,70,,16.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.36,80,,18.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.98,65,,15.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.22,35,,8.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.28,90,,21.02,percent of total billed charges,90% of total billed charges for outpatient setting,3.75,26.28,
ERYTHROMYCIN L(ERYTHROMYCIN) INJ:1000GM,3301038,CDM,636,RC,J1364,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,70,,17.36,percent of total billed charges,70% of total billed charges for outpatient setting,26.31,84.88,,21.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.25,75,,18.6,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,70,,17.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,12.84,,3.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.8,80,,19.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,3.98,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.15,65,,16.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.14,100,,,Fee Schedule,100% of Custom Fee Schedule,27.9,90,,22.32,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,84.9,
ERYTHROMYCIN LACT (ERYTHROCIN) 500mg INJ,3301037,CDM,636,RC,J1364,HCPCS,Outpatient,,,290.29,290.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.2,70,,162.56,percent of total billed charges,70% of total billed charges for outpatient setting,246.4,84.88,,197.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,217.72,75,,174.18,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,70,,162.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.27,12.84,,29.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,80,,185.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.27,12.84,,29.82,percent of total billed charges,12.84% of total billed charges,37.27,12.84,,29.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,188.69,65,,150.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.14,100,,,Fee Schedule,100% of Custom Fee Schedule,261.26,90,,209.01,percent of total billed charges,90% of total billed charges for outpatient setting,37.27,261.26,
ERYTHROMYCIN OPHTH OINT 3.5GM TUBE,3313350,CDM,259,RC,,,Outpatient,,,45.52,45.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.86,70,,25.49,percent of total billed charges,70% of total billed charges for outpatient setting,38.64,84.88,,30.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.76,50,,18.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.14,75,,27.31,percent of total billed charges,75% of total billed charges for outpatient setting,31.86,70,,25.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.42,80,,29.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.59,65,,23.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,35,,12.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.97,90,,32.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.84,40.97,
ERYTHROPOIETIN,202561,CDM,301,RC,82668,HCPCS,Outpatient,,,84.56,76.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.19,70,,47.35,percent of total billed charges,70% of total billed charges for outpatient setting,71.77,84.88,,57.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,63.42,75,,50.74,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,70,,47.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.65,80,,54.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,100,,,Fee Schedule,100% of Custom Fee Schedule,76.1,90,,60.88,percent of total billed charges,90% of total billed charges for outpatient setting,18.79,76.1,
ESCITALOPRAM (genericLEXAPRO) 10 MG TAB,3303047,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ESCITALOPRAM (genericLEXAPRO) 20 MG TAB,3302996,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ESMARK 3X9 LTX FREE // DYNJ05914,69162495,CDM,272,RC,,,Outpatient,,,16.64,16.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.65,70,,9.32,percent of total billed charges,70% of total billed charges for outpatient setting,14.12,84.88,,11.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.32,50,,6.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.48,75,,9.98,percent of total billed charges,75% of total billed charges for outpatient setting,11.65,70,,9.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,80,,10.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.82,65,,8.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,35,,4.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.98,90,,11.98,percent of total billed charges,90% of total billed charges for outpatient setting,2.14,14.98,
ESMARK 4X9 LTX FREE / 820-3409,69159902,CDM,272,RC,,,Outpatient,,,17.64,17.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,14.97,84.88,,11.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.82,50,,7.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.23,75,,10.58,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,80,,11.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.47,65,,9.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,35,,4.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.88,90,,12.7,percent of total billed charges,90% of total billed charges for outpatient setting,2.26,15.88,
ESMARK 6IN LATEX FREE / 820-3612,6152655,CDM,270,RC,,,Outpatient,,,26.88,26.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.82,70,,15.06,percent of total billed charges,70% of total billed charges for outpatient setting,22.82,84.88,,18.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.44,50,,10.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.16,75,,16.13,percent of total billed charges,75% of total billed charges for outpatient setting,18.82,70,,15.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.45,12.84,,2.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.5,80,,17.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.45,12.84,,2.76,percent of total billed charges,12.84% of total billed charges,3.45,12.84,,2.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.47,65,,13.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,35,,7.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.19,90,,19.35,percent of total billed charges,90% of total billed charges for outpatient setting,3.45,24.19,
ESMOLOL (BREVIBLOC) INJ 10MG/ML 10 ML,3301039,CDM,250,RC,,,Outpatient,,,103.05,103.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.14,70,,57.71,percent of total billed charges,70% of total billed charges for outpatient setting,87.47,84.88,,69.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.53,50,,41.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.29,75,,61.83,percent of total billed charges,75% of total billed charges for outpatient setting,72.14,70,,57.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,12.84,,10.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.44,80,,65.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,13.23,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.98,65,,53.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.07,35,,28.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.75,90,,74.2,percent of total billed charges,90% of total billed charges for outpatient setting,13.23,92.75,
ESOPHAGUS,2400585,CDM,320,RC,74220,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
ESTABLISHED LEVEL I,5100156,CDM,510,RC,99211,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,9.58,302.15,
ESTABLISHED LEVEL II,5100157,CDM,510,RC,99212,HCPCS,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,218.22,65,,174.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.59,100,,,Fee Schedule,100% of Custom Fee Schedule,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,302.15,
ESTABLISHED LEVEL III,5100158,CDM,510,RC,99213,HCPCS,Outpatient,,,342.55,342.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.79,70,,191.83,percent of total billed charges,70% of total billed charges for outpatient setting,290.76,84.88,,232.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,171.28,50,,137.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.91,75,,205.53,percent of total billed charges,75% of total billed charges for outpatient setting,239.79,70,,191.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.04,80,,219.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,222.66,65,,178.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of Custom Fee Schedule,308.3,90,,246.64,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,308.3,
ESTIMATED GLOMERULAR FILTRATION RATE,200157,CDM,300,RC,82565,HCPCS,Outpatient,,,23.04,20.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.28,75,,13.82,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,80,,14.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of Custom Fee Schedule,20.74,90,,16.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,20.74,
ESTRADIOL (ESTRADERM) 0.05MG 24HR PATCH:,3301042,CDM,259,RC,,,Outpatient,,,59.1,59.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.37,70,,33.1,percent of total billed charges,70% of total billed charges for outpatient setting,50.16,84.88,,40.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.55,50,,23.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.33,75,,35.46,percent of total billed charges,75% of total billed charges for outpatient setting,41.37,70,,33.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.28,80,,37.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.42,65,,30.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.69,35,,16.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.19,90,,42.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.59,53.19,
ESTRADIOL (ESTRADERM) 0.1 MG 24HR PATCH:,3301043,CDM,259,RC,,,Outpatient,,,63.36,63.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.35,70,,35.48,percent of total billed charges,70% of total billed charges for outpatient setting,53.78,84.88,,43.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.68,50,,25.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.52,75,,38.02,percent of total billed charges,75% of total billed charges for outpatient setting,44.35,70,,35.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.14,12.84,,6.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,80,,40.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.14,12.84,,6.51,percent of total billed charges,12.84% of total billed charges,8.14,12.84,,6.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.18,65,,32.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.18,35,,17.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.02,90,,45.62,percent of total billed charges,90% of total billed charges for outpatient setting,8.14,57.02,
ESTRADIOL (ESTRADERM) TAB : 0.5 MG,3301041,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ESTRADIOL (ESTRADERM) TAB : 1 MG,3301040,CDM,259,RC,,,Outpatient,,,10.42,10.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,84.88,,7.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.21,50,,4.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.82,75,,6.26,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,80,,6.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.77,65,,5.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,35,,2.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.38,90,,7.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.38,
ESTRADIOL 1MG TAB,3303231,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ESTRADIOL FEMALE ADULT PRE-MENOPAUS,220493,CDM,301,RC,82670,HCPCS,Outpatient,,,125.73,113.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,106.72,84.88,,85.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,94.3,75,,75.44,percent of total billed charges,75% of total billed charges for outpatient setting,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,80,,80.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,40.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,100,,,Fee Schedule,100% of Custom Fee Schedule,113.16,90,,90.53,percent of total billed charges,90% of total billed charges for outpatient setting,27.94,113.16,
ESTRADIOL MALE CHILD FEMALE POST-MENO,220445,CDM,301,RC,82670,HCPCS,Outpatient,,,125.73,113.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,106.72,84.88,,85.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,94.3,75,,75.44,percent of total billed charges,75% of total billed charges for outpatient setting,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,80,,80.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,40.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,100,,,Fee Schedule,100% of Custom Fee Schedule,113.16,90,,90.53,percent of total billed charges,90% of total billed charges for outpatient setting,27.94,113.16,
ESTRADIOL TRANSDERMAL 0.05MG PATCH,3302702,CDM,259,RC,,,Outpatient,,,114.07,114.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.85,70,,63.88,percent of total billed charges,70% of total billed charges for outpatient setting,96.82,84.88,,77.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.04,50,,45.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.55,75,,68.44,percent of total billed charges,75% of total billed charges for outpatient setting,79.85,70,,63.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.65,12.84,,11.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.26,80,,73.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.65,12.84,,11.72,percent of total billed charges,12.84% of total billed charges,14.65,12.84,,11.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.15,65,,59.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.92,35,,31.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.66,90,,82.13,percent of total billed charges,90% of total billed charges for outpatient setting,14.65,102.66,
ESTRADIOL TRANSDERMAL 0.1 MG PATCH,3302808,CDM,259,RC,,,Outpatient,,,57.08,57.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,70,,31.97,percent of total billed charges,70% of total billed charges for outpatient setting,48.45,84.88,,38.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.54,50,,22.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.81,75,,34.25,percent of total billed charges,75% of total billed charges for outpatient setting,39.96,70,,31.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.66,80,,36.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.1,65,,29.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,35,,15.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.37,90,,41.1,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,51.37,
ESTRADIOL VAGINAL CR 0.01% 42.5GMS,3313646,CDM,259,RC,,,Outpatient,,,622.16,622.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.51,70,,348.41,percent of total billed charges,70% of total billed charges for outpatient setting,528.09,84.88,,422.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,311.08,50,,248.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466.62,75,,373.3,percent of total billed charges,75% of total billed charges for outpatient setting,435.51,70,,348.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.73,80,,398.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,404.4,65,,323.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.76,35,,174.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,559.94,90,,447.95,percent of total billed charges,90% of total billed charges for outpatient setting,79.89,559.94,
"ESTRADIOL, SENSITIVE, LC/MS",220925,CDM,301,RC,82670,HCPCS,Outpatient,,,125.73,113.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,106.72,84.88,,85.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,94.3,75,,75.44,percent of total billed charges,75% of total billed charges for outpatient setting,88.01,70,,70.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,80,,80.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,40.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,100,,,Fee Schedule,100% of Custom Fee Schedule,113.16,90,,90.53,percent of total billed charges,90% of total billed charges for outpatient setting,27.94,113.16,
ESTRIOL SERUM,220095,CDM,301,RC,82677,HCPCS,Outpatient,,,108.81,97.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.17,70,,60.94,percent of total billed charges,70% of total billed charges for outpatient setting,92.36,84.88,,73.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,81.61,75,,65.29,percent of total billed charges,75% of total billed charges for outpatient setting,76.17,70,,60.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.05,80,,69.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,35.31,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,100,,,Fee Schedule,100% of Custom Fee Schedule,97.93,90,,78.34,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,97.93,
ESTROGEN CONJ (PERMARIN) 0.5 MG TAB :,3301045,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ESTROGEN CONJ (PREMARIN) CREAM 30 GM,3301044,CDM,259,RC,,,Outpatient,,,1624.52,1624.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.16,70,,909.73,percent of total billed charges,70% of total billed charges for outpatient setting,1378.89,84.88,,1103.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,812.26,50,,649.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1218.39,75,,974.71,percent of total billed charges,75% of total billed charges for outpatient setting,1137.16,70,,909.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.59,12.84,,166.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1299.62,80,,1039.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.59,12.84,,166.87,percent of total billed charges,12.84% of total billed charges,208.59,12.84,,166.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1055.94,65,,844.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.58,35,,454.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1462.07,90,,1169.66,percent of total billed charges,90% of total billed charges for outpatient setting,208.59,1462.07,
ESTROGEN CONJ (PREMARIN):0.625 MG,3302921,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ESTROGEN CONJ (PREMARIN):0.9 MG,3303171,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
ESTROGEN CONJ (PREMARIN):1.25 MG,3301046,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ESTROGEN ESTER (MENEST) TAB: 0.625 MG,3301047,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ESTROGENS TOTAL,220088,CDM,301,RC,82672,HCPCS,Outpatient,,,97.65,87.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.36,70,,54.69,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,84.88,,66.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,73.24,75,,58.59,percent of total billed charges,75% of total billed charges for outpatient setting,68.36,70,,54.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,80,,62.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.14,100,,,Fee Schedule,100% of Custom Fee Schedule,87.89,90,,70.31,percent of total billed charges,90% of total billed charges for outpatient setting,21.7,87.89,
ESTRONE,220094,CDM,301,RC,82679,HCPCS,Outpatient,,,112.28,101.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.6,70,,62.88,percent of total billed charges,70% of total billed charges for outpatient setting,95.3,84.88,,76.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,84.21,75,,67.37,percent of total billed charges,75% of total billed charges for outpatient setting,78.6,70,,62.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.82,80,,71.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.33,100,,,Fee Schedule,100% of Custom Fee Schedule,101.05,90,,80.84,percent of total billed charges,90% of total billed charges for outpatient setting,24.95,101.05,
ESTROVEN PM CAPLETS,3304207,CDM,259,RC,,,Outpatient,,,1.17,1.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.82,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,84.88,,0.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.59,50,,0.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.88,75,,0.7,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,80,,0.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.76,65,,0.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.41,35,,0.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.05,90,,0.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,1.05,
ESZOPICLONE (LUNESTA): 1 MG,3303213,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ETA PROTEIN 14.3.3,220918,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
ETHANOL BLOOD,220827,CDM,301,RC,80320,HCPCS,Outpatient,,,185.64,167.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.95,70,,103.96,percent of total billed charges,70% of total billed charges for outpatient setting,157.57,84.88,,126.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.82,50,,74.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.23,75,,111.38,percent of total billed charges,75% of total billed charges for outpatient setting,129.95,70,,103.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.51,80,,118.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.08,90,,133.66,percent of total billed charges,90% of total billed charges for outpatient setting,23.52,167.08,
ETHANOLAMINE (ETHAMOLIN) 5% INJ: 2 ML,3301048,CDM,250,RC,,,Outpatient,,,159.54,159.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.68,70,,89.34,percent of total billed charges,70% of total billed charges for outpatient setting,135.42,84.88,,108.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.77,50,,63.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.66,75,,95.73,percent of total billed charges,75% of total billed charges for outpatient setting,111.68,70,,89.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.48,12.84,,16.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.63,80,,102.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.48,12.84,,16.38,percent of total billed charges,12.84% of total billed charges,20.48,12.84,,16.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,103.7,65,,82.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,35,,44.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.59,90,,114.87,percent of total billed charges,90% of total billed charges for outpatient setting,20.48,143.59,
ETHEZYME 830: 30 GM OINT,3303048,CDM,259,RC,,,Outpatient,,,57.26,57.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.08,70,,32.06,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,84.88,,38.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.63,50,,22.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.95,75,,34.36,percent of total billed charges,75% of total billed charges for outpatient setting,40.08,70,,32.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,12.84,,5.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.81,80,,36.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,12.84,,5.88,percent of total billed charges,12.84% of total billed charges,7.35,12.84,,5.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.22,65,,29.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.04,35,,16.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.53,90,,41.22,percent of total billed charges,90% of total billed charges for outpatient setting,7.35,51.53,
ETHILON 4-0  P-3 / 699H,6150166,CDM,272,RC,,,Outpatient,,,22.95,22.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.48,84.88,,15.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.48,50,,9.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,75,,13.77,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,80,,14.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.92,65,,11.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,35,,6.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,2.95,20.66,
ETHILON 5-0 P-3 / 698G,760930,CDM,272,RC,,,Outpatient,,,20.43,20.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.3,70,,11.44,percent of total billed charges,70% of total billed charges for outpatient setting,17.34,84.88,,13.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.22,50,,8.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.32,75,,12.26,percent of total billed charges,75% of total billed charges for outpatient setting,14.3,70,,11.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.62,12.84,,2.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.34,80,,13.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.62,12.84,,2.1,percent of total billed charges,12.84% of total billed charges,2.62,12.84,,2.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.28,65,,10.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,35,,5.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.39,90,,14.71,percent of total billed charges,90% of total billed charges for outpatient setting,2.62,18.39,
ETHYL ALCOHOL (ALCOHOL) AMP: 5 ML,3301050,CDM,250,RC,,,Outpatient,,,99.41,99.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.59,70,,55.67,percent of total billed charges,70% of total billed charges for outpatient setting,84.38,84.88,,67.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.71,50,,39.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.56,75,,59.65,percent of total billed charges,75% of total billed charges for outpatient setting,69.59,70,,55.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,12.84,,10.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.53,80,,63.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,12.84,,10.21,percent of total billed charges,12.84% of total billed charges,12.76,12.84,,10.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.62,65,,51.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,35,,27.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.47,90,,71.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.76,89.47,
ETHYL ALCOHOL 98% INJ : 1 ML,3301049,CDM,250,RC,,,Outpatient,,,21.91,21.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,70,,12.27,percent of total billed charges,70% of total billed charges for outpatient setting,18.6,84.88,,14.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.96,50,,8.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.43,75,,13.14,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,70,,12.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,12.84,,2.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.53,80,,14.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,12.84,,2.25,percent of total billed charges,12.84% of total billed charges,2.81,12.84,,2.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.24,65,,11.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.67,35,,6.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.72,90,,15.78,percent of total billed charges,90% of total billed charges for outpatient setting,2.81,19.72,
ETHYL CHLORIDE (GEBAUER) MED : 105ML,3301051,CDM,259,RC,,,Outpatient,,,36.34,36.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.44,70,,20.35,percent of total billed charges,70% of total billed charges for outpatient setting,30.85,84.88,,24.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.17,50,,14.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.26,75,,21.81,percent of total billed charges,75% of total billed charges for outpatient setting,25.44,70,,20.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.07,80,,23.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.62,65,,18.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,35,,10.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.71,90,,26.17,percent of total billed charges,90% of total billed charges for outpatient setting,4.67,32.71,
ETIDRONATE (DIDRONEL) TAB: 200 MG,3301052,CDM,259,RC,,,Outpatient,,,137.43,137.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.2,70,,76.96,percent of total billed charges,70% of total billed charges for outpatient setting,116.65,84.88,,93.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.72,50,,54.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.07,75,,82.46,percent of total billed charges,75% of total billed charges for outpatient setting,96.2,70,,76.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,80,,87.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.33,65,,71.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.1,35,,38.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.69,90,,98.95,percent of total billed charges,90% of total billed charges for outpatient setting,17.65,123.69,
ETODOLAC (LODINE) CAP : 200 MG,3301053,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ETODOLAC ER 400MG TABS(LODINE XL),3305113,CDM,259,RC,,,Outpatient,,,33.65,33.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,28.56,84.88,,22.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.83,50,,13.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.24,75,,20.19,percent of total billed charges,75% of total billed charges for outpatient setting,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,12.84,,3.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,80,,21.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,4.32,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.87,65,,17.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.78,35,,9.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.29,90,,24.23,percent of total billed charges,90% of total billed charges for outpatient setting,4.32,30.29,
ETOMIDATE (AMIDATE) INJ 2MG/ML  10ML,3301054,CDM,250,RC,,,Outpatient,,,45.87,45.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,70,,25.69,percent of total billed charges,70% of total billed charges for outpatient setting,38.93,84.88,,31.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.94,50,,18.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.4,75,,27.52,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,70,,25.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.89,12.84,,4.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.7,80,,29.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.89,12.84,,4.71,percent of total billed charges,12.84% of total billed charges,5.89,12.84,,4.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.82,65,,23.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,35,,12.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.28,90,,33.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.89,41.28,
ETOPOSIDE (VEPESID) INJ 20 MG/ML: 5 ML,3301055,CDM,250,RC,,,Outpatient,,,353.36,353.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.35,70,,197.88,percent of total billed charges,70% of total billed charges for outpatient setting,299.93,84.88,,239.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,176.68,50,,141.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.02,75,,212.02,percent of total billed charges,75% of total billed charges for outpatient setting,247.35,70,,197.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,12.84,,36.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.69,80,,226.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,12.84,,36.3,percent of total billed charges,12.84% of total billed charges,45.37,12.84,,36.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,229.68,65,,183.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.68,35,,98.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,318.02,90,,254.42,percent of total billed charges,90% of total billed charges for outpatient setting,45.37,318.02,
EUCERIN CALMING CREME: 8 OZ,3303244,CDM,259,RC,,,Outpatient,,,29.7,29.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,70,,16.63,percent of total billed charges,70% of total billed charges for outpatient setting,25.21,84.88,,20.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.85,50,,11.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.28,75,,17.82,percent of total billed charges,75% of total billed charges for outpatient setting,20.79,70,,16.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,80,,19.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,3.81,12.84,,3.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.31,65,,15.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.4,35,,8.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.73,90,,21.38,percent of total billed charges,90% of total billed charges for outpatient setting,3.81,26.73,
EVAMIST (ESTRADIOL TRANSDERMAL):1.53G,3303281,CDM,259,RC,,,Outpatient,,,172.79,172.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.95,70,,96.76,percent of total billed charges,70% of total billed charges for outpatient setting,146.66,84.88,,117.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,50,,69.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.59,75,,103.67,percent of total billed charges,75% of total billed charges for outpatient setting,120.95,70,,96.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.19,12.84,,17.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.23,80,,110.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.19,12.84,,17.75,percent of total billed charges,12.84% of total billed charges,22.19,12.84,,17.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.31,65,,89.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,35,,48.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.51,90,,124.41,percent of total billed charges,90% of total billed charges for outpatient setting,22.19,155.51,
EVENT MONITORING,2600105,CDM,731,RC,93271,HCPCS,Outpatient,,,361.5,361.5,,143.93,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,152.93,170,,,Fee Schedule,170% of Medicare OPPS rate,193.41,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,157.41,175,,,Fee Schedule,175% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,125.94,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,112.45,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,89.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,137.78,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
EVENT MONITORING HOOKUP,2600108,CDM,731,RC,93270,HCPCS,Outpatient,,,361.5,361.5,,53.38,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,56.72,170,,,Fee Schedule,170% of Medicare OPPS rate,71.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,58.39,175,,,Fee Schedule,175% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,46.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,41.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,33.36,325.35,
EVOXAC (CEVIMELINE) 30MG CAP,3305951,CDM,259,RC,,,Outpatient,,,14.04,14.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.83,70,,7.86,percent of total billed charges,70% of total billed charges for outpatient setting,11.92,84.88,,9.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.02,50,,5.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.53,75,,8.42,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,70,,7.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,80,,8.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.13,65,,7.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,35,,3.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.64,90,,10.11,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,12.64,
EXACTO COLD SNARE / 00711115,70000016,CDM,272,RC,,,Outpatient,,,90.85,90.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,70,,50.88,percent of total billed charges,70% of total billed charges for outpatient setting,77.11,84.88,,61.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.43,50,,36.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.14,75,,54.51,percent of total billed charges,75% of total billed charges for outpatient setting,63.6,70,,50.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,80,,58.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.05,65,,47.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.8,35,,25.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.77,90,,65.42,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,81.77,
EXCALIBUR 4MM / AR-8400EX,69162028,CDM,272,RC,,,Outpatient,,,247.8,247.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,210.33,84.88,,168.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.9,50,,99.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.85,75,,148.68,percent of total billed charges,75% of total billed charges for outpatient setting,173.46,70,,138.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,80,,158.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,31.82,12.84,,25.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.07,65,,128.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,35,,69.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.02,90,,178.42,percent of total billed charges,90% of total billed charges for outpatient setting,31.82,223.02,
EXCALIBUR CURVED 4MM / AR-8400CEX,69169847,CDM,272,RC,,,Outpatient,,,277.2,277.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,235.29,84.88,,188.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.6,50,,110.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,75,,166.32,percent of total billed charges,75% of total billed charges for outpatient setting,194.04,70,,155.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,80,,177.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,35.59,12.84,,28.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.18,65,,144.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,90,,199.58,percent of total billed charges,90% of total billed charges for outpatient setting,35.59,249.48,
EXCEDRIN EXTRA STRENGTH HEADACHE,3303331,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
EXELON CAP: 3MG,3302818,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
EXPRESS DRY SEAL CHEST DRAIN / 16400,69160628,CDM,272,RC,,,Outpatient,,,345.32,345.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.72,70,,193.38,percent of total billed charges,70% of total billed charges for outpatient setting,293.11,84.88,,234.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,172.66,50,,138.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.99,75,,207.19,percent of total billed charges,75% of total billed charges for outpatient setting,241.72,70,,193.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.34,12.84,,35.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.26,80,,221.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.34,12.84,,35.47,percent of total billed charges,12.84% of total billed charges,44.34,12.84,,35.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.46,65,,179.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,35,,96.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,310.79,90,,248.63,percent of total billed charges,90% of total billed charges for outpatient setting,44.34,310.79,
EXT ART BILAT R/O,2200720,CDM,323,RC,75716,HCPCS,Outpatient,,,4499.45,3374.59,,4104.4,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3149.62,70,,2519.7,percent of total billed charges,70% of total billed charges for outpatient setting,3819.13,84.88,,3055.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,3466.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3374.59,75,,2699.67,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,4360.92,170,,,Fee Schedule,170% of Medicare OPPS rate,5515.29,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,577.73,12.84,,462.184,percent of total billed charges,12.84% of total billed charges,4489.19,175,,,Fee Schedule,175% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3599.56,80,,2879.65,percent of total billed charges,80% of total billed charges for outpatient setting,3591.35,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,3206.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,577.73,12.84,,462.18,percent of total billed charges,12.84% of total billed charges,577.73,12.84,,462.18,percent of total billed charges,12.84% of total billed charges,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3064.89,100,,,Fee Schedule,100% of Custom Fee Schedule,4049.51,90,,3239.61,percent of total billed charges,90% of total billed charges for outpatient setting,128,5515.29,
EXT SET  1.2 MICRON FILTER /20127E,69169495,CDM,272,RC,,,Outpatient,,,24.1,24.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,70,,13.5,percent of total billed charges,70% of total billed charges for outpatient setting,20.46,84.88,,16.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.05,50,,9.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.08,75,,14.46,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,70,,13.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.28,80,,15.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.67,65,,12.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,35,,6.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.69,90,,17.35,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,21.69,
EXT SET IV 7IN CLAVE / MP9002,69162045,CDM,272,RC,,,Outpatient,,,23.22,23.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,19.71,84.88,,15.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.61,50,,9.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.42,75,,13.94,percent of total billed charges,75% of total billed charges for outpatient setting,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,80,,14.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.09,65,,12.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,35,,6.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.9,90,,16.72,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,20.9,
EXTENDER STEM TRTHLN / 5571-S-050,71000824,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114.68,2114.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.81,60,,1015.05,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.94,84.88,,1435.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1586.01,75,,1268.81,percent of total billed charges,75% of total billed charges for outpatient setting,1057.34,50,,845.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.74,80,,1353.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2220.41,105,,1776.33,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.14,35,,592.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.81,60,,1015.05,percent of total billed charges,60% of total billed charges for outpatient setting,271.52,2220.41,
EXTRACTABLE NUCLEAR ANTIGEN ANTIBODIES,200461,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
EXTRACTOR 2.5MM QUICK RLS / 80-0600,1315379,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448,70,,358.4,percent of total billed charges,70% of total billed charges for outpatient setting,543.23,84.88,,434.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,320,50,,256,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,480,75,,384,percent of total billed charges,75% of total billed charges for outpatient setting,448,70,,358.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.18,12.84,,65.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512,80,,409.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.18,12.84,,65.74,percent of total billed charges,12.84% of total billed charges,82.18,12.84,,65.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416,65,,332.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,35,,179.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,576,90,,460.8,percent of total billed charges,90% of total billed charges for outpatient setting,82.18,576,
EXTRACTOR SURGICAL CONICAL / 309.520,446347,CDM,272,RC,,,Outpatient,,,358.92,358.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.24,70,,200.99,percent of total billed charges,70% of total billed charges for outpatient setting,304.65,84.88,,243.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.46,50,,143.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.19,75,,215.35,percent of total billed charges,75% of total billed charges for outpatient setting,251.24,70,,200.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.09,12.84,,36.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.14,80,,229.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.09,12.84,,36.87,percent of total billed charges,12.84% of total billed charges,46.09,12.84,,36.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,233.3,65,,186.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.62,35,,100.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,323.03,90,,258.42,percent of total billed charges,90% of total billed charges for outpatient setting,46.09,323.03,
EYE PAD OVAL / C-EYP22S,6150464,CDM,272,RC,,,Outpatient,,,0.72,0.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,70,,0.4,percent of total billed charges,70% of total billed charges for outpatient setting,0.61,84.88,,0.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.36,50,,0.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.54,75,,0.43,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,70,,0.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.09,12.84,,0.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,80,,0.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.09,12.84,,0.07,percent of total billed charges,12.84% of total billed charges,0.09,12.84,,0.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.47,65,,0.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,35,,0.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.65,90,,0.52,percent of total billed charges,90% of total billed charges for outpatient setting,0.09,0.65,
EYE WICK DRAIN/8065913196,6150518,CDM,272,RC,,,Outpatient,,,39.27,39.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.49,70,,21.99,percent of total billed charges,70% of total billed charges for outpatient setting,33.33,84.88,,26.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.64,50,,15.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,75,,23.56,percent of total billed charges,75% of total billed charges for outpatient setting,27.49,70,,21.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,80,,25.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.53,65,,20.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.74,35,,10.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.34,90,,28.27,percent of total billed charges,90% of total billed charges for outpatient setting,5.04,35.34,
EZ CLIP 10MM   EZM10-10-10,69169359,CDM,278,RC,C1713,HCPCS,Outpatient,,,3481.7,3481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2089.02,60,,1671.22,percent of total billed charges,60% of total Billed charges for outpatient setting,2955.27,84.88,,2364.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2611.28,75,,2089.02,percent of total billed charges,75% of total billed charges for outpatient setting,1740.85,50,,1392.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.05,12.84,,357.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2785.36,80,,2228.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.05,12.84,,357.64,percent of total billed charges,12.84% of total billed charges,447.05,12.84,,357.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3655.79,105,,2924.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.6,35,,974.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2089.02,60,,1671.22,percent of total billed charges,60% of total billed charges for outpatient setting,447.05,3655.79,
EZ CLIP 12MM   EZM12-10-10,69161629,CDM,278,RC,,,Outpatient,,,3795.88,3795.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2277.53,60,,1822.02,percent of total billed charges,60% of total Billed charges for outpatient setting,3221.94,84.88,,2577.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1897.94,50,,1518.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2846.91,75,,2277.53,percent of total billed charges,75% of total billed charges for outpatient setting,1897.94,50,,1518.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.39,12.84,,389.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3036.7,80,,2429.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.39,12.84,,389.91,percent of total billed charges,12.84% of total billed charges,487.39,12.84,,389.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3985.67,105,,3188.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1328.56,35,,1062.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2277.53,60,,1822.02,percent of total billed charges,60% of total billed charges for outpatient setting,487.39,3985.67,
EZ CLIP 15MM   EZM15-15-15,69161630,CDM,278,RC,,,Outpatient,,,2638.4,2638.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.04,60,,1266.43,percent of total billed charges,60% of total Billed charges for outpatient setting,2239.47,84.88,,1791.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1319.2,50,,1055.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1978.8,75,,1583.04,percent of total billed charges,75% of total billed charges for outpatient setting,1319.2,50,,1055.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.77,12.84,,271.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2110.72,80,,1688.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.77,12.84,,271.02,percent of total billed charges,12.84% of total billed charges,338.77,12.84,,271.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2770.32,105,,2216.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,923.44,35,,738.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1583.04,60,,1266.43,percent of total billed charges,60% of total billed charges for outpatient setting,338.77,2770.32,
F2 GENE ANALYSIS 20210G>A VARIANT,220903,CDM,310,RC,81240,HCPCS,Outpatient,,,295.61,266.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.93,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,250.91,84.88,,200.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,221.71,75,,177.37,percent of total billed charges,75% of total billed charges for outpatient setting,206.93,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.49,80,,189.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.13,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.31,100,,,Fee Schedule,100% of Custom Fee Schedule,266.05,90,,212.84,percent of total billed charges,90% of total billed charges for outpatient setting,37.96,266.05,
FACIAL BONES COMPLETE,2400055,CDM,320,RC,70150,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
FACIAL BONES LESS THAN THREE VIEWS,2400050,CDM,320,RC,70140,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FACTOR II ACTIVITY,220804,CDM,305,RC,85210,HCPCS,Outpatient,,,58.41,52.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.89,70,,32.71,percent of total billed charges,70% of total billed charges for outpatient setting,49.58,84.88,,39.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.29,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.81,75,,35.05,percent of total billed charges,75% of total billed charges for outpatient setting,40.89,70,,32.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.73,80,,37.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.96,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,100,,,Fee Schedule,100% of Custom Fee Schedule,52.57,90,,42.06,percent of total billed charges,90% of total billed charges for outpatient setting,7.04,52.57,
FACTOR II PROTHROMBIN DNA ANALYSIS,220803,CDM,301,RC,81240,HCPCS,Outpatient,,,295.61,266.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.93,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,250.91,84.88,,200.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,221.71,75,,177.37,percent of total billed charges,75% of total billed charges for outpatient setting,206.93,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.49,80,,189.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.13,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.31,100,,,Fee Schedule,100% of Custom Fee Schedule,266.05,90,,212.84,percent of total billed charges,90% of total billed charges for outpatient setting,37.96,266.05,
FACTOR IX ACTIVITY,220811,CDM,305,RC,85250,HCPCS,Outpatient,,,85.68,77.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.98,70,,47.98,percent of total billed charges,70% of total billed charges for outpatient setting,72.73,84.88,,58.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,64.26,75,,51.41,percent of total billed charges,75% of total billed charges for outpatient setting,59.98,70,,47.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.54,80,,54.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.1,100,,,Fee Schedule,100% of Custom Fee Schedule,77.11,90,,61.69,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,77.11,
FACTOR V ACTIVITY,202854,CDM,300,RC,85220,HCPCS,Outpatient,,,79.43,71.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,67.42,84.88,,53.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.57,75,,47.66,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.54,80,,50.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.81,100,,,Fee Schedule,100% of Custom Fee Schedule,71.49,90,,57.19,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,71.49,
FACTOR V ACTIVITY,220815,CDM,300,RC,85220,HCPCS,Outpatient,,,79.43,71.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,67.42,84.88,,53.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.57,75,,47.66,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.54,80,,50.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.81,100,,,Fee Schedule,100% of Custom Fee Schedule,71.49,90,,57.19,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,71.49,
FACTOR V LEIDEN MUTATION ANALYSIS,220894,CDM,301,RC,81241,HCPCS,Outpatient,,,330.17,297.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,70,,184.9,percent of total billed charges,70% of total billed charges for outpatient setting,280.25,84.88,,224.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,104.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,247.63,75,,198.1,percent of total billed charges,75% of total billed charges for outpatient setting,231.12,70,,184.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.14,80,,211.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,83.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.88,100,,,Fee Schedule,100% of Custom Fee Schedule,297.15,90,,237.72,percent of total billed charges,90% of total billed charges for outpatient setting,55.03,297.15,
FACTOR VIII,220747,CDM,305,RC,85240,HCPCS,Outpatient,,,80.55,72.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.39,70,,45.11,percent of total billed charges,70% of total billed charges for outpatient setting,68.37,84.88,,54.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.41,75,,48.33,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,70,,45.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.44,80,,51.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.96,100,,,Fee Schedule,100% of Custom Fee Schedule,72.5,90,,58,percent of total billed charges,90% of total billed charges for outpatient setting,17.9,72.5,
FACTOR XII,220810,CDM,305,RC,85280,HCPCS,Outpatient,,,87.08,78.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,73.91,84.88,,59.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.31,75,,52.25,percent of total billed charges,75% of total billed charges for outpatient setting,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.66,80,,55.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.81,100,,,Fee Schedule,100% of Custom Fee Schedule,78.37,90,,62.7,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,78.37,
FAMOTIDINE (genericPEPCID) 20MG  TAB,3305889,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FAMOTIDINE (genPEPCID) INJ 10MG/ML 2ML,3301063,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FAMOTIDINE (PEPCID) INJ 10MG/ML: 20ML,3301061,CDM,250,RC,,,Outpatient,,,127.45,127.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.22,70,,71.38,percent of total billed charges,70% of total billed charges for outpatient setting,108.18,84.88,,86.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.73,50,,50.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.59,75,,76.47,percent of total billed charges,75% of total billed charges for outpatient setting,89.22,70,,71.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.36,12.84,,13.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.96,80,,81.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.36,12.84,,13.09,percent of total billed charges,12.84% of total billed charges,16.36,12.84,,13.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.84,65,,66.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.61,35,,35.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.71,90,,91.77,percent of total billed charges,90% of total billed charges for outpatient setting,16.36,114.71,
FAMOTIDINE (PEPCID) INJ 10MG/ML: 2ML,3301056,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FAMOTIDINE (PEPCID) INJ 10MG/ML: 2ML,3301057,CDM,250,RC,,,Outpatient,,,11.06,11.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.74,70,,6.19,percent of total billed charges,70% of total billed charges for outpatient setting,9.39,84.88,,7.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.53,50,,4.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.3,75,,6.64,percent of total billed charges,75% of total billed charges for outpatient setting,7.74,70,,6.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,80,,7.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.19,65,,5.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,35,,3.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.95,90,,7.96,percent of total billed charges,90% of total billed charges for outpatient setting,1.42,9.95,
FAMOTIDINE (PEPCID) INJ 10MG/ML: 2ML,3301062,CDM,250,RC,,,Outpatient,,,11.59,11.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.11,70,,6.49,percent of total billed charges,70% of total billed charges for outpatient setting,9.84,84.88,,7.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.8,50,,4.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.69,75,,6.95,percent of total billed charges,75% of total billed charges for outpatient setting,8.11,70,,6.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,80,,7.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.53,65,,6.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.06,35,,3.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.43,90,,8.34,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.43,
FAMOTIDINE (PEPCID) INJ 10MG/ML: 4ML,3301058,CDM,250,RC,,,Outpatient,,,25.48,25.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,70,,14.27,percent of total billed charges,70% of total billed charges for outpatient setting,21.63,84.88,,17.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.74,50,,10.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.11,75,,15.29,percent of total billed charges,75% of total billed charges for outpatient setting,17.84,70,,14.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,80,,16.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.56,65,,13.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.92,35,,7.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.93,90,,18.34,percent of total billed charges,90% of total billed charges for outpatient setting,3.27,22.93,
FAMOTIDINE (PEPCID) SF INJ 10MG/ML: 2ML,3301059,CDM,250,RC,,,Outpatient,,,40.16,40.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.11,70,,22.49,percent of total billed charges,70% of total billed charges for outpatient setting,34.09,84.88,,27.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.08,50,,16.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.12,75,,24.1,percent of total billed charges,75% of total billed charges for outpatient setting,28.11,70,,22.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,12.84,,4.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.13,80,,25.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,12.84,,4.13,percent of total billed charges,12.84% of total billed charges,5.16,12.84,,4.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.1,65,,20.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.06,35,,11.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.14,90,,28.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,36.14,
FAMOTIDINE (PEPCID) TAB : 20 MG  U/D,3301060,CDM,259,RC,,,Outpatient,,,4.73,4.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,70,,2.65,percent of total billed charges,70% of total billed charges for outpatient setting,4.01,84.88,,3.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.37,50,,1.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.55,75,,2.84,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,70,,2.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,80,,3.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.07,65,,2.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,35,,1.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.26,90,,3.41,percent of total billed charges,90% of total billed charges for outpatient setting,0.61,4.26,
FAMOTIDINE (PEPCID) TAB: 20 MG,3301064,CDM,259,RC,,,Outpatient,,,4.99,4.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,70,,2.79,percent of total billed charges,70% of total billed charges for outpatient setting,4.24,84.88,,3.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.5,50,,2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.74,75,,2.99,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,70,,2.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,80,,3.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.24,65,,2.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,35,,1.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.49,90,,3.59,percent of total billed charges,90% of total billed charges for outpatient setting,0.64,4.49,
FASCIA LATA SUSPEND 2X12CM / 93-7212,69161302,CDM,278,RC,C1762,HCPCS,Outpatient,,,2846,2846,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.6,60,,1366.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2415.68,84.88,,1932.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2134.5,75,,1707.6,percent of total billed charges,75% of total billed charges for outpatient setting,1423,50,,1138.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.43,12.84,,292.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2276.8,80,,1821.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.43,12.84,,292.34,percent of total billed charges,12.84% of total billed charges,365.43,12.84,,292.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2988.3,105,,2390.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996.1,35,,796.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1707.6,60,,1366.08,percent of total billed charges,60% of total billed charges for outpatient setting,365.43,2988.3,
FAT EMULSION (INTRALIPID) 10% INJ:500 ML,3301067,CDM,258,RC,,,Outpatient,,,33.96,33.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,70,,19.02,percent of total billed charges,70% of total billed charges for outpatient setting,28.83,84.88,,23.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.98,50,,13.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.47,75,,20.38,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,70,,19.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,80,,21.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,4.36,12.84,,3.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.07,65,,17.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.89,35,,9.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.56,90,,24.45,percent of total billed charges,90% of total billed charges for outpatient setting,4.36,30.56,
FAT EMULSION (LIPOSYN II) 10% INJ :500ML,3301065,CDM,258,RC,,,Outpatient,,,64.56,64.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.19,70,,36.15,percent of total billed charges,70% of total billed charges for outpatient setting,54.8,84.88,,43.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.28,50,,25.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.42,75,,38.74,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,70,,36.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,12.84,,6.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.65,80,,41.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,12.84,,6.63,percent of total billed charges,12.84% of total billed charges,8.29,12.84,,6.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.96,65,,33.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.6,35,,18.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.1,90,,46.48,percent of total billed charges,90% of total billed charges for outpatient setting,8.29,58.1,
FAT EMULSION (LIPOSYN II) 10% INJ:500 ML,3301068,CDM,258,RC,,,Outpatient,,,46.04,46.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.23,70,,25.78,percent of total billed charges,70% of total billed charges for outpatient setting,39.08,84.88,,31.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.02,50,,18.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.53,75,,27.62,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,70,,25.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,12.84,,4.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.83,80,,29.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,12.84,,4.73,percent of total billed charges,12.84% of total billed charges,5.91,12.84,,4.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.93,65,,23.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.11,35,,12.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.44,90,,33.15,percent of total billed charges,90% of total billed charges for outpatient setting,5.91,41.44,
FAT EMULSION (LIPOSYN III) 10% INJ:500ML,3301066,CDM,258,RC,,,Outpatient,,,73.04,73.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.13,70,,40.9,percent of total billed charges,70% of total billed charges for outpatient setting,62,84.88,,49.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.52,50,,29.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.78,75,,43.82,percent of total billed charges,75% of total billed charges for outpatient setting,51.13,70,,40.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,12.84,,7.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.43,80,,46.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,12.84,,7.5,percent of total billed charges,12.84% of total billed charges,9.38,12.84,,7.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.48,65,,37.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,35,,20.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.74,90,,52.59,percent of total billed charges,90% of total billed charges for outpatient setting,9.38,65.74,
FDP,200343,CDM,300,RC,85362,HCPCS,Outpatient,,,31.01,27.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,26.32,84.88,,21.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.26,75,,18.61,percent of total billed charges,75% of total billed charges for outpatient setting,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.81,80,,19.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.77,100,,,Fee Schedule,100% of Custom Fee Schedule,27.91,90,,22.33,percent of total billed charges,90% of total billed charges for outpatient setting,6.69,27.91,
FEBRILE AGGLUTININS,201084,CDM,302,RC,86000,HCPCS,Outpatient,,,31.41,28.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,26.66,84.88,,21.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.56,75,,18.85,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.13,80,,20.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.19,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,100,,,Fee Schedule,100% of Custom Fee Schedule,28.27,90,,22.62,percent of total billed charges,90% of total billed charges for outpatient setting,6.98,28.27,
FECAL FAT QUAL,201522,CDM,306,RC,82705,HCPCS,Outpatient,,,22.95,20.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.48,84.88,,15.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.21,75,,13.77,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,80,,14.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.43,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.65,100,,,Fee Schedule,100% of Custom Fee Schedule,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,20.66,
FECAL FAT QUAL-STOOL,200470,CDM,300,RC,82705,HCPCS,Outpatient,,,22.95,20.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.48,84.88,,15.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.21,75,,13.77,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,80,,14.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.43,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.65,100,,,Fee Schedule,100% of Custom Fee Schedule,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,20.66,
FECAL FAT QUANT STOOL,220093,CDM,300,RC,82710,HCPCS,Outpatient,,,75.6,68.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.17,84.88,,51.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.7,75,,45.36,percent of total billed charges,75% of total billed charges for outpatient setting,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,80,,48.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,100,,,Fee Schedule,100% of Custom Fee Schedule,68.04,90,,54.43,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,68.04,
FECAL WBC,201521,CDM,306,RC,87205,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
FECAL WBCS,200725,CDM,300,RC,87205,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
FEEDING TUBE 22 FR BALLOON REPLACEMENT,69169059,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.5,65,,109.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189,90,,151.2,percent of total billed charges,90% of total billed charges for outpatient setting,26.96,189,
FEEDING TUBE 24 FR BALLOON REPLACEMENT,6050137,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.5,65,,109.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189,90,,151.2,percent of total billed charges,90% of total billed charges for outpatient setting,26.96,189,
FEEDING TUBE KIT,69159351,CDM,272,RC,,,Outpatient,,,371.21,371.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.85,70,,207.88,percent of total billed charges,70% of total billed charges for outpatient setting,315.08,84.88,,252.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,185.61,50,,148.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.41,75,,222.73,percent of total billed charges,75% of total billed charges for outpatient setting,259.85,70,,207.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,12.84,,38.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.97,80,,237.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,12.84,,38.13,percent of total billed charges,12.84% of total billed charges,47.66,12.84,,38.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,241.29,65,,193.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.92,35,,103.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,334.09,90,,267.27,percent of total billed charges,90% of total billed charges for outpatient setting,47.66,334.09,
FELODIPINE (PLENDIL) TAB: 2.5 MG,3303088,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FELODIPINE (PLENDIL) TAB: 5 MG,3301069,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FELODIPINE ER (PLENDIL) TAB: 2.5,3303214,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
FEMORAL 5 RT ATTUNE / 1504-00-225,71000255,CDM,278,RC,C1713,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL 6 LT ATTUNE / 1504-00-126,71000207,CDM,278,RC,C1713,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL COMP 3 LEFT POST STAB/71421213,69161847,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 4 LEFT POST STAB/71421214,69161436,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 4 RIGHT CRUC  / 1960-01-400,69161987,CDM,278,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMORAL COMP 4 RT CRUC RET / 71421224,69161174,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 5  LT CRUC RET / 71421235,70000080,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 6 LEFT POST STAB / 71421216,69161100,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 6 RIGHT CRUC RET /71421226,69161213,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 6 RIGHT POST STAB/ 71421206,69161119,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 7 RT CRUC RET / 71421227,69161178,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 7 RT POST STAB / 71421207,69161091,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
FEMORAL COMP 8 LEFT POST STAB  71421228,69161534,CDM,278,RC,,,Outpatient,,,5699.4,5699.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.64,60,,2735.71,percent of total billed charges,60% of total Billed charges for outpatient setting,4837.65,84.88,,3870.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4274.55,75,,3419.64,percent of total billed charges,75% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.52,80,,3647.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5984.37,105,,4787.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.79,35,,1595.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3419.64,60,,2735.71,percent of total billed charges,60% of total billed charges for outpatient setting,731.8,5984.37,
FEMORAL COMP 8 LEFT POST STAB/71421218,69161544,CDM,278,RC,,,Outpatient,,,5699.4,5699.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.64,60,,2735.71,percent of total billed charges,60% of total Billed charges for outpatient setting,4837.65,84.88,,3870.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4274.55,75,,3419.64,percent of total billed charges,75% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.52,80,,3647.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5984.37,105,,4787.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.79,35,,1595.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3419.64,60,,2735.71,percent of total billed charges,60% of total billed charges for outpatient setting,731.8,5984.37,
FEMORAL COMP 8 RIGHT CRUC RET 71421228,69161285,CDM,278,RC,,,Outpatient,,,5244,5244,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3146.4,60,,2517.12,percent of total billed charges,60% of total Billed charges for outpatient setting,4451.11,84.88,,3560.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,2622,50,,2097.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3933,75,,3146.4,percent of total billed charges,75% of total billed charges for outpatient setting,2622,50,,2097.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.33,12.84,,538.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4195.2,80,,3356.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.33,12.84,,538.66,percent of total billed charges,12.84% of total billed charges,673.33,12.84,,538.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5506.2,105,,4404.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1835.4,35,,1468.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3146.4,60,,2517.12,percent of total billed charges,60% of total billed charges for outpatient setting,673.33,5506.2,
FEMORAL COMP 8 RIGHT POST STAB/71421208,69161168,CDM,278,RC,,,Outpatient,,,5428,5428,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3256.8,60,,2605.44,percent of total billed charges,60% of total Billed charges for outpatient setting,4607.29,84.88,,3685.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,2714,50,,2171.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4071,75,,3256.8,percent of total billed charges,75% of total billed charges for outpatient setting,2714,50,,2171.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.96,12.84,,557.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.4,80,,3473.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.96,12.84,,557.57,percent of total billed charges,12.84% of total billed charges,696.96,12.84,,557.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5699.4,105,,4559.52,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1899.8,35,,1519.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3256.8,60,,2605.44,percent of total billed charges,60% of total billed charges for outpatient setting,696.96,5699.4,
FEMORAL COMP SZ 3 RT CR / 5517-F-302,71000116,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
FEMORAL COMP SZ 4 RIGHT /96-0014,69162542,CDM,278,RC,,,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
FEMORAL COMP SZ 7 LFT CR / 5517-F-701,69169761,CDM,278,RC,C1776,HCPCS,Outpatient,,,3530.4,3530.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.24,60,,1694.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2996.6,84.88,,2397.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.8,75,,2118.24,percent of total billed charges,75% of total billed charges for outpatient setting,1765.2,50,,1412.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2824.32,80,,2259.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,453.3,12.84,,362.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3706.92,105,,2965.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.64,35,,988.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2118.24,60,,1694.59,percent of total billed charges,60% of total billed charges for outpatient setting,453.3,3706.92,
"FEMORAL COMP, 3 LEFT, CRUC. RET/71421233",69162559,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
"FEMORAL COMP, 3 RIGHT, CRUC. RET..",69161584,CDM,278,RC,,,Outpatient,,,5506.2,5506.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3303.72,60,,2642.98,percent of total billed charges,60% of total Billed charges for outpatient setting,4673.66,84.88,,3738.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,2753.1,50,,2202.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4129.65,75,,3303.72,percent of total billed charges,75% of total billed charges for outpatient setting,2753.1,50,,2202.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707,12.84,,565.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4404.96,80,,3523.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707,12.84,,565.6,percent of total billed charges,12.84% of total billed charges,707,12.84,,565.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5781.51,105,,4625.21,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.17,35,,1541.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3303.72,60,,2642.98,percent of total billed charges,60% of total billed charges for outpatient setting,707,5781.51,
"FEMORAL COMP, 4 LEFT, CRUC. RET.71421234",69161143,CDM,278,RC,,,Outpatient,,,5000,5000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,60,,2400,percent of total billed charges,60% of total Billed charges for outpatient setting,4244,84.88,,3395.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750,75,,3000,percent of total billed charges,75% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4000,80,,3200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5250,105,,4200,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,35,,1400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3000,60,,2400,percent of total billed charges,60% of total billed charges for outpatient setting,642,5250,
"FEMORAL COMP, 5 LEFT, POST STAB.",69161133,CDM,278,RC,,,Outpatient,,,5699.4,5699.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.64,60,,2735.71,percent of total billed charges,60% of total Billed charges for outpatient setting,4837.65,84.88,,3870.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4274.55,75,,3419.64,percent of total billed charges,75% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.52,80,,3647.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5984.37,105,,4787.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.79,35,,1595.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3419.64,60,,2735.71,percent of total billed charges,60% of total billed charges for outpatient setting,731.8,5984.37,
"FEMORAL COMP, 7 LEFT, POST STAB.",69161210,CDM,278,RC,,,Outpatient,,,5699.4,5699.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.64,60,,2735.71,percent of total billed charges,60% of total Billed charges for outpatient setting,4837.65,84.88,,3870.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4274.55,75,,3419.64,percent of total billed charges,75% of total billed charges for outpatient setting,2849.7,50,,2279.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4559.52,80,,3647.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,731.8,12.84,,585.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5984.37,105,,4787.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.79,35,,1595.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3419.64,60,,2735.71,percent of total billed charges,60% of total billed charges for outpatient setting,731.8,5984.37,
FEMORAL COMPONENT SZ 5 / 71356105,69162336,CDM,278,RC,,,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
FEMORAL HEAD 36M-2 12/14 / 1365-50-000,69169773,CDM,278,RC,C1776,HCPCS,Outpatient,,,2100,2100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,60,,1008,percent of total billed charges,60% of total Billed charges for outpatient setting,1782.48,84.88,,1425.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,75,,1260,percent of total billed charges,75% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,80,,1344,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2205,105,,1764,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,35,,588,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1260,60,,1008,percent of total billed charges,60% of total billed charges for outpatient setting,269.64,2205,
FEMORAL HEAD 36MM / 71343600,69162337,CDM,278,RC,,,Outpatient,,,3200,3200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,60,,1536,percent of total billed charges,60% of total Billed charges for outpatient setting,2716.16,84.88,,2172.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,1600,50,,1280,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2400,75,,1920,percent of total billed charges,75% of total billed charges for outpatient setting,1600,50,,1280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.88,12.84,,328.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2560,80,,2048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.88,12.84,,328.7,percent of total billed charges,12.84% of total billed charges,410.88,12.84,,328.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3360,105,,2688,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,35,,896,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1920,60,,1536,percent of total billed charges,60% of total billed charges for outpatient setting,410.88,3360,
FEMORAL LG TWIN PEG OXF PART KNEE 161470,69162279,CDM,278,RC,,,Outpatient,,,4470,4470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2682,60,,2145.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3794.14,84.88,,3035.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,2235,50,,1788,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3352.5,75,,2682,percent of total billed charges,75% of total billed charges for outpatient setting,2235,50,,1788,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3576,80,,2860.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4693.5,105,,3754.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1564.5,35,,1251.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2682,60,,2145.6,percent of total billed charges,60% of total billed charges for outpatient setting,573.95,4693.5,
FEMORAL L-WEDGE 5mmx5mm 71421741,69161368,CDM,278,RC,,,Outpatient,,,2737.5,2737.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1642.5,60,,1314,percent of total billed charges,60% of total Billed charges for outpatient setting,2323.59,84.88,,1858.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,1368.75,50,,1095,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2053.13,75,,1642.5,percent of total billed charges,75% of total billed charges for outpatient setting,1368.75,50,,1095,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190,80,,1752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2874.38,105,,2299.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.13,35,,766.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1642.5,60,,1314,percent of total billed charges,60% of total billed charges for outpatient setting,351.5,2874.38,
FEMORAL L-WEDGE10mmx5mm 71421743,69161369,CDM,278,RC,,,Outpatient,,,2737.5,2737.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1642.5,60,,1314,percent of total billed charges,60% of total Billed charges for outpatient setting,2323.59,84.88,,1858.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,1368.75,50,,1095,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2053.13,75,,1642.5,percent of total billed charges,75% of total billed charges for outpatient setting,1368.75,50,,1095,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190,80,,1752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,351.5,12.84,,281.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2874.38,105,,2299.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.13,35,,766.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1642.5,60,,1314,percent of total billed charges,60% of total billed charges for outpatient setting,351.5,2874.38,
FEMORAL MED TWIN PEG OXF UNI/ 161469,69162914,CDM,278,RC,C1713,HCPCS,Outpatient,,,4470,4470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2682,60,,2145.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3794.14,84.88,,3035.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3352.5,75,,2682,percent of total billed charges,75% of total billed charges for outpatient setting,2235,50,,1788,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3576,80,,2860.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,573.95,12.84,,459.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4693.5,105,,3754.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1564.5,35,,1251.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2682,60,,2145.6,percent of total billed charges,60% of total billed charges for outpatient setting,573.95,4693.5,
FEMORAL STEM   15MMX155MM 1554-01-150,69162288,CDM,278,RC,,,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
FEMORAL STEM SZ 5 X 145MM / 1570-12-11,69169777,CDM,278,RC,,,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
FEMORAL STEM SZ 9 / 3L92499,71000473,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
FEMORAL SZ 3 RIGHT  SIGMA/96-0013,69162109,CDM,278,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMORAL SZ 4 ATTUNE RT / 1504-00-204,71000407,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
FEMORAL SZ 4 LEFT SIGMA,70000007,CDM,278,RC,,,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
FEMORAL SZ 6 ATTUNE RT / 1504-00-206,71000338,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114,2114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.4,60,,1014.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.36,84.88,,1435.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.5,75,,1268.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057,50,,845.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.2,80,,1352.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,271.44,12.84,,217.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.7,105,,1775.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.9,35,,591.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.4,60,,1014.72,percent of total billed charges,60% of total billed charges for outpatient setting,271.44,2219.7,
FEMORAL SZ 7 ATTUNE LT / 1504-00-107,71000795,CDM,278,RC,C1713,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL SZ 8 ATTUNE LT / 1504-00-108,71000934,CDM,278,RC,C1776,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL SZ 8 ATTUNE RT / 1504-00-208,71000677,CDM,278,RC,C1776,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL SZ 9 ATTUNE RT / 1504-00-209,71000857,CDM,278,RC,C1713,HCPCS,Outpatient,,,2916,2916,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.6,60,,1399.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2475.1,84.88,,1980.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187,75,,1749.6,percent of total billed charges,75% of total billed charges for outpatient setting,1458,50,,1166.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.8,80,,1866.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,374.41,12.84,,299.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3061.8,105,,2449.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.6,35,,816.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1749.6,60,,1399.68,percent of total billed charges,60% of total billed charges for outpatient setting,374.41,3061.8,
FEMORAL TWN PEG SM OXFORD PART KN/161468,69161904,CDM,278,RC,,,Outpatient,,,5464,5464,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3278.4,60,,2622.72,percent of total billed charges,60% of total Billed charges for outpatient setting,4637.84,84.88,,3710.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,2732,50,,2185.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4098,75,,3278.4,percent of total billed charges,75% of total billed charges for outpatient setting,2732,50,,2185.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.58,12.84,,561.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4371.2,80,,3496.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.58,12.84,,561.26,percent of total billed charges,12.84% of total billed charges,701.58,12.84,,561.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5737.2,105,,4589.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1912.4,35,,1529.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3278.4,60,,2622.72,percent of total billed charges,60% of total billed charges for outpatient setting,701.58,5737.2,
FEMORAL WEDGE SZ 4 /10mm 71421662,69161872,CDM,278,RC,,,Outpatient,,,2838,2838,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1702.8,60,,1362.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2408.89,84.88,,1927.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,1419,50,,1135.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2128.5,75,,1702.8,percent of total billed charges,75% of total billed charges for outpatient setting,1419,50,,1135.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2270.4,80,,1816.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2979.9,105,,2383.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.3,35,,794.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1702.8,60,,1362.24,percent of total billed charges,60% of total billed charges for outpatient setting,364.4,2979.9,
FEMORAL WEDGE SZ 4 /15mm 71421663,69161871,CDM,278,RC,,,Outpatient,,,2838,2838,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1702.8,60,,1362.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2408.89,84.88,,1927.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,1419,50,,1135.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2128.5,75,,1702.8,percent of total billed charges,75% of total billed charges for outpatient setting,1419,50,,1135.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2270.4,80,,1816.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,364.4,12.84,,291.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2979.9,105,,2383.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.3,35,,794.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1702.8,60,,1362.24,percent of total billed charges,60% of total billed charges for outpatient setting,364.4,2979.9,
FEMUR BILAT 2 OR MORE VIEWS,2400337,CDM,320,RC,73552,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
FEMUR COMP SZ 10 LT CR / 42-5026-068-01,69169483,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 10 R CR / 42-5020-068-02,71000209,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 10 RIGHT CR/42-5026-068-02,69169826,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 11 LEFT CR /42-5020-070-01,71000013,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 11 LT CR /42-5026-070-01,69169683,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 11 RIGHT PS/42-5006-070-02,69169419,CDM,278,RC,C1776,HCPCS,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
FEMUR COMP SZ 11 RT CR /42-5026-070-02,69169663,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 12 L CR / 42-5026-074-01,71000485,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 12 LEFT CR /42-5026-074-02,69169512,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 12 LT CR / 42-5006-074-01,71000113,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 12 RT CR / 42-5006-074-02,71000183,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 3 LT PS / 42-5006-054-01,71000134,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 3 RT CR / 42-5020-054-02,71000523,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 4 LEFT CR /42-5026-056-01,69169747,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 4 LT CR / 42-5020-056-01,71000193,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 4 LT PS / 42-5006-056-01,71000185,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 4 RIGHT CR /42-5026-056-02,69169631,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 4 RIGHT CR/ 42-5020-062-02,72000005,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 5 L PS / 42-5006-058-01,71000317,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 5 LEFT CR /42-5026-058-01,69169562,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 5 LT CR / 42-5020-058-01,71000204,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 5 R PS / 42-5006-058-02,71000173,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 5 RIGHT CR /42-5026-058-02,69069368,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 5 RT CR / 42-5020-058-02,71000522,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 6 CR L / 42-5026-060-01,69169469,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 6 L PSN / 42-5726-060-01,71000199,CDM,278,RC,C1776,HCPCS,Outpatient,,,12950,12950,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7770,60,,6216,percent of total billed charges,60% of total Billed charges for outpatient setting,10991.96,84.88,,8793.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9712.5,75,,7770,percent of total billed charges,75% of total billed charges for outpatient setting,6475,50,,5180,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.78,12.84,,1330.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10360,80,,8288,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.78,12.84,,1330.22,percent of total billed charges,12.84% of total billed charges,1662.78,12.84,,1330.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13597.5,105,,10878,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4532.5,35,,3626,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7770,60,,6216,percent of total billed charges,60% of total billed charges for outpatient setting,1662.78,13597.5,
FEMUR COMP SZ 6 LT CR / 42-5020-060-01,71000059,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 6 RGHT CR / 42-5020-060-02,71000040,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 6 RIGHT CR /42-5026-060-02,69169368,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 6 RT PSN / 42-5726-060-02,71000052,CDM,278,RC,C1776,HCPCS,Outpatient,,,12950,12950,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7770,60,,6216,percent of total billed charges,60% of total Billed charges for outpatient setting,10991.96,84.88,,8793.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9712.5,75,,7770,percent of total billed charges,75% of total billed charges for outpatient setting,6475,50,,5180,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.78,12.84,,1330.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10360,80,,8288,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.78,12.84,,1330.22,percent of total billed charges,12.84% of total billed charges,1662.78,12.84,,1330.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13597.5,105,,10878,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4532.5,35,,3626,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7770,60,,6216,percent of total billed charges,60% of total billed charges for outpatient setting,1662.78,13597.5,
FEMUR COMP SZ 7 LEFT CR /42-5026-062-01,69169499,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 7 LEFT NTR /42-5726-062-01,69169782,CDM,278,RC,C1776,HCPCS,Outpatient,,,13597.5,13597.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8158.5,60,,6526.8,percent of total billed charges,60% of total Billed charges for outpatient setting,11541.56,84.88,,9233.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10198.13,75,,8158.5,percent of total billed charges,75% of total billed charges for outpatient setting,6798.75,50,,5439,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.92,12.84,,1396.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10878,80,,8702.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.92,12.84,,1396.74,percent of total billed charges,12.84% of total billed charges,1745.92,12.84,,1396.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14277.38,105,,11421.9,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4759.13,35,,3807.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8158.5,60,,6526.8,percent of total billed charges,60% of total billed charges for outpatient setting,1745.92,14277.38,
FEMUR COMP SZ 7 LT CR / 42-5020-062-01,71000130,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 7 LT PS / 42-5006-062-01,71000181,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
FEMUR COMP SZ 7 R PSN / 42-5726-062-02,71000307,CDM,278,RC,C1776,HCPCS,Outpatient,,,7400,7400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4440,60,,3552,percent of total billed charges,60% of total Billed charges for outpatient setting,6281.12,84.88,,5024.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5550,75,,4440,percent of total billed charges,75% of total billed charges for outpatient setting,3700,50,,2960,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.16,12.84,,760.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5920,80,,4736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.16,12.84,,760.13,percent of total billed charges,12.84% of total billed charges,950.16,12.84,,760.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7770,105,,6216,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2590,35,,2072,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4440,60,,3552,percent of total billed charges,60% of total billed charges for outpatient setting,950.16,7770,
FEMUR COMP SZ 7 RIGHT CR /42-5026-062-02,69169446,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 7 RIGHT PS /42-5006-062-02,69169418,CDM,278,RC,C1776,HCPCS,Outpatient,,,7533.75,7533.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4520.25,60,,3616.2,percent of total billed charges,60% of total Billed charges for outpatient setting,6394.65,84.88,,5115.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5650.31,75,,4520.25,percent of total billed charges,75% of total billed charges for outpatient setting,3766.88,50,,3013.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.33,12.84,,773.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027,80,,4821.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.33,12.84,,773.86,percent of total billed charges,12.84% of total billed charges,967.33,12.84,,773.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7910.44,105,,6328.35,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2636.81,35,,2109.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4520.25,60,,3616.2,percent of total billed charges,60% of total billed charges for outpatient setting,967.33,7910.44,
FEMUR COMP SZ 7 RT CR / 42-5020-062-02,69169691,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 8 LEFT CR / 42-5026-064-01,69169224,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 8 LEFT CR /42-5020-064-01,69169666,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 8 RIGHT CR /42-5020-064-02,69169531,CDM,278,RC,C1776,HCPCS,Outpatient,,,6615,6615,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,60,,3175.2,percent of total billed charges,60% of total Billed charges for outpatient setting,5614.81,84.88,,4491.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4961.25,75,,3969,percent of total billed charges,75% of total billed charges for outpatient setting,3307.5,50,,2646,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5292,80,,4233.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,849.37,12.84,,679.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6945.75,105,,5556.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,35,,1852.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3969,60,,3175.2,percent of total billed charges,60% of total billed charges for outpatient setting,849.37,6945.75,
FEMUR COMP SZ 8 RIGHT CR /42-5026-064-02,69169581,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 8 RIGHT PS /42-5006-064-02,69169398,CDM,278,RC,C1776,HCPCS,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
FEMUR COMP SZ 9 LEFT CR /42-5026-066-01,69169393,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 9 LT CR / 42-5020-066-01,71000246,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 9 RIGHT CR /42-5026-066-02,69169489,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 9 RT CR / 42-5020-066-02,71000161,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ 9 RT PS / 42-5000-066-02,71000144,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
FEMUR COMP SZ E RIGHT  LCCK /5994-15-92,69169574,CDM,278,RC,C1776,HCPCS,Outpatient,,,11828,11828,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7096.8,60,,5677.44,percent of total billed charges,60% of total Billed charges for outpatient setting,10039.61,84.88,,8031.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8871,75,,7096.8,percent of total billed charges,75% of total billed charges for outpatient setting,5914,50,,4731.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.72,12.84,,1214.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9462.4,80,,7569.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.72,12.84,,1214.98,percent of total billed charges,12.84% of total billed charges,1518.72,12.84,,1214.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12419.4,105,,9935.52,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4139.8,35,,3311.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7096.8,60,,5677.44,percent of total billed charges,60% of total billed charges for outpatient setting,1518.72,12419.4,
FEMUR LEFT  1 VW,2400338,CDM,320,RC,73551,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FEMUR LEFT 2 OR MORE VIEWS,2400339,CDM,320,RC,73552,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FEMUR RIGHT 1 VIEW,2400343,CDM,320,RC,73551,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FEMUR RIGHT 2 OR MORE VIEWS,2400344,CDM,320,RC,73552,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FEMUR SZ 3 RIGHT CR / 96-0013,69169648,CDM,278,RC,C1776,HCPCS,Outpatient,,,2080,2080,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,60,,998.4,percent of total billed charges,60% of total Billed charges for outpatient setting,1765.5,84.88,,1412.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,75,,1248,percent of total billed charges,75% of total billed charges for outpatient setting,1040,50,,832,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.07,12.84,,213.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1664,80,,1331.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.07,12.84,,213.66,percent of total billed charges,12.84% of total billed charges,267.07,12.84,,213.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2080,65,,1664,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728,35,,582.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1248,60,,998.4,percent of total billed charges,60% of total billed charges for outpatient setting,267.07,2080,
FENOLDOPAM 10 MG/ML: 1 ML,3303188,CDM,250,RC,,,Outpatient,,,443.26,443.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.28,70,,248.22,percent of total billed charges,70% of total billed charges for outpatient setting,376.24,84.88,,300.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,221.63,50,,177.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,332.45,75,,265.96,percent of total billed charges,75% of total billed charges for outpatient setting,310.28,70,,248.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.91,12.84,,45.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.61,80,,283.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.91,12.84,,45.53,percent of total billed charges,12.84% of total billed charges,56.91,12.84,,45.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,288.12,65,,230.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.14,35,,124.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.93,90,,319.14,percent of total billed charges,90% of total billed charges for outpatient setting,56.91,398.93,
FENTANYL (DURAGESIC) PATCH 100 MCG HR:,3301073,CDM,259,RC,,,Outpatient,,,113.87,113.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.71,70,,63.77,percent of total billed charges,70% of total billed charges for outpatient setting,96.65,84.88,,77.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.94,50,,45.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.4,75,,68.32,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,70,,63.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,12.84,,11.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.1,80,,72.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,12.84,,11.7,percent of total billed charges,12.84% of total billed charges,14.62,12.84,,11.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.02,65,,59.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.85,35,,31.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.48,90,,81.98,percent of total billed charges,90% of total billed charges for outpatient setting,14.62,102.48,
FENTANYL (DURAGESIC) PATCH 25 MCG/HR,3301070,CDM,259,RC,,,Outpatient,,,34.96,34.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.47,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,29.67,84.88,,23.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.48,50,,13.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.22,75,,20.98,percent of total billed charges,75% of total billed charges for outpatient setting,24.47,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,80,,22.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.72,65,,18.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,35,,9.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.46,90,,25.17,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.46,
FENTANYL (DURAGESIC) PATCH 50 MCG/HR,3301071,CDM,259,RC,,,Outpatient,,,57,57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.9,70,,31.92,percent of total billed charges,70% of total billed charges for outpatient setting,48.38,84.88,,38.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.5,50,,22.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,75,,34.2,percent of total billed charges,75% of total billed charges for outpatient setting,39.9,70,,31.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.32,12.84,,5.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,80,,36.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.32,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,7.32,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.05,65,,29.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,35,,15.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,90% of total billed charges for outpatient setting,7.32,51.3,
FENTANYL (DURAGESIC) PATCH 75 MCG/HR:,3301072,CDM,259,RC,,,Outpatient,,,91.41,91.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.99,70,,51.19,percent of total billed charges,70% of total billed charges for outpatient setting,77.59,84.88,,62.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.71,50,,36.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.56,75,,54.85,percent of total billed charges,75% of total billed charges for outpatient setting,63.99,70,,51.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,12.84,,9.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.13,80,,58.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,12.84,,9.39,percent of total billed charges,12.84% of total billed charges,11.74,12.84,,9.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.42,65,,47.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.99,35,,25.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.27,90,,65.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.74,82.27,
FENTANYL (genSUBLIMAZE)   50mcg/ML  2ML,3301076,CDM,636,RC,J3010,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FENTANYL (INNOVAR) INJ 0.05/ML: 2ML,3301074,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FENTANYL (INNOVAR) INJ 0.05/ML: 5ML,3301077,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FENTANYL (INNOVAR) INJ 0.05/ML: 5ML,3301078,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FENTANYL (INNOVAR) INJ 0.05/ML: 5ML,3301075,CDM,250,RC,,,Outpatient,,,74.14,74.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,62.93,84.88,,50.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.07,50,,29.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.61,75,,44.49,percent of total billed charges,75% of total billed charges for outpatient setting,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.31,80,,47.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.19,65,,38.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,35,,20.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.73,90,,53.38,percent of total billed charges,90% of total billed charges for outpatient setting,9.52,66.73,
FENTANYL (SUBLIMAZE)   0.05/ML  1ML,3313377,CDM,636,RC,J3010,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FENTANYL (SUBLIMAZE)   0.05/ML: 10ML,3301079,CDM,250,RC,,,Outpatient,,,19.96,19.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,84.88,,13.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.98,50,,7.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.97,75,,11.98,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.97,80,,12.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.97,65,,10.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,35,,5.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.96,90,,14.37,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.96,
FENTANYL 100CC:EPIDURAL,3302842,CDM,250,RC,,,Outpatient,,,588.17,588.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.72,70,,329.38,percent of total billed charges,70% of total billed charges for outpatient setting,499.24,84.88,,399.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,294.09,50,,235.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.13,75,,352.9,percent of total billed charges,75% of total billed charges for outpatient setting,411.72,70,,329.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.52,12.84,,60.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.54,80,,376.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.52,12.84,,60.42,percent of total billed charges,12.84% of total billed charges,75.52,12.84,,60.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.31,65,,305.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.86,35,,164.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.35,90,,423.48,percent of total billed charges,90% of total billed charges for outpatient setting,75.52,529.35,
FENTANYL 20CC: AMP,3302841,CDM,250,RC,,,Outpatient,,,588.17,588.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.72,70,,329.38,percent of total billed charges,70% of total billed charges for outpatient setting,499.24,84.88,,399.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,294.09,50,,235.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.13,75,,352.9,percent of total billed charges,75% of total billed charges for outpatient setting,411.72,70,,329.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.52,12.84,,60.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.54,80,,376.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.52,12.84,,60.42,percent of total billed charges,12.84% of total billed charges,75.52,12.84,,60.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.31,65,,305.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.86,35,,164.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.35,90,,423.48,percent of total billed charges,90% of total billed charges for outpatient setting,75.52,529.35,
FENTANYL 250 MCG/5 ML AMP,3302967,CDM,636,RC,J3010,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FENTANYL(gen SUBLIMAZE) 50mcg/ML  1ml,3313261,CDM,636,RC,J3010,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FENTANYL(SUBLIMAZE)50MCG/ML INJ:50ML,3302951,CDM,250,RC,J3010,HCPCS,Outpatient,,,206.22,206.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.35,70,,115.48,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,84.88,,140.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,154.67,75,,123.74,percent of total billed charges,75% of total billed charges for outpatient setting,144.35,70,,115.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,12.84,,21.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.98,80,,131.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,12.84,,21.18,percent of total billed charges,12.84% of total billed charges,26.48,12.84,,21.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.04,65,,107.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,185.6,90,,148.48,percent of total billed charges,90% of total billed charges for outpatient setting,0.79,185.6,
FEO-GEN FORTE,3302974,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
FERRITIN,201728,CDM,301,RC,82728,HCPCS,Outpatient,,,61.34,55.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,52.07,84.88,,41.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.01,75,,36.81,percent of total billed charges,75% of total billed charges for outpatient setting,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.07,80,,39.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.84,100,,,Fee Schedule,100% of Custom Fee Schedule,55.21,90,,44.17,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,55.21,
FERROUS GLUC: 325MG,3302929,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FERROUS SULF (FEOSOL) 325MG TAB U/D,3301085,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FERROUS SULF (FEOSOL) SYRUP 300MG:5ML UD,3301084,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FERROUS SULF (FEOSOL) TAB : 324 MG U/D,3301083,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FERROUS SULF (FEOSOL) TAB : 325 MG,3301080,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FERROUS SULF (FEOSOL) TAB : 325 MG,3301081,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FERROUS SULF (FEOSOL) TAB : 325 MG U/D,3301082,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FEXOFENADINE (ALLEGRA) CAP: 60 MG,3301086,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FIBER 5CC INFLUX / ISTO-CF-05,7204808,CDM,278,RC,C9359,HCPCS,Outpatient,,,2376.5,2376.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.9,60,,1140.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2017.17,84.88,,1613.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1782.38,75,,1425.9,percent of total billed charges,75% of total billed charges for outpatient setting,1188.25,50,,950.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.14,12.84,,244.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1901.2,80,,1520.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.14,12.84,,244.11,percent of total billed charges,12.84% of total billed charges,305.14,12.84,,244.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2495.33,105,,1996.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.78,35,,665.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1425.9,60,,1140.72,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2495.33,
FIBER OPT DEVICE OTW 2.0mmX150cm/420-006,69159810,CDM,272,RC,C1885,HCPCS,Outpatient,,,3750,3750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625,70,,2100,percent of total billed charges,70% of total billed charges for outpatient setting,3183,84.88,,2546.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2812.5,75,,2250,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.5,12.84,,385.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,80,,2400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.5,12.84,,385.2,percent of total billed charges,12.84% of total billed charges,481.5,12.84,,385.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2437.5,65,,1950,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312.5,35,,1050,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3375,90,,2700,percent of total billed charges,90% of total billed charges for outpatient setting,481.5,3375,
FIBERCON: TAB,3303003,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FIBERLINK 1.3MM SUTURE W/ LOOP / AR-7535,71000497,CDM,272,RC,A4649,HCPCS,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
FIBERLINK SUTURE BLUE / AR-7235,69162241,CDM,272,RC,,,Outpatient,,,237.93,237.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,201.95,84.88,,161.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.97,50,,95.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.45,75,,142.76,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.34,80,,152.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.65,65,,123.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.28,35,,66.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.14,90,,171.31,percent of total billed charges,90% of total billed charges for outpatient setting,30.55,214.14,
FIBERLOOP NO 2 BLUE / AR-7234,69161809,CDM,278,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.78,60,,103.82,percent of total billed charges,60% of total Billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,216.3,65,,173.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.78,60,,103.82,percent of total billed charges,60% of total billed charges for outpatient setting,27.77,216.3,
FIBERLOOP NO.2 / AR-7234C / BLUE,69162450,CDM,278,RC,,,Outpatient,,,250.64,250.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.38,60,,120.3,percent of total billed charges,60% of total Billed charges for outpatient setting,212.74,84.88,,170.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.98,75,,150.38,percent of total billed charges,75% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.51,80,,160.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,250.64,65,,200.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.72,35,,70.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.38,60,,120.3,percent of total billed charges,60% of total billed charges for outpatient setting,32.18,250.64,
FIBEROS 2CC   / FB020,69169157,CDM,278,RC,,,Outpatient,,,13929.72,13929.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8357.83,60,,6686.26,percent of total billed charges,60% of total Billed charges for outpatient setting,11823.55,84.88,,9458.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,6964.86,50,,5571.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10447.29,75,,8357.83,percent of total billed charges,75% of total billed charges for outpatient setting,6964.86,50,,5571.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1788.58,12.84,,1430.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11143.78,80,,8915.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1788.58,12.84,,1430.86,percent of total billed charges,12.84% of total billed charges,1788.58,12.84,,1430.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14626.21,105,,11700.97,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4875.4,35,,3900.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8357.83,60,,6686.26,percent of total billed charges,60% of total billed charges for outpatient setting,1788.58,14626.21,
FIBEROS 5CC / FB050,69169155,CDM,278,RC,,,Outpatient,,,2460.41,2460.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1476.25,60,,1181,percent of total billed charges,60% of total Billed charges for outpatient setting,2088.4,84.88,,1670.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1230.21,50,,984.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1845.31,75,,1476.25,percent of total billed charges,75% of total billed charges for outpatient setting,1230.21,50,,984.17,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.92,12.84,,252.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968.33,80,,1574.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.92,12.84,,252.74,percent of total billed charges,12.84% of total billed charges,315.92,12.84,,252.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2583.43,105,,2066.74,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,861.14,35,,688.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1476.25,60,,1181,percent of total billed charges,60% of total billed charges for outpatient setting,315.92,2583.43,
"FIBERSTICK #2, #2 FIBERWIRE  AR-7209",69161715,CDM,272,RC,,,Outpatient,,,256.21,256.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.35,70,,143.48,percent of total billed charges,70% of total billed charges for outpatient setting,217.47,84.88,,173.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.11,50,,102.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.16,75,,153.73,percent of total billed charges,75% of total billed charges for outpatient setting,179.35,70,,143.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.97,80,,163.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.54,65,,133.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.67,35,,71.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.59,90,,184.47,percent of total billed charges,90% of total billed charges for outpatient setting,32.9,230.59,
FIBERSTITCH IMPLANT CURVED / AR-4570,69169730,CDM,278,RC,,,Outpatient,,,2079,2079,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.4,60,,997.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1764.66,84.88,,1411.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,1039.5,50,,831.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1559.25,75,,1247.4,percent of total billed charges,75% of total billed charges for outpatient setting,1039.5,50,,831.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1663.2,80,,1330.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2079,65,,1663.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.65,35,,582.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1247.4,60,,997.92,percent of total billed charges,60% of total billed charges for outpatient setting,266.94,2079,
FIBERTAPE / AR-7237-7,69162243,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
FIBERTAPE 17IN BLU / AR-7237-17N,71000927,CDM,272,RC,,,Outpatient,,,319.2,319.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.44,70,,178.75,percent of total billed charges,70% of total billed charges for outpatient setting,270.94,84.88,,216.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.6,50,,127.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.4,75,,191.52,percent of total billed charges,75% of total billed charges for outpatient setting,223.44,70,,178.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,12.84,,32.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.36,80,,204.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,12.84,,32.79,percent of total billed charges,12.84% of total billed charges,40.99,12.84,,32.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,207.48,65,,165.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.72,35,,89.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,287.28,90,,229.82,percent of total billed charges,90% of total billed charges for outpatient setting,40.99,287.28,
FIBERTAPE 17IN W/ STR NDL / AR-7237-17LN,70000519,CDM,272,RC,,,Outpatient,,,319.2,319.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.44,70,,178.75,percent of total billed charges,70% of total billed charges for outpatient setting,270.94,84.88,,216.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.6,50,,127.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.4,75,,191.52,percent of total billed charges,75% of total billed charges for outpatient setting,223.44,70,,178.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,12.84,,32.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.36,80,,204.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,12.84,,32.79,percent of total billed charges,12.84% of total billed charges,40.99,12.84,,32.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,207.48,65,,165.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.72,35,,89.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,287.28,90,,229.82,percent of total billed charges,90% of total billed charges for outpatient setting,40.99,287.28,
FIBERTAPE 2MM TO #2 FIBERWIRE /AR-7237,69162640,CDM,272,RC,,,Outpatient,,,454.23,454.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.96,70,,254.37,percent of total billed charges,70% of total billed charges for outpatient setting,385.55,84.88,,308.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,227.12,50,,181.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.67,75,,272.54,percent of total billed charges,75% of total billed charges for outpatient setting,317.96,70,,254.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,80,,290.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,295.25,65,,236.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,35,,127.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,408.81,90,,327.05,percent of total billed charges,90% of total billed charges for outpatient setting,58.32,408.81,
FIBERWIRE 5 38IN W/ NEEDLES / AR-7212,70000253,CDM,278,RC,,,Outpatient,,,454.23,454.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.54,60,,218.03,percent of total billed charges,60% of total Billed charges for outpatient setting,385.55,84.88,,308.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,227.12,50,,181.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.67,75,,272.54,percent of total billed charges,75% of total billed charges for outpatient setting,227.12,50,,181.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,80,,290.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,454.23,65,,363.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,35,,127.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,272.54,60,,218.03,percent of total billed charges,60% of total billed charges for outpatient setting,58.32,454.23,
FIBRINOGEN,220179,CDM,300,RC,85384,HCPCS,Outpatient,,,43.74,39.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,70,,24.5,percent of total billed charges,70% of total billed charges for outpatient setting,37.13,84.88,,29.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.81,75,,26.25,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,70,,24.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.99,80,,27.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,100,,,Fee Schedule,100% of Custom Fee Schedule,39.37,90,,31.5,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,39.37,
FIBRINOLYTIC FACTORS;ALPHA-2 ANTIPLASMIN,201315,CDM,300,RC,85410,HCPCS,Outpatient,,,34.7,31.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.29,70,,19.43,percent of total billed charges,70% of total billed charges for outpatient setting,29.45,84.88,,23.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.03,75,,20.82,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,70,,19.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.76,80,,22.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,100,,,Fee Schedule,100% of Custom Fee Schedule,31.23,90,,24.98,percent of total billed charges,90% of total billed charges for outpatient setting,7.71,31.23,
FILGRASTIM (NEUPOGEN) INJ 300MCG: 1ML,3301087,CDM,636,RC,J1440,HCPCS,Outpatient,,,805.52,805.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.86,70,,451.09,percent of total billed charges,70% of total billed charges for outpatient setting,683.73,84.88,,546.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,402.76,50,,322.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,604.14,75,,483.31,percent of total billed charges,75% of total billed charges for outpatient setting,563.86,70,,451.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.43,12.84,,82.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.42,80,,515.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.43,12.84,,82.74,percent of total billed charges,12.84% of total billed charges,103.43,12.84,,82.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,523.59,65,,418.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.93,35,,225.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,724.97,90,,579.98,percent of total billed charges,90% of total billed charges for outpatient setting,103.43,724.97,
FILGRASTIM (NEUPOGEN)INJ. 480 MCG: 1.8ML,3303071,CDM,636,RC,J1441,HCPCS,Outpatient,,,1595.07,1595.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.55,70,,893.24,percent of total billed charges,70% of total billed charges for outpatient setting,1353.9,84.88,,1083.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,797.54,50,,638.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1196.3,75,,957.04,percent of total billed charges,75% of total billed charges for outpatient setting,1116.55,70,,893.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.81,12.84,,163.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1276.06,80,,1020.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.81,12.84,,163.85,percent of total billed charges,12.84% of total billed charges,204.81,12.84,,163.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1036.8,65,,829.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.27,35,,446.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1435.56,90,,1148.45,percent of total billed charges,90% of total billed charges for outpatient setting,204.81,1435.56,
FILSHIE CLIPS / AVM-851,6150680,CDM,272,RC,,,Outpatient,,,415.13,415.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.59,70,,232.47,percent of total billed charges,70% of total billed charges for outpatient setting,352.36,84.88,,281.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.57,50,,166.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.35,75,,249.08,percent of total billed charges,75% of total billed charges for outpatient setting,290.59,70,,232.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.1,80,,265.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,269.83,65,,215.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.3,35,,116.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.62,90,,298.9,percent of total billed charges,90% of total billed charges for outpatient setting,53.3,373.62,
FILTER 0.45 MICRON / OF001,6051193,CDM,270,RC,,,Outpatient,,,75.71,75.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53,70,,42.4,percent of total billed charges,70% of total billed charges for outpatient setting,64.26,84.88,,51.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.86,50,,30.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.78,75,,45.42,percent of total billed charges,75% of total billed charges for outpatient setting,53,70,,42.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,12.84,,7.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.57,80,,48.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,12.84,,7.78,percent of total billed charges,12.84% of total billed charges,9.72,12.84,,7.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.21,65,,39.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,35,,21.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.14,90,,54.51,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,68.14,
FILTER INSUFFLATION BULB PROCTO / 30210,69160938,CDM,271,RC,,,Outpatient,,,78.89,78.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.22,70,,44.18,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,84.88,,53.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.45,50,,31.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.17,75,,47.34,percent of total billed charges,75% of total billed charges for outpatient setting,55.22,70,,44.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.13,12.84,,8.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.11,80,,50.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.13,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,10.13,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.28,65,,41.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.61,35,,22.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71,90,,56.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.13,71,
FINASTERIDE (genericPROSCAR) TAB  5 MG,3301088,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FINE NDL ASP BX WO IMG GUID 1ST LESION,200335,CDM,360,RC,10021,HCPCS,Outpatient,,,216.44,216.44,,495.56,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.51,70,,121.21,percent of total billed charges,70% of total billed charges for outpatient setting,183.71,84.88,,146.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.26,50,,345.81,percent of total billed charges,50% of total Billed charges for outpatient setting,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,162.33,75,,129.86,percent of total billed charges,75% of total billed charges for outpatient setting,151.51,70,,121.21,percent of total billed charges,70% of total billed charges for outpatient setting,526.53,170,,,Fee Schedule,170% of Medicare OPPS rate,665.91,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,27.79,12.84,,22.232,percent of total billed charges,12.84% of total billed charges,542.02,175,,,Fee Schedule,175% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.15,80,,138.52,percent of total billed charges,80% of total billed charges for outpatient setting,433.62,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,387.16,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,27.79,12.84,,22.23,percent of total billed charges,12.84% of total billed charges,27.79,12.84,,22.23,percent of total billed charges,12.84% of total billed charges,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,175.33,100,,,Fee Schedule,100% of Custom Fee Schedule,194.8,90,,155.84,percent of total billed charges,90% of total billed charges for outpatient setting,27.79,665.91,
FINE NDL ASP DEEP WO IMG GUIDE,200340,CDM,360,RC,10021,HCPCS,Outpatient,,,216.44,216.44,,495.56,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.51,70,,121.21,percent of total billed charges,70% of total billed charges for outpatient setting,183.71,84.88,,146.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.26,50,,345.81,percent of total billed charges,50% of total Billed charges for outpatient setting,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,162.33,75,,129.86,percent of total billed charges,75% of total billed charges for outpatient setting,151.51,70,,121.21,percent of total billed charges,70% of total billed charges for outpatient setting,526.53,170,,,Fee Schedule,170% of Medicare OPPS rate,665.91,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,27.79,12.84,,22.232,percent of total billed charges,12.84% of total billed charges,542.02,175,,,Fee Schedule,175% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.15,80,,138.52,percent of total billed charges,80% of total billed charges for outpatient setting,433.62,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,387.16,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,27.79,12.84,,22.23,percent of total billed charges,12.84% of total billed charges,27.79,12.84,,22.23,percent of total billed charges,12.84% of total billed charges,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,309.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,175.33,100,,,Fee Schedule,100% of Custom Fee Schedule,194.8,90,,155.84,percent of total billed charges,90% of total billed charges for outpatient setting,27.79,665.91,
FINGER COT PADDED 1.5 IN / 7971903,69169620,CDM,270,RC,,,Outpatient,,,6.71,6.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,84.88,,4.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.36,50,,2.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.03,75,,4.02,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.37,80,,4.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.36,65,,3.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,35,,1.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.04,90,,4.83,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,6.04,
FINGER COT PADDED 2.25IN / 7971905,69169621,CDM,270,RC,,,Outpatient,,,6.71,6.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,84.88,,4.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.36,50,,2.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.03,75,,4.02,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.37,80,,4.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.36,65,,3.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,35,,1.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.04,90,,4.83,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,6.04,
FINGER COT PADDED 3.25IN /7971907,6151028,CDM,270,RC,,,Outpatient,,,6.71,6.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,84.88,,4.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.36,50,,2.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.03,75,,4.02,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,70,,3.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.37,80,,4.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.36,65,,3.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,35,,1.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.04,90,,4.83,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,6.04,
FINGER(S)  2 VWS BILATERAL,2400557,CDM,320,RC,73140,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FINGER(S) MIN OF 2 VWS LEFT,2400556,CDM,320,RC,73140,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FINGER(S) MIN OF 2 VWS RIGHT,2400555,CDM,320,RC,73140,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FIRST AID (CARRASYN) GEL: 0.5 OZ,3301089,CDM,259,RC,,,Outpatient,,,16.25,16.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,70,,9.1,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,84.88,,11.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.13,50,,6.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.19,75,,9.75,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,70,,9.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13,80,,10.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.56,65,,8.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,35,,4.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.63,90,,11.7,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.63,
FIX CORT 5.5 TI 7X35MM / 1867-31-735,70000493,CDM,278,RC,C1713,HCPCS,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
FIX CORTICAL TI 5X40MM / 1867-31-540,70000450,CDM,278,RC,C1713,HCPCS,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
FLANDERS BUTTOCKS OINT 113 G,3303283,CDM,259,RC,,,Outpatient,,,46.79,46.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.75,70,,26.2,percent of total billed charges,70% of total billed charges for outpatient setting,39.72,84.88,,31.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.4,50,,18.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.09,75,,28.07,percent of total billed charges,75% of total billed charges for outpatient setting,32.75,70,,26.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.43,80,,29.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,6.01,12.84,,4.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.41,65,,24.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.38,35,,13.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.11,90,,33.69,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,42.11,
FLAT SKIN BARRIER W/FLANGE 2 1/4 / 15603,6152631,CDM,272,RC,,,Outpatient,,,7.37,7.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,70,,4.13,percent of total billed charges,70% of total billed charges for outpatient setting,6.26,84.88,,5.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.69,50,,2.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.53,75,,4.42,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,70,,4.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.9,80,,4.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.79,65,,3.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,35,,2.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.63,90,,5.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.95,6.63,
FLAVOXATE (URISPAS) TAB: 100 MG,3301090,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FLECAINIE 100MG(TAMBOCOR):TAB,3302763,CDM,259,RC,,,Outpatient,,,14.62,14.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,12.41,84.88,,9.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.31,50,,5.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.97,75,,8.78,percent of total billed charges,75% of total billed charges for outpatient setting,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.7,80,,9.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.5,65,,7.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,35,,4.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.16,90,,10.53,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.16,
FLEET ENEMA (ADULT) MINERAL OIL 133ML,3309444,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLEET ENEMA (PEDIATRIC): 66 ML,3302634,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLEET generic ENEMA (ADULT) 133ML,3302633,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLEET PHOSPHO-SODA ORAL SALINE:45MLS,3302788,CDM,259,RC,,,Outpatient,,,14.78,14.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,70,,8.28,percent of total billed charges,70% of total billed charges for outpatient setting,12.55,84.88,,10.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.39,50,,5.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.09,75,,8.87,percent of total billed charges,75% of total billed charges for outpatient setting,10.35,70,,8.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.82,80,,9.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.61,65,,7.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,35,,4.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.3,90,,10.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.9,13.3,
FLEXIBLE IRIS RETRACTOR / 611.75,6150521,CDM,270,RC,,,Outpatient,,,399.95,399.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.97,70,,223.98,percent of total billed charges,70% of total billed charges for outpatient setting,339.48,84.88,,271.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,199.98,50,,159.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.96,75,,239.97,percent of total billed charges,75% of total billed charges for outpatient setting,279.97,70,,223.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.96,80,,255.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.97,65,,207.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.98,35,,111.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,359.96,90,,287.97,percent of total billed charges,90% of total billed charges for outpatient setting,51.35,359.96,
Flexible Tunneler Sheath (Green) 9009-18,69159316,CDM,272,RC,,,Outpatient,,,246.91,246.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.84,70,,138.27,percent of total billed charges,70% of total billed charges for outpatient setting,209.58,84.88,,167.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.46,50,,98.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.18,75,,148.14,percent of total billed charges,75% of total billed charges for outpatient setting,172.84,70,,138.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.53,80,,158.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,160.49,65,,128.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.42,35,,69.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,222.22,90,,177.78,percent of total billed charges,90% of total billed charges for outpatient setting,31.7,222.22,
FLORA Q CAPSULES,3303146,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
FLORASTOR (SACCHAROMYCES BOULAR) 250MG,3303344,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
FLOSEAL HEMOSTATIC MATRIX 10ML/ ADS20184,69169270,CDM,270,RC,,,Outpatient,,,1643.52,1643.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.46,70,,920.37,percent of total billed charges,70% of total billed charges for outpatient setting,1395.02,84.88,,1116.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,821.76,50,,657.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1232.64,75,,986.11,percent of total billed charges,75% of total billed charges for outpatient setting,1150.46,70,,920.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.03,12.84,,168.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.82,80,,1051.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.03,12.84,,168.82,percent of total billed charges,12.84% of total billed charges,211.03,12.84,,168.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1068.29,65,,854.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.23,35,,460.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1479.17,90,,1183.34,percent of total billed charges,90% of total billed charges for outpatient setting,211.03,1479.17,
FLOSEAL MALLEABLE TIPS/ ADS201816,70000825,CDM,270,RC,,,Outpatient,,,122.22,122.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.55,70,,68.44,percent of total billed charges,70% of total billed charges for outpatient setting,103.74,84.88,,82.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.11,50,,48.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.67,75,,73.34,percent of total billed charges,75% of total billed charges for outpatient setting,85.55,70,,68.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.69,12.84,,12.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.78,80,,78.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.69,12.84,,12.55,percent of total billed charges,12.84% of total billed charges,15.69,12.84,,12.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.44,65,,63.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.78,35,,34.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110,90,,88,percent of total billed charges,90% of total billed charges for outpatient setting,15.69,110,
FLOSHIELD PLS 5MM/0DG. STRZ FSS-01-0500U,69161816,CDM,272,RC,,,Outpatient,,,556.97,556.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.88,70,,311.9,percent of total billed charges,70% of total billed charges for outpatient setting,472.76,84.88,,378.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,278.49,50,,222.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417.73,75,,334.18,percent of total billed charges,75% of total billed charges for outpatient setting,389.88,70,,311.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.51,12.84,,57.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,80,,356.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.51,12.84,,57.21,percent of total billed charges,12.84% of total billed charges,71.51,12.84,,57.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,362.03,65,,289.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.94,35,,155.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,501.27,90,,401.02,percent of total billed charges,90% of total billed charges for outpatient setting,71.51,501.27,
FLOSHIELD PLS 5MM/30DG STRZ FSS-01-0530U,69161817,CDM,272,RC,,,Outpatient,,,556.97,556.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.88,70,,311.9,percent of total billed charges,70% of total billed charges for outpatient setting,472.76,84.88,,378.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,278.49,50,,222.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417.73,75,,334.18,percent of total billed charges,75% of total billed charges for outpatient setting,389.88,70,,311.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.51,12.84,,57.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,80,,356.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.51,12.84,,57.21,percent of total billed charges,12.84% of total billed charges,71.51,12.84,,57.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,362.03,65,,289.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.94,35,,155.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,501.27,90,,401.02,percent of total billed charges,90% of total billed charges for outpatient setting,71.51,501.27,
FLOW CYTOMETRY CELL EACH ADD MARKER,201441,CDM,302,RC,88185,HCPCS,Outpatient,,,51.25,46.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,84.88,,34.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.44,75,,30.75,percent of total billed charges,75% of total billed charges for outpatient setting,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41,80,,32.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.13,90,,36.9,percent of total billed charges,90% of total billed charges for outpatient setting,18.93,46.13,
FLOW CYTOMETRY CELL SURF NUC MRK 1ST,900050,CDM,311,RC,88184,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,38.33,1044.92,
FLOW CYTOMETRY CELL SURF NUC MRK EA ADD,900051,CDM,311,RC,88185,HCPCS,Outpatient,,,61.46,55.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,52.17,84.88,,41.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.1,75,,36.88,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.17,80,,39.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.31,90,,44.25,percent of total billed charges,90% of total billed charges for outpatient setting,18.93,55.31,
FLOW CYTOMETRY CELL SURFACE NUC MARKER,900008,CDM,311,RC,88184,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,38.33,1044.92,
FLOW CYTOMETRY INTERP  2 TO 8 MRKRS,900052,CDM,311,RC,88187,HCPCS,Outpatient,,,61.46,55.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,52.17,84.88,,41.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.73,50,,24.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.1,75,,36.88,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.17,80,,39.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.73,100,,,Fee Schedule,100% of Custom Fee Schedule,55.31,90,,44.25,percent of total billed charges,90% of total billed charges for outpatient setting,7.89,213.73,
FLOW CYTOMETRY INTERP 16 OR MORE MRKRS,900054,CDM,311,RC,88189,HCPCS,Outpatient,,,181.67,163.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.17,70,,101.74,percent of total billed charges,70% of total billed charges for outpatient setting,154.2,84.88,,123.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.84,50,,72.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.25,75,,109,percent of total billed charges,75% of total billed charges for outpatient setting,127.17,70,,101.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,12.84,,18.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.34,80,,116.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,12.84,,18.66,percent of total billed charges,12.84% of total billed charges,23.33,12.84,,18.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,163.5,90,,130.8,percent of total billed charges,90% of total billed charges for outpatient setting,23.33,163.5,
FLOW CYTOMETRY INTERP 9 TO 15 MRKRS,900053,CDM,311,RC,88188,HCPCS,Outpatient,,,61.46,55.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,52.17,84.88,,41.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.73,50,,24.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.1,75,,36.88,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,70,,34.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.17,80,,39.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,7.89,12.84,,6.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.98,100,,,Fee Schedule,100% of Custom Fee Schedule,55.31,90,,44.25,percent of total billed charges,90% of total billed charges for outpatient setting,7.89,330.98,
"FLOW CYTOMETRY,EA.CELL SURFACE",201657,CDM,311,RC,88182,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,41.69,178.52,
FLOW SENSOR - ANES / 2069358-001-S,6150854,CDM,270,RC,,,Outpatient,,,726.77,726.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.74,70,,406.99,percent of total billed charges,70% of total billed charges for outpatient setting,616.88,84.88,,493.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,363.39,50,,290.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,545.08,75,,436.06,percent of total billed charges,75% of total billed charges for outpatient setting,508.74,70,,406.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.32,12.84,,74.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.42,80,,465.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.32,12.84,,74.66,percent of total billed charges,12.84% of total billed charges,93.32,12.84,,74.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,472.4,65,,377.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.37,35,,203.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,654.09,90,,523.27,percent of total billed charges,90% of total billed charges for outpatient setting,93.32,654.09,
FLOXIN OTIC SOLN: 5CC,3302836,CDM,259,RC,,,Outpatient,,,134.79,134.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.35,70,,75.48,percent of total billed charges,70% of total billed charges for outpatient setting,114.41,84.88,,91.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.4,50,,53.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.09,75,,80.87,percent of total billed charges,75% of total billed charges for outpatient setting,94.35,70,,75.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,12.84,,13.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.83,80,,86.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,12.84,,13.85,percent of total billed charges,12.84% of total billed charges,17.31,12.84,,13.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.61,65,,70.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,35,,37.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.31,90,,97.05,percent of total billed charges,90% of total billed charges for outpatient setting,17.31,121.31,
FLOXIN(OFLOXACIN OTIC)SINGLES 0.3%:SOLN,3303184,CDM,259,RC,,,Outpatient,,,124.99,124.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,106.09,84.88,,84.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.5,50,,50,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.74,75,,74.99,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.99,80,,79.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.24,65,,64.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.75,35,,35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.49,90,,89.99,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.49,
FLU A/B PROFICIENCY,201915,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
FLUCONAZOLE (genDIFLUCAN)INJ 200MG/100ML,3301092,CDM,636,RC,J1450,HCPCS,Outpatient,,,29.9,29.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,70,,16.74,percent of total billed charges,70% of total billed charges for outpatient setting,25.38,84.88,,20.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.43,75,,17.94,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,70,,16.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.92,80,,19.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.44,65,,15.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,100,,,Fee Schedule,100% of Custom Fee Schedule,26.91,90,,21.53,percent of total billed charges,90% of total billed charges for outpatient setting,3.43,26.91,
FLUCONAZOLE (genericDIFLUCAN) 100MG TAB,3302949,CDM,259,RC,,,Outpatient,,,73.77,73.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.64,70,,41.31,percent of total billed charges,70% of total billed charges for outpatient setting,62.62,84.88,,50.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.89,50,,29.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.33,75,,44.26,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,70,,41.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,12.84,,7.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.02,80,,47.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,12.84,,7.58,percent of total billed charges,12.84% of total billed charges,9.47,12.84,,7.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.95,65,,38.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.82,35,,20.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.39,90,,53.11,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,66.39,
FLUCONAZOLE (genericDIFLUCAN) 150 MG TAB,3302844,CDM,259,RC,,,Outpatient,,,63.22,63.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.25,70,,35.4,percent of total billed charges,70% of total billed charges for outpatient setting,53.66,84.88,,42.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.61,50,,25.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.42,75,,37.94,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,70,,35.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.12,12.84,,6.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.58,80,,40.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.12,12.84,,6.5,percent of total billed charges,12.84% of total billed charges,8.12,12.84,,6.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.09,65,,32.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.13,35,,17.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.9,90,,45.52,percent of total billed charges,90% of total billed charges for outpatient setting,8.12,56.9,
FLUCONAZOLE (genericDIFLUCAN) 200MG TAB,3303340,CDM,259,RC,,,Outpatient,,,73.77,73.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.64,70,,41.31,percent of total billed charges,70% of total billed charges for outpatient setting,62.62,84.88,,50.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.89,50,,29.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.33,75,,44.26,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,70,,41.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,12.84,,7.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.02,80,,47.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,12.84,,7.58,percent of total billed charges,12.84% of total billed charges,9.47,12.84,,7.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.95,65,,38.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.82,35,,20.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.39,90,,53.11,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,66.39,
FLUCONAZOLE (genericDIFLUCAN) 50MG TAB,3308545,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLUDROCORTISONE 0.1MG,3301093,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
FLUMAZENIL (ROMAZICON) INJ 0.1 MG,3301094,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLUNISOLIDE (AEROBID) INH 250MCG:7 GM,3301095,CDM,259,RC,,,Outpatient,,,202.73,202.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.91,70,,113.53,percent of total billed charges,70% of total billed charges for outpatient setting,172.08,84.88,,137.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.37,50,,81.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.05,75,,121.64,percent of total billed charges,75% of total billed charges for outpatient setting,141.91,70,,113.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.03,12.84,,20.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.18,80,,129.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.03,12.84,,20.82,percent of total billed charges,12.84% of total billed charges,26.03,12.84,,20.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.77,65,,105.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.96,35,,56.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.46,90,,145.97,percent of total billed charges,90% of total billed charges for outpatient setting,26.03,182.46,
FLUNISOLIDE (AEROBID-M) INH 250MCG:7 GM,3301096,CDM,259,RC,,,Outpatient,,,180.69,180.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.48,70,,101.18,percent of total billed charges,70% of total billed charges for outpatient setting,153.37,84.88,,122.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.35,50,,72.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.52,75,,108.42,percent of total billed charges,75% of total billed charges for outpatient setting,126.48,70,,101.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.55,80,,115.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,23.2,12.84,,18.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.45,65,,93.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.24,35,,50.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.62,90,,130.1,percent of total billed charges,90% of total billed charges for outpatient setting,23.2,162.62,
FLUOCINONIDE CRM: 30 GM,3301097,CDM,259,RC,,,Outpatient,,,37.96,37.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,32.22,84.88,,25.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.98,50,,15.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.47,75,,22.78,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,70,,21.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.37,80,,24.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.67,65,,19.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.29,35,,10.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.16,90,,27.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.87,34.16,
FLUORESCEIN (FLUORETS) OPTH 2%:1ML,3301098,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY,200243,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
FLUORESCENT NONINFECTIOUS AGENT ANTIBODY,200967,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
FLUORESENCE IMAGING PROC KIT / 950156,69162117,CDM,272,RC,,,Outpatient,,,844.31,844.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.02,70,,472.82,percent of total billed charges,70% of total billed charges for outpatient setting,716.65,84.88,,573.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,422.16,50,,337.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.23,75,,506.58,percent of total billed charges,75% of total billed charges for outpatient setting,591.02,70,,472.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.41,12.84,,86.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.45,80,,540.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.41,12.84,,86.73,percent of total billed charges,12.84% of total billed charges,108.41,12.84,,86.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.8,65,,439.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.51,35,,236.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.88,90,,607.9,percent of total billed charges,90% of total billed charges for outpatient setting,108.41,759.88,
FLUORO DIAPHRAGM,2400858,CDM,320,RC,76000,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
FLUORO FOR NEEDLE PL NON-SPINAL,2400860,CDM,320,RC,77002,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
FLUORO GUIDNC ACCESS OR REMV INFUSAPORT,2400849,CDM,320,RC,77001,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
FLUORO LESS THAN ONE HOUR,2400168,CDM,320,RC,76000,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
FLUORO PACEMAKER INSERTION,2400165,CDM,320,RC,76000,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
FLUORO UP TO 1 HOUR,2400855,CDM,320,RC,76000,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
FLUOROURACIL (ADRUCIL) INJ 50MG/ML:10ML,3301099,CDM,250,RC,,,Outpatient,,,90.65,90.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.46,70,,50.77,percent of total billed charges,70% of total billed charges for outpatient setting,76.94,84.88,,61.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.33,50,,36.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.99,75,,54.39,percent of total billed charges,75% of total billed charges for outpatient setting,63.46,70,,50.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,12.84,,9.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.52,80,,58.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.92,65,,47.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,35,,25.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.59,90,,65.27,percent of total billed charges,90% of total billed charges for outpatient setting,11.64,81.59,
FLUOXETINE (PROZAC) CAP: 20 MG,3301102,CDM,259,RC,,,Outpatient,,,7.14,7.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,6.06,84.88,,4.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.57,50,,2.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.36,75,,4.29,percent of total billed charges,75% of total billed charges for outpatient setting,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,80,,4.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.64,65,,3.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,35,,2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.43,90,,5.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.92,6.43,
FLUOXETINE (PROZAC) SOL 20/5ML UD:5ML,3301104,CDM,259,RC,,,Outpatient,,,29.93,29.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.95,70,,16.76,percent of total billed charges,70% of total billed charges for outpatient setting,25.4,84.88,,20.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.97,50,,11.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.45,75,,17.96,percent of total billed charges,75% of total billed charges for outpatient setting,20.95,70,,16.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.94,80,,19.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,3.84,12.84,,3.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.45,65,,15.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.48,35,,8.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.94,90,,21.55,percent of total billed charges,90% of total billed charges for outpatient setting,3.84,26.94,
FLUOXETINE (PROZAC) SOL 20MG/5ML:120ML,3301101,CDM,259,RC,,,Outpatient,,,372.7,372.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.89,70,,208.71,percent of total billed charges,70% of total billed charges for outpatient setting,316.35,84.88,,253.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.35,50,,149.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.53,75,,223.62,percent of total billed charges,75% of total billed charges for outpatient setting,260.89,70,,208.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.85,12.84,,38.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.16,80,,238.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.85,12.84,,38.28,percent of total billed charges,12.84% of total billed charges,47.85,12.84,,38.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,242.26,65,,193.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.45,35,,104.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,335.43,90,,268.34,percent of total billed charges,90% of total billed charges for outpatient setting,47.85,335.43,
FLUOXETINE (PROZAC) TAB: 10 MG,3301100,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
FLUOXETINE (PROZAC)CAP 20MG U/D,3301103,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FLUPHENAZINE (PROLIXIN) TAB : 1 MG,3301105,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FLUPHENAZINE (PROLIXIN) TAB : 5 MG,3301106,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
FLURAZEPAM (DALMANE) CAP: 15MG,3302611,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
FLURAZEPAM (DALMANE) CAP: 30MG,3302612,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FLURBIPROFEN(OCUFEN)OPTH SOL 0.03%:2.5ML,3301107,CDM,259,RC,,,Outpatient,,,23.59,23.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.51,70,,13.21,percent of total billed charges,70% of total billed charges for outpatient setting,20.02,84.88,,16.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.8,50,,9.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.69,75,,14.15,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,70,,13.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.87,80,,15.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.33,65,,12.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,35,,6.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.23,90,,16.98,percent of total billed charges,90% of total billed charges for outpatient setting,3.03,21.23,
FLURBIPROFEN(OCUFEN)OPTH SOL 0.03%:2.5ML,3301108,CDM,259,RC,,,Outpatient,,,52.57,52.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.8,70,,29.44,percent of total billed charges,70% of total billed charges for outpatient setting,44.62,84.88,,35.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.29,50,,21.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.43,75,,31.54,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,70,,29.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,12.84,,5.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.06,80,,33.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,12.84,,5.4,percent of total billed charges,12.84% of total billed charges,6.75,12.84,,5.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.17,65,,27.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,35,,14.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.31,90,,37.85,percent of total billed charges,90% of total billed charges for outpatient setting,6.75,47.31,
FLUTAMIDE (EULEXIN) CAP: 125 MG,3301109,CDM,259,RC,,,Outpatient,,,6.88,6.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,5.84,84.88,,4.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.44,50,,2.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.16,75,,4.13,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,80,,4.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.47,65,,3.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,35,,1.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.19,90,,4.95,percent of total billed charges,90% of total billed charges for outpatient setting,0.88,6.19,
FLUTAMIDE 125MG CAP(EULEXIN),3304065,CDM,259,RC,,,Outpatient,,,5.46,5.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,84.88,,3.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,50,,2.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.55,65,,2.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.91,90,,3.93,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.91,
FLUTICASONE (ADVAIR DIS) INH 250-50MCG:,3301110,CDM,259,RC,,,Outpatient,,,269.72,269.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.8,70,,151.04,percent of total billed charges,70% of total billed charges for outpatient setting,228.94,84.88,,183.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.86,50,,107.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.29,75,,161.83,percent of total billed charges,75% of total billed charges for outpatient setting,188.8,70,,151.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.63,12.84,,27.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.78,80,,172.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.63,12.84,,27.7,percent of total billed charges,12.84% of total billed charges,34.63,12.84,,27.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.32,65,,140.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.4,35,,75.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.75,90,,194.2,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,242.75,
FLUTICASONE (FLOVENT) HFA 220MCG: 12 GM,3305017,CDM,250,RC,,,Outpatient,,,736,736,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.2,70,,412.16,percent of total billed charges,70% of total billed charges for outpatient setting,624.72,84.88,,499.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,368,50,,294.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,552,75,,441.6,percent of total billed charges,75% of total billed charges for outpatient setting,515.2,70,,412.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,12.84,,75.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.8,80,,471.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,12.84,,75.6,percent of total billed charges,12.84% of total billed charges,94.5,12.84,,75.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,478.4,65,,382.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.6,35,,206.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,662.4,90,,529.92,percent of total billed charges,90% of total billed charges for outpatient setting,94.5,662.4,
FLUTICASONE (FLOVENT) INH 110MCG: 7.9GM,3301113,CDM,259,RC,,,Outpatient,,,145.39,145.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.77,70,,81.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.41,84.88,,98.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.7,50,,58.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.04,75,,87.23,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,70,,81.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.67,12.84,,14.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.31,80,,93.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.67,12.84,,14.94,percent of total billed charges,12.84% of total billed charges,18.67,12.84,,14.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.5,65,,75.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.89,35,,40.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.85,90,,104.68,percent of total billed charges,90% of total billed charges for outpatient setting,18.67,130.85,
FLUTICASONE (FLOVENT) INH 220MCG: 7.9GM,3301115,CDM,259,RC,,,Outpatient,,,230.11,230.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.08,70,,128.86,percent of total billed charges,70% of total billed charges for outpatient setting,195.32,84.88,,156.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.06,50,,92.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.58,75,,138.06,percent of total billed charges,75% of total billed charges for outpatient setting,161.08,70,,128.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.55,12.84,,23.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.09,80,,147.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.55,12.84,,23.64,percent of total billed charges,12.84% of total billed charges,29.55,12.84,,23.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.57,65,,119.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.54,35,,64.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.1,90,,165.68,percent of total billed charges,90% of total billed charges for outpatient setting,29.55,207.1,
FLUTICASONE (FLOVENT) INH 44MCG: 8GM,3301111,CDM,259,RC,,,Outpatient,,,112.97,112.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.08,70,,63.26,percent of total billed charges,70% of total billed charges for outpatient setting,95.89,84.88,,76.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.49,50,,45.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.73,75,,67.78,percent of total billed charges,75% of total billed charges for outpatient setting,79.08,70,,63.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.38,80,,72.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,14.51,12.84,,11.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.43,65,,58.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.54,35,,31.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.67,90,,81.34,percent of total billed charges,90% of total billed charges for outpatient setting,14.51,101.67,
FLUTICASONE (FLOVENT) INH 50 MCG: 16 GM,3301114,CDM,259,RC,,,Outpatient,,,139.25,139.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.48,70,,77.98,percent of total billed charges,70% of total billed charges for outpatient setting,118.2,84.88,,94.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.63,50,,55.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.44,75,,83.55,percent of total billed charges,75% of total billed charges for outpatient setting,97.48,70,,77.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.88,12.84,,14.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.4,80,,89.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.88,12.84,,14.3,percent of total billed charges,12.84% of total billed charges,17.88,12.84,,14.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.51,65,,72.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,35,,38.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.33,90,,100.26,percent of total billed charges,90% of total billed charges for outpatient setting,17.88,125.33,
FLUTICASONE (FLOVENT) ROTDISK INH 50MCG:,3301112,CDM,259,RC,,,Outpatient,,,112.47,112.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.73,70,,62.98,percent of total billed charges,70% of total billed charges for outpatient setting,95.46,84.88,,76.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.24,50,,44.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.35,75,,67.48,percent of total billed charges,75% of total billed charges for outpatient setting,78.73,70,,62.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.44,12.84,,11.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.98,80,,71.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.44,12.84,,11.55,percent of total billed charges,12.84% of total billed charges,14.44,12.84,,11.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.11,65,,58.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,35,,31.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.22,90,,80.98,percent of total billed charges,90% of total billed charges for outpatient setting,14.44,101.22,
FLUTICASONE PROP NASAL 50microgm/spray,3302811,CDM,259,RC,,,Outpatient,,,121.21,121.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.85,70,,67.88,percent of total billed charges,70% of total billed charges for outpatient setting,102.88,84.88,,82.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.61,50,,48.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.91,75,,72.73,percent of total billed charges,75% of total billed charges for outpatient setting,84.85,70,,67.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.56,12.84,,12.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.97,80,,77.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.56,12.84,,12.45,percent of total billed charges,12.84% of total billed charges,15.56,12.84,,12.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78.79,65,,63.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.42,35,,33.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,109.09,90,,87.27,percent of total billed charges,90% of total billed charges for outpatient setting,15.56,109.09,
FLUTICASONE VILANTEROL (BREO) 100-25MIC,3313589,CDM,250,RC,,,Outpatient,,,571.49,571.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.04,70,,320.03,percent of total billed charges,70% of total billed charges for outpatient setting,485.08,84.88,,388.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,285.75,50,,228.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,428.62,75,,342.9,percent of total billed charges,75% of total billed charges for outpatient setting,400.04,70,,320.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.38,12.84,,58.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.19,80,,365.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.38,12.84,,58.7,percent of total billed charges,12.84% of total billed charges,73.38,12.84,,58.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,371.47,65,,297.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.02,35,,160.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,514.34,90,,411.47,percent of total billed charges,90% of total billed charges for outpatient setting,73.38,514.34,
FLUVASTATIN (LESCOL) CAP : 20 MG,3301116,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FLUVASTATIN (LESCOL) CAP : 20 MG,3301117,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FLUVOXAMINE (LUVOX) TAB: 50 MG,3301118,CDM,259,RC,,,Outpatient,,,8.9,8.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,84.88,,6.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.45,50,,3.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.68,75,,5.34,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,80,,5.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.79,65,,4.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.01,90,,6.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,8.01,
FOAM CRADLE ARM RESTS / ALP303,6152889,CDM,270,RC,,,Outpatient,,,22.5,22.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,19.1,84.88,,15.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.25,50,,9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.88,75,,13.5,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.89,12.84,,2.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,80,,14.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.89,12.84,,2.31,percent of total billed charges,12.84% of total billed charges,2.89,12.84,,2.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.63,65,,11.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,35,,6.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.25,90,,16.2,percent of total billed charges,90% of total billed charges for outpatient setting,2.89,20.25,
FOAM CUSHION ARTHREX LEG HOLDER/AR-1502,6152912,CDM,270,RC,,,Outpatient,,,227.24,227.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,192.88,84.88,,154.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.62,50,,90.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,75,,136.34,percent of total billed charges,75% of total billed charges for outpatient setting,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,12.84,,23.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.79,80,,145.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.71,65,,118.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.53,35,,63.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.52,90,,163.62,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,204.52,
FOLBEE TAB,3303101,CDM,250,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
FOLBIC (FOLTX) TAB,3302966,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FOLEY 16FR W/TEMP SENSOR SIL / 81-080416,69162234,CDM,272,RC,,,Outpatient,,,102.18,102.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,70,,57.22,percent of total billed charges,70% of total billed charges for outpatient setting,86.73,84.88,,69.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.09,50,,40.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.64,75,,61.31,percent of total billed charges,75% of total billed charges for outpatient setting,71.53,70,,57.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,12.84,,10.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.74,80,,65.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.12,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,13.12,12.84,,10.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.42,65,,53.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.76,35,,28.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.96,90,,73.57,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,91.96,
FOLIC ACID,220378,CDM,300,RC,82746,HCPCS,Outpatient,,,66.15,59.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.88,100,,,Fee Schedule,100% of Custom Fee Schedule,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,14.7,59.54,
FOLIC ACID (FOLVITE) INJ 5MG/ML: 10ML,3301121,CDM,250,RC,,,Outpatient,,,33.3,33.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.31,70,,18.65,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,84.88,,22.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.65,50,,13.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.98,75,,19.98,percent of total billed charges,75% of total billed charges for outpatient setting,23.31,70,,18.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,12.84,,3.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,80,,21.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,12.84,,3.42,percent of total billed charges,12.84% of total billed charges,4.28,12.84,,3.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.65,65,,17.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.66,35,,9.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.97,90,,23.98,percent of total billed charges,90% of total billed charges for outpatient setting,4.28,29.97,
FOLIC ACID (FOLVITE) INJ 5MG/ML: 10ML,3301120,CDM,250,RC,,,Outpatient,,,33.69,33.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.58,70,,18.86,percent of total billed charges,70% of total billed charges for outpatient setting,28.6,84.88,,22.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.85,50,,13.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.27,75,,20.22,percent of total billed charges,75% of total billed charges for outpatient setting,23.58,70,,18.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,12.84,,3.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,80,,21.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,4.33,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.9,65,,17.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.79,35,,9.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.32,90,,24.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.33,30.32,
FOLIC ACID (genericFOLVITE) TAB  1 MG,3301119,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FOLIC ACID 5MG/ML  INJ.,3302930,CDM,250,RC,,,Outpatient,,,141.56,141.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.09,70,,79.27,percent of total billed charges,70% of total billed charges for outpatient setting,120.16,84.88,,96.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.78,50,,56.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.17,75,,84.94,percent of total billed charges,75% of total billed charges for outpatient setting,99.09,70,,79.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.18,12.84,,14.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.25,80,,90.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.18,12.84,,14.54,percent of total billed charges,12.84% of total billed charges,18.18,12.84,,14.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.01,65,,73.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.55,35,,39.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.4,90,,101.92,percent of total billed charges,90% of total billed charges for outpatient setting,18.18,127.4,
"FOLIC ACID, RBC",220754,CDM,301,RC,82747,HCPCS,Outpatient,,,79.43,71.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,67.42,84.88,,53.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.57,75,,47.66,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,70,,44.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.54,80,,50.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of Custom Fee Schedule,71.49,90,,57.19,percent of total billed charges,90% of total billed charges for outpatient setting,17.65,71.49,
FOOD PROFILE SEROLAB,201086,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
FOOT 2 VWS BILATERAL,2400437,CDM,320,RC,73620,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
FOOT 2 VWS LEFT,2400436,CDM,320,RC,73620,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FOOT 2 VWS RIGHT,2400435,CDM,320,RC,73620,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FOOT 3+ VWS BILATERAL,2400442,CDM,320,RC,73630,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
FOOT 3+ VWS LEFT,2400441,CDM,320,RC,73630,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FOOT 3+ VWS RIGHT,2400440,CDM,320,RC,73630,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FOOT SCD EXPRESS REG / 5897,70000101,CDM,270,RC,,,Outpatient,,,155.74,155.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,132.19,84.88,,105.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.87,50,,62.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.81,75,,93.45,percent of total billed charges,75% of total billed charges for outpatient setting,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.59,80,,99.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.23,65,,80.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,35,,43.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.17,90,,112.14,percent of total billed charges,90% of total billed charges for outpatient setting,20,140.17,
FOOTCARE (CLOTRIMAXOLE) CREAM 1%:30GM,3301123,CDM,259,RC,,,Outpatient,,,20.76,20.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,70,,11.62,percent of total billed charges,70% of total billed charges for outpatient setting,17.62,84.88,,14.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.38,50,,8.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.57,75,,12.46,percent of total billed charges,75% of total billed charges for outpatient setting,14.53,70,,11.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.67,12.84,,2.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,80,,13.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.67,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,2.67,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.49,65,,10.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,35,,5.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.67,18.68,
FOOTCARE (TOLNAFTATE) POWDER 1% : 45GM,3301122,CDM,259,RC,,,Outpatient,,,12.59,12.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,70,,7.05,percent of total billed charges,70% of total billed charges for outpatient setting,10.69,84.88,,8.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,50,,5.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.44,75,,7.55,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,70,,7.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.07,80,,8.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.18,65,,6.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.33,90,,9.06,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.33,
FOOTWEAR SLIP RESIST XXL / 68125-GRN,70000662,CDM,270,RC,,,Outpatient,,,8.12,8.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,70,,4.54,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,84.88,,5.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.06,50,,3.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.09,75,,4.87,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,70,,4.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,80,,5.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.28,65,,4.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.84,35,,2.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.31,90,,5.85,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.31,
FORADIL(FORMOTEROL FUMERATE:AEROLIZER,3303026,CDM,259,RC,,,Outpatient,,,133.69,133.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,113.48,84.88,,90.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.85,50,,53.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.27,75,,80.22,percent of total billed charges,75% of total billed charges for outpatient setting,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.17,12.84,,13.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.95,80,,85.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.17,12.84,,13.74,percent of total billed charges,12.84% of total billed charges,17.17,12.84,,13.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.9,65,,69.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,35,,37.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.32,90,,96.26,percent of total billed charges,90% of total billed charges for outpatient setting,17.17,120.32,
FORCEP 1.8MM BRONCH BOSTON / M00515181,6051180,CDM,270,RC,,,Outpatient,,,231.29,231.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.9,70,,129.52,percent of total billed charges,70% of total billed charges for outpatient setting,196.32,84.88,,157.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.65,50,,92.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.47,75,,138.78,percent of total billed charges,75% of total billed charges for outpatient setting,161.9,70,,129.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.03,80,,148.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.34,65,,120.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.95,35,,64.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,208.16,90,,166.53,percent of total billed charges,90% of total billed charges for outpatient setting,29.7,208.16,
FORCEP 2.8MM 230CM ALIGATOR / FB-220U.A,576097,CDM,272,RC,,,Outpatient,,,42,42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,70,,23.52,percent of total billed charges,70% of total billed charges for outpatient setting,35.65,84.88,,28.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,21,50,,16.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,75,,25.2,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,70,,23.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,12.84,,4.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,80,,26.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,12.84,,4.31,percent of total billed charges,12.84% of total billed charges,5.39,12.84,,4.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.3,65,,21.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,35,,11.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.8,90,,30.24,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,37.8,
FORCEP 8IN 1.5MM BIPOLAR / 20-1583IMT,1975286,CDM,272,RC,,,Outpatient,,,1209.6,1209.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,846.72,70,,677.38,percent of total billed charges,70% of total billed charges for outpatient setting,1026.71,84.88,,821.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,604.8,50,,483.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,907.2,75,,725.76,percent of total billed charges,75% of total billed charges for outpatient setting,846.72,70,,677.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.31,12.84,,124.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.68,80,,774.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.31,12.84,,124.25,percent of total billed charges,12.84% of total billed charges,155.31,12.84,,124.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,786.24,65,,628.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.36,35,,338.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1088.64,90,,870.91,percent of total billed charges,90% of total billed charges for outpatient setting,155.31,1088.64,
FORCEP BIOPSY (40 TO BOX) / M00513332,69159842,CDM,272,RC,,,Outpatient,,,111.54,111.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.08,70,,62.46,percent of total billed charges,70% of total billed charges for outpatient setting,94.68,84.88,,75.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.77,50,,44.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.66,75,,66.93,percent of total billed charges,75% of total billed charges for outpatient setting,78.08,70,,62.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.32,12.84,,11.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.23,80,,71.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.32,12.84,,11.46,percent of total billed charges,12.84% of total billed charges,14.32,12.84,,11.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.5,65,,58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,35,,31.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.39,90,,80.31,percent of total billed charges,90% of total billed charges for outpatient setting,14.32,100.39,
FORCEP BIOPSY / 1333 (20 TO BOX),8370155,CDM,272,RC,,,Outpatient,,,113.18,113.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.23,70,,63.38,percent of total billed charges,70% of total billed charges for outpatient setting,96.07,84.88,,76.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.59,50,,45.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.89,75,,67.91,percent of total billed charges,75% of total billed charges for outpatient setting,79.23,70,,63.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,12.84,,11.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.54,80,,72.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,12.84,,11.62,percent of total billed charges,12.84% of total billed charges,14.53,12.84,,11.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.57,65,,58.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.61,35,,31.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.86,90,,81.49,percent of total billed charges,90% of total billed charges for outpatient setting,14.53,101.86,
FORCEP BIPOLAR IRIS CRVD / 8065129101,299655,CDM,272,RC,,,Outpatient,,,105.9,105.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.13,70,,59.3,percent of total billed charges,70% of total billed charges for outpatient setting,89.89,84.88,,71.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.95,50,,42.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.43,75,,63.54,percent of total billed charges,75% of total billed charges for outpatient setting,74.13,70,,59.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.72,80,,67.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.84,65,,55.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.07,35,,29.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.31,90,,76.25,percent of total billed charges,90% of total billed charges for outpatient setting,13.6,95.31,
FORCEP SCREW HOLDING  / 319.97,71000105,CDM,272,RC,,,Outpatient,,,295.6,295.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.92,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,250.91,84.88,,200.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,147.8,50,,118.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.7,75,,177.36,percent of total billed charges,75% of total billed charges for outpatient setting,206.92,70,,165.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.48,80,,189.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,37.96,12.84,,30.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,192.14,65,,153.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.46,35,,82.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,266.04,90,,212.83,percent of total billed charges,90% of total billed charges for outpatient setting,37.96,266.04,
FORCEPS COMPRESSION / 03.211.400,962743,CDM,272,RC,,,Outpatient,,,4132.52,4132.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2892.76,70,,2314.21,percent of total billed charges,70% of total billed charges for outpatient setting,3507.68,84.88,,2806.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,2066.26,50,,1653.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3099.39,75,,2479.51,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.62,12.84,,424.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3306.02,80,,2644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.62,12.84,,424.5,percent of total billed charges,12.84% of total billed charges,530.62,12.84,,424.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2686.14,65,,2148.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.38,35,,1157.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3719.27,90,,2975.42,percent of total billed charges,90% of total billed charges for outpatient setting,530.62,3719.27,
FORCEPS GASTIC PEDIATRIC,69159774,CDM,270,RC,,,Outpatient,,,204.97,204.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.48,70,,114.78,percent of total billed charges,70% of total billed charges for outpatient setting,173.98,84.88,,139.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.49,50,,81.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.73,75,,122.98,percent of total billed charges,75% of total billed charges for outpatient setting,143.48,70,,114.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.98,80,,131.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.23,65,,106.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.74,35,,57.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.47,90,,147.58,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.47,
FORCEPS HOOKED PRONG GRASPING,69169869,CDM,272,RC,,,Outpatient,,,698,698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,592.46,84.88,,473.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,349,50,,279.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,523.5,75,,418.8,percent of total billed charges,75% of total billed charges for outpatient setting,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.4,80,,446.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,453.7,65,,362.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,35,,195.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.2,90,,502.56,percent of total billed charges,90% of total billed charges for outpatient setting,89.62,628.2,
FORCEPS HOT BX/1550,6051179,CDM,270,RC,,,Outpatient,,,234.78,234.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.35,70,,131.48,percent of total billed charges,70% of total billed charges for outpatient setting,199.28,84.88,,159.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.39,50,,93.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.09,75,,140.87,percent of total billed charges,75% of total billed charges for outpatient setting,164.35,70,,131.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,12.84,,24.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.82,80,,150.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,12.84,,24.12,percent of total billed charges,12.84% of total billed charges,30.15,12.84,,24.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.61,65,,122.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.17,35,,65.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.3,90,,169.04,percent of total billed charges,90% of total billed charges for outpatient setting,30.15,211.3,
FORCEPS HOT RADIAL JAW / M00515033,69159841,CDM,270,RC,,,Outpatient,,,108.7,108.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.09,70,,60.87,percent of total billed charges,70% of total billed charges for outpatient setting,92.26,84.88,,73.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.35,50,,43.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.53,75,,65.22,percent of total billed charges,75% of total billed charges for outpatient setting,76.09,70,,60.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,12.84,,11.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,80,,69.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,12.84,,11.17,percent of total billed charges,12.84% of total billed charges,13.96,12.84,,11.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.66,65,,56.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.05,35,,30.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.83,90,,78.26,percent of total billed charges,90% of total billed charges for outpatient setting,13.96,97.83,
FOREARM 2 VIEWS BILATERAL,2400522,CDM,320,RC,73090,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
FOREARM TWO VIEWS LEFT,2400521,CDM,320,RC,73090,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FOREARM TWO VIEWS RIGHT,2400520,CDM,320,RC,73090,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
FORTAZ INJ : 1GM,3302543,CDM,250,RC,,,Outpatient,,,96.18,96.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.33,70,,53.86,percent of total billed charges,70% of total billed charges for outpatient setting,81.64,84.88,,65.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.09,50,,38.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.14,75,,57.71,percent of total billed charges,75% of total billed charges for outpatient setting,67.33,70,,53.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.94,80,,61.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.52,65,,50.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.66,35,,26.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.56,90,,69.25,percent of total billed charges,90% of total billed charges for outpatient setting,12.35,86.56,
FOSINOPRIL (MONOPRIL) TAB : 10 MG,3303218,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FOSINOPRIL (MONOPRIL) TAB : 20 MG,3301125,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FOSINOPRIL (MONOPRIL) TAB : 20 MG  U/D,3301124,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FOSPHENYTOIN(CEREBYX) 50MG/PE ML 2 ML,3302840,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FOSRENOL 500 MG : TAB,3303140,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
FOUR IN ONE OPTH DROP 0.5ML SYRINGE,3308252,CDM,250,RC,,,Outpatient,,,33.6,33.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,70,,18.82,percent of total billed charges,70% of total billed charges for outpatient setting,28.52,84.88,,22.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.8,50,,13.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,75,,20.16,percent of total billed charges,75% of total billed charges for outpatient setting,23.52,70,,18.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,80,,21.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,4.31,12.84,,3.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.84,65,,17.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,35,,9.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.24,90,,24.19,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,30.24,
FRESH FROZEN PLASMA,1000025,CDM,383,RC,P9017,HCPCS,Outpatient,,,187.56,187.56,,135.04,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,131.29,70,,105.03,percent of total billed charges,70% of total billed charges for outpatient setting,159.2,84.88,,127.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.67,75,,112.54,percent of total billed charges,75% of total billed charges for outpatient setting,131.29,70,,105.03,percent of total billed charges,70% of total billed charges for outpatient setting,143.47,170,,,Fee Schedule,170% of Medicare OPPS rate,181.46,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,24.08,12.84,,19.264,percent of total billed charges,12.84% of total billed charges,147.69,175,,,Fee Schedule,175% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.05,80,,120.04,percent of total billed charges,80% of total billed charges for outpatient setting,118.16,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,105.5,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,24.08,12.84,,19.26,percent of total billed charges,12.84% of total billed charges,24.08,12.84,,19.26,percent of total billed charges,12.84% of total billed charges,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.91,65,,97.53,percent of total billed charges,65% of total billed charges for outpatient setting,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.4,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,65.65,35,,52.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,168.8,90,,135.04,percent of total billed charges,90% of total billed charges for outpatient setting,24.08,181.46,
FRONTAL BALLOON SZ 6 / 1830617FRT,69161911,CDM,272,RC,,,Outpatient,,,2968.58,2968.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2078.01,70,,1662.41,percent of total billed charges,70% of total billed charges for outpatient setting,2519.73,84.88,,2015.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1484.29,50,,1187.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2226.44,75,,1781.15,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.17,12.84,,304.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2374.86,80,,1899.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.17,12.84,,304.94,percent of total billed charges,12.84% of total billed charges,381.17,12.84,,304.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1929.58,65,,1543.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1039,35,,831.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2671.72,90,,2137.38,percent of total billed charges,90% of total billed charges for outpatient setting,381.17,2671.72,
FRONTAL BALLOON SZ6 70DEG/ 1830617FRT70,69162664,CDM,272,RC,,,Outpatient,,,2115.41,2115.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.79,70,,1184.63,percent of total billed charges,70% of total billed charges for outpatient setting,1795.56,84.88,,1436.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1057.71,50,,846.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1586.56,75,,1269.25,percent of total billed charges,75% of total billed charges for outpatient setting,1480.79,70,,1184.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.62,12.84,,217.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1692.33,80,,1353.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.62,12.84,,217.3,percent of total billed charges,12.84% of total billed charges,271.62,12.84,,217.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1375.02,65,,1100.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.39,35,,592.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1903.87,90,,1523.1,percent of total billed charges,90% of total billed charges for outpatient setting,271.62,1903.87,
FRT 6X17MM 70 DEG BLLOON  / 1830617FRT70,69162680,CDM,272,RC,,,Outpatient,,,2457,2457,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.9,70,,1375.92,percent of total billed charges,70% of total billed charges for outpatient setting,2085.5,84.88,,1668.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,1228.5,50,,982.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1842.75,75,,1474.2,percent of total billed charges,75% of total billed charges for outpatient setting,1719.9,70,,1375.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.48,12.84,,252.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965.6,80,,1572.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.48,12.84,,252.38,percent of total billed charges,12.84% of total billed charges,315.48,12.84,,252.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1597.05,65,,1277.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,859.95,35,,687.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2211.3,90,,1769.04,percent of total billed charges,90% of total billed charges for outpatient setting,315.48,2211.3,
FRUCTOSAMINE,200563,CDM,301,RC,82985,HCPCS,Outpatient,,,75.42,67.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.79,70,,42.23,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,84.88,,51.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.57,75,,45.26,percent of total billed charges,75% of total billed charges for outpatient setting,52.79,70,,42.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.34,80,,48.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,67.88,90,,54.3,percent of total billed charges,90% of total billed charges for outpatient setting,16.76,67.88,
FSH,220489,CDM,300,RC,83001,HCPCS,Outpatient,,,83.61,75.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.53,70,,46.82,percent of total billed charges,70% of total billed charges for outpatient setting,70.97,84.88,,56.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.71,75,,50.17,percent of total billed charges,75% of total billed charges for outpatient setting,58.53,70,,46.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.89,80,,53.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.24,100,,,Fee Schedule,100% of Custom Fee Schedule,75.25,90,,60.2,percent of total billed charges,90% of total billed charges for outpatient setting,18.58,75.25,
FTA  ABS,220479,CDM,300,RC,86780,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,53.62,
FULGTING ELECTRODE 2FR 105CM / BE-202,69162808,CDM,272,RC,,,Outpatient,,,378.14,378.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.7,70,,211.76,percent of total billed charges,70% of total billed charges for outpatient setting,320.97,84.88,,256.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.07,50,,151.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.61,75,,226.89,percent of total billed charges,75% of total billed charges for outpatient setting,264.7,70,,211.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.55,12.84,,38.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.51,80,,242.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.55,12.84,,38.84,percent of total billed charges,12.84% of total billed charges,48.55,12.84,,38.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,245.79,65,,196.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.35,35,,105.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,340.33,90,,272.26,percent of total billed charges,90% of total billed charges for outpatient setting,48.55,340.33,
FULL RADIUS 3.5MM / C9248,69159350,CDM,272,RC,,,Outpatient,,,243.73,243.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.61,70,,136.49,percent of total billed charges,70% of total billed charges for outpatient setting,206.88,84.88,,165.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.87,50,,97.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.8,75,,146.24,percent of total billed charges,75% of total billed charges for outpatient setting,170.61,70,,136.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.29,12.84,,25.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.98,80,,155.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.29,12.84,,25.03,percent of total billed charges,12.84% of total billed charges,31.29,12.84,,25.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,158.42,65,,126.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.31,35,,68.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,219.36,90,,175.49,percent of total billed charges,90% of total billed charges for outpatient setting,31.29,219.36,
FUNGUS CULTURE,222031,CDM,300,RC,87102,HCPCS,Outpatient,,,37.85,34.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,32.13,84.88,,25.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.39,75,,22.71,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,80,,24.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,100,,,Fee Schedule,100% of Custom Fee Schedule,34.07,90,,27.26,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,34.07,
FUNGUS STAIN,222032,CDM,300,RC,87206,HCPCS,Outpatient,,,24.26,21.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.59,84.88,,16.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.2,75,,14.56,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,80,,15.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.2,100,,,Fee Schedule,100% of Custom Fee Schedule,21.83,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,21.83,
FUROSEMIDE (genLASIX) 100MG/10ML VIAL,3301139,CDM,636,RC,J1940,HCPCS,Outpatient,,,89.37,89.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.56,70,,50.05,percent of total billed charges,70% of total billed charges for outpatient setting,75.86,84.88,,60.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.03,75,,53.62,percent of total billed charges,75% of total billed charges for outpatient setting,62.56,70,,50.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,12.84,,9.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.5,80,,57.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,12.84,,9.18,percent of total billed charges,12.84% of total billed charges,11.48,12.84,,9.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.09,65,,46.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,100,,,Fee Schedule,100% of Custom Fee Schedule,80.43,90,,64.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,80.43,
FUROSEMIDE (genLASIX) 20MG TAB UD,3301131,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FUROSEMIDE (genLASIX) 20MG/2ML VIAL,3301136,CDM,636,RC,J1940,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FUROSEMIDE (genLASIX) 40 MG TAB,3301134,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FUROSEMIDE (genLASIX) 40MG/4ML VIAL,3301137,CDM,636,RC,J1940,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
FUROSEMIDE (genLASIX) 80MG TAB,3301132,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FUROSEMIDE (LASIX) INJ 10MG/ML:  2ML,3301140,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) INJ 10MG/ML: 10ML,3301142,CDM,250,RC,,,Outpatient,,,6.21,6.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,84.88,,4.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,50,,2.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.66,75,,3.73,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,80,,3.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.04,65,,3.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.59,90,,4.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.59,
FUROSEMIDE (LASIX) INJ 10MG/ML: 4ML,3301141,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) SOL 10MG/ML: 60ML,3301129,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
FUROSEMIDE (LASIX) TAB : 20 MG,3301128,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 20 MG  U/D,3301127,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 20 MG  U/D,3301130,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 40 MG   U/D,3301126,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 40 MG   U/D,3301133,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 40 MG   U/D,3301138,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
FUROSEMIDE (LASIX) TAB : 80 MG   U/D,3301135,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GABAPENTIN,220026,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
GABAPENTIN (genericNEURONTIN) 100 MG CAP,3301143,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GABAPENTIN (genericNEURONTIN) 300MG CAP,3301144,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GABAPENTIN (genericNEURONTIN) 400 MG CAP,3301145,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GALANTAMINE (RAZADYNE ER): 8 MG TAB,3303137,CDM,259,RC,,,Outpatient,,,12.41,12.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.69,70,,6.95,percent of total billed charges,70% of total billed charges for outpatient setting,10.53,84.88,,8.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.21,50,,4.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.31,75,,7.45,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,70,,6.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.93,80,,7.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.07,65,,6.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.34,35,,3.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.17,90,,8.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,11.17,
GALANTAMINE (REMINYL)4MG:TAB0,3303061,CDM,259,RC,,,Outpatient,,,12.47,12.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,10.58,84.88,,8.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.35,75,,7.48,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,35,,3.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.22,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.22,
GAMMAGLOBULIN  IGA  IGD  IGG  IGM  EACH,202373,CDM,301,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
GAMMAGLOBULIN IgA IgD IgG IgM EACH,200898,CDM,301,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
GANGLIOSIDE ANTIBODY PANEL,220142,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
GASTRIC EMPTYING BREATH TEST 7 SPEC,6000200,CDM,300,RC,0106U,HCPCS,Outpatient,,,2186.23,1967.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.36,70,,1224.29,percent of total billed charges,70% of total billed charges for outpatient setting,1855.67,84.88,,1484.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1216.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1639.67,75,,1311.74,percent of total billed charges,75% of total billed charges for outpatient setting,1530.36,70,,1224.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,12.84,,224.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1748.98,80,,1399.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,12.84,,224.57,percent of total billed charges,12.84% of total billed charges,280.71,12.84,,224.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1093.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.18,35,,612.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1967.61,90,,1574.09,percent of total billed charges,90% of total billed charges for outpatient setting,280.71,1967.61,
GASTRIN,220899,CDM,301,RC,82941,HCPCS,Outpatient,,,79.34,71.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,67.34,84.88,,53.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.51,75,,47.61,percent of total billed charges,75% of total billed charges for outpatient setting,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.47,80,,50.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.44,100,,,Fee Schedule,100% of Custom Fee Schedule,71.41,90,,57.13,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,71.41,
GASTROCCULT,200620,CDM,300,RC,82271,HCPCS,Outpatient,,,23.94,21.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,84.88,,16.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.96,75,,14.37,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.15,80,,15.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,21.55,90,,17.24,percent of total billed charges,90% of total billed charges for outpatient setting,4.51,21.55,
GASTROCULT,201160,CDM,300,RC,82271,HCPCS,Outpatient,,,23.94,21.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,84.88,,16.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.96,75,,14.37,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.15,80,,15.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,21.55,90,,17.24,percent of total billed charges,90% of total billed charges for outpatient setting,4.51,21.55,
GASTROFRAFIN SOLN 66-10%: 120ML,3302250,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
"GASTROINTESTINAL PROFILE,STOOL,PCR",222009,CDM,306,RC,87507,HCPCS,Outpatient,,,1041.95,937.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.37,70,,583.5,percent of total billed charges,70% of total billed charges for outpatient setting,884.41,84.88,,707.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,715.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,781.46,75,,625.17,percent of total billed charges,75% of total billed charges for outpatient setting,729.37,70,,583.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.56,80,,666.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,567.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.96,100,,,Fee Schedule,100% of Custom Fee Schedule,937.76,90,,750.21,percent of total billed charges,90% of total billed charges for outpatient setting,416.78,937.76,
GATAFLOXACIN(TEQUIN):200MG TAB,3302762,CDM,259,RC,,,Outpatient,,,41.18,41.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,34.95,84.88,,27.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.59,50,,16.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.89,75,,24.71,percent of total billed charges,75% of total billed charges for outpatient setting,28.83,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.94,80,,26.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.77,65,,21.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,35,,11.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.06,90,,29.65,percent of total billed charges,90% of total billed charges for outpatient setting,5.29,37.06,
GATIFLOXACIN (TEQUIN) TAB: 400MG,3302725,CDM,259,RC,,,Outpatient,,,67.34,67.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.14,70,,37.71,percent of total billed charges,70% of total billed charges for outpatient setting,57.16,84.88,,45.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.67,50,,26.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.51,75,,40.41,percent of total billed charges,75% of total billed charges for outpatient setting,47.14,70,,37.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.87,80,,43.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.77,65,,35.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,35,,18.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.61,90,,48.49,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,60.61,
GATOR 4.2MM / 9263A,69159344,CDM,272,RC,,,Outpatient,,,243.73,243.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.61,70,,136.49,percent of total billed charges,70% of total billed charges for outpatient setting,206.88,84.88,,165.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.87,50,,97.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.8,75,,146.24,percent of total billed charges,75% of total billed charges for outpatient setting,170.61,70,,136.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.29,12.84,,25.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.98,80,,155.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.29,12.84,,25.03,percent of total billed charges,12.84% of total billed charges,31.29,12.84,,25.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,158.42,65,,126.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.31,35,,68.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,219.36,90,,175.49,percent of total billed charges,90% of total billed charges for outpatient setting,31.29,219.36,
GAUZE IODOFORM PACKING STRIPS/KC7833,5150202,CDM,272,RC,,,Outpatient,,,24.47,24.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.13,70,,13.7,percent of total billed charges,70% of total billed charges for outpatient setting,20.77,84.88,,16.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.24,50,,9.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.35,75,,14.68,percent of total billed charges,75% of total billed charges for outpatient setting,17.13,70,,13.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,80,,15.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.91,65,,12.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,35,,6.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.02,90,,17.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.14,22.02,
GAVISCON 31.7-137 MG/5 ML LIQ:355 ML,3302650,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GEL ELECTROPHERESIS,201510,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
GELFILM 12.5 sq cm: 2 sq in,3302654,CDM,259,RC,,,Outpatient,,,115.48,115.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.84,70,,64.67,percent of total billed charges,70% of total billed charges for outpatient setting,98.02,84.88,,78.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.74,50,,46.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.61,75,,69.29,percent of total billed charges,75% of total billed charges for outpatient setting,80.84,70,,64.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.83,12.84,,11.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,80,,73.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.83,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,14.83,12.84,,11.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.06,65,,60.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.42,35,,32.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,103.93,90,,83.14,percent of total billed charges,90% of total billed charges for outpatient setting,14.83,103.93,
GELFOAM SIZE 100 TOP GELATIN SPONGE,3302655,CDM,259,RC,,,Outpatient,,,123.68,123.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.58,70,,69.26,percent of total billed charges,70% of total billed charges for outpatient setting,104.98,84.88,,83.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.84,50,,49.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.76,75,,74.21,percent of total billed charges,75% of total billed charges for outpatient setting,86.58,70,,69.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,12.84,,12.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,80,,79.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,12.84,,12.7,percent of total billed charges,12.84% of total billed charges,15.88,12.84,,12.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.39,65,,64.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.29,35,,34.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111.31,90,,89.05,percent of total billed charges,90% of total billed charges for outpatient setting,15.88,111.31,
GELFOAM SPNG  12-7M,3301146,CDM,259,RC,,,Outpatient,,,30.24,30.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,25.67,84.88,,20.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.12,50,,12.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.68,75,,18.14,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,80,,19.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.66,65,,15.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,35,,8.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.22,90,,21.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.88,27.22,
GEMFIBROZIL (LOPID) TAB : 600 MG,3301147,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GEMFIBROZIL (LOPID) TAB : 600 MG   U/D,3301148,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GENERA BITE BLOCKS / GIS-3-M,6050105,CDM,272,RC,,,Outpatient,,,19.95,19.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,16.93,84.88,,13.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.98,50,,7.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.96,75,,11.97,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.96,80,,12.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.97,65,,10.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,35,,5.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.96,90,,14.37,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.96,
GENERATION OF AUTOMATED DATA,3000155,CDM,341,RC,,,Outpatient,,,373.45,280.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.42,70,,209.14,percent of total billed charges,70% of total billed charges for outpatient setting,316.98,84.88,,253.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.73,50,,149.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.09,75,,224.07,percent of total billed charges,75% of total billed charges for outpatient setting,261.42,70,,209.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,12.84,,38.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.76,80,,239.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,12.84,,38.36,percent of total billed charges,12.84% of total billed charges,47.95,12.84,,38.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.71,35,,104.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,336.11,90,,268.89,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,774,
GENERATOR FORTIFY VR CD1231-40,69161293,CDM,275,RC,C1722,HCPCS,Outpatient,,,29000,29000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20300,70,,16240,percent of total billed charges,70% of total billed charges for outpatient setting,24615.2,84.88,,19692.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21750,75,,17400,percent of total billed charges,75% of total billed charges for outpatient setting,14500,50,,11600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3723.6,12.84,,2978.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23200,80,,18560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3723.6,12.84,,2978.88,percent of total billed charges,12.84% of total billed charges,3723.6,12.84,,2978.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30450,105,,24360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10150,35,,8120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26100,90,,20880,percent of total billed charges,90% of total billed charges for outpatient setting,3723.6,30450,
GENERATOR MRI ADVISA / A2DR01,70000094,CDM,278,RC,C1785,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
GENERATOR WAVEWRITER 16 / SC-1240A,71000611,CDM,278,RC,C1822,HCPCS,Outpatient,,,34600,34600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20760,60,,16608,percent of total billed charges,60% of total Billed charges for outpatient setting,29368.48,84.88,,23494.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25950,75,,20760,percent of total billed charges,75% of total billed charges for outpatient setting,17300,50,,13840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4442.64,12.84,,3554.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27680,80,,22144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4442.64,12.84,,3554.11,percent of total billed charges,12.84% of total billed charges,4442.64,12.84,,3554.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36330,105,,29064,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20760,60,,16608,percent of total billed charges,60% of total billed charges for outpatient setting,4442.64,36330,
GENTAMICIN (GARAMYCIN) CRM : 15 GM,3301149,CDM,259,RC,,,Outpatient,,,9.7,9.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,70,,5.43,percent of total billed charges,70% of total billed charges for outpatient setting,8.23,84.88,,6.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.85,50,,3.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.28,75,,5.82,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,70,,5.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,80,,6.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.31,65,,5.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,35,,2.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.73,90,,6.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.25,8.73,
GENTAMICIN (GARAMYCIN) INJ 10MG/ML: 2ML,3301154,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GENTAMICIN (GARAMYCIN) INJ 40MG/ML: 2ML,3301153,CDM,250,RC,,,Outpatient,,,14.29,14.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,70,,8,percent of total billed charges,70% of total billed charges for outpatient setting,12.13,84.88,,9.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.15,50,,5.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.72,75,,8.58,percent of total billed charges,75% of total billed charges for outpatient setting,10,70,,8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,80,,9.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.29,65,,7.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,35,,4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.86,90,,10.29,percent of total billed charges,90% of total billed charges for outpatient setting,1.83,12.86,
GENTAMICIN (GARAMYCIN) SOL 3% : 5ML,3301155,CDM,259,RC,,,Outpatient,,,18.61,18.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,70,,10.42,percent of total billed charges,70% of total billed charges for outpatient setting,15.8,84.88,,12.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.31,50,,7.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.96,75,,11.17,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,70,,10.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,80,,11.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.1,65,,9.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,35,,5.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.75,90,,13.4,percent of total billed charges,90% of total billed charges for outpatient setting,2.39,16.75,
GENTAMICIN (GENT ISOP) DROP 80MG/50ML:,3301158,CDM,250,RC,,,Outpatient,,,10.78,10.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,70,,6.04,percent of total billed charges,70% of total billed charges for outpatient setting,9.15,84.88,,7.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.39,50,,4.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.09,75,,6.47,percent of total billed charges,75% of total billed charges for outpatient setting,7.55,70,,6.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,80,,6.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.01,65,,5.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,35,,3.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.7,90,,7.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.7,
GENTAMICIN (GENTAK) ONIT : 30 GM,3301150,CDM,259,RC,,,Outpatient,,,13.22,13.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,70,,7.4,percent of total billed charges,70% of total billed charges for outpatient setting,11.22,84.88,,8.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.61,50,,5.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.92,75,,7.94,percent of total billed charges,75% of total billed charges for outpatient setting,9.25,70,,7.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,80,,8.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.59,65,,6.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,35,,3.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.9,90,,9.52,percent of total billed charges,90% of total billed charges for outpatient setting,1.7,11.9,
GENTAMICIN (GENTAK) OPTH OINT : 3.5GM,3301151,CDM,259,RC,,,Outpatient,,,39.35,39.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.55,70,,22.04,percent of total billed charges,70% of total billed charges for outpatient setting,33.4,84.88,,26.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.68,50,,15.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.51,75,,23.61,percent of total billed charges,75% of total billed charges for outpatient setting,27.55,70,,22.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.48,80,,25.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.58,65,,20.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.77,35,,11.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.42,90,,28.34,percent of total billed charges,90% of total billed charges for outpatient setting,5.05,35.42,
GENTAMICIN (GENTAK) SOL 0.3% : 5ML,3301156,CDM,259,RC,,,Outpatient,,,22.04,22.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.43,70,,12.34,percent of total billed charges,70% of total billed charges for outpatient setting,18.71,84.88,,14.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.02,50,,8.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.53,75,,13.22,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,70,,12.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,80,,14.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.33,65,,11.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,35,,6.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.84,90,,15.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.83,19.84,
GENTAMICIN 40MG/ML 2ML INJ,3301152,CDM,636,RC,J1580,HCPCS,Outpatient,,,26.46,26.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.52,70,,14.82,percent of total billed charges,70% of total billed charges for outpatient setting,22.46,84.88,,17.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.85,75,,15.88,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,70,,14.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,80,,16.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,3.4,12.84,,2.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.2,65,,13.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,100,,,Fee Schedule,100% of Custom Fee Schedule,23.81,90,,19.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,23.81,
GENTAMICIN 80 MG/NS 100 ML PREMIX,3303136,CDM,250,RC,J1580,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GENTAMICIN 80 MG/NS 50 ML PREMIX,3309559,CDM,250,RC,J1580,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GENTAMICIN PEAK,220034,CDM,300,RC,80170,HCPCS,Outpatient,,,73.71,66.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.6,70,,41.28,percent of total billed charges,70% of total billed charges for outpatient setting,62.57,84.88,,50.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.28,75,,44.22,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,70,,41.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.97,80,,47.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,66.34,90,,53.07,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,66.34,
GENTAMICIN SULFATE OPTH SOLN 5ML,3305298,CDM,259,RC,,,Outpatient,,,43.37,43.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.36,70,,24.29,percent of total billed charges,70% of total billed charges for outpatient setting,36.81,84.88,,29.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.69,50,,17.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.53,75,,26.02,percent of total billed charges,75% of total billed charges for outpatient setting,30.36,70,,24.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.7,80,,27.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.19,65,,22.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.18,35,,12.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.03,90,,31.22,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,39.03,
GENTAMICIN TROUGH,220035,CDM,300,RC,80170,HCPCS,Outpatient,,,73.71,66.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.6,70,,41.28,percent of total billed charges,70% of total billed charges for outpatient setting,62.57,84.88,,50.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.28,75,,44.22,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,70,,41.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.97,80,,47.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,66.34,90,,53.07,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,66.34,
GENTIAN VIOLET 1%:30 ML,3302790,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GEODON (ZIPRASIDONE):20 MG INJECTION,3303008,CDM,250,RC,,,Outpatient,,,188.39,188.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.87,70,,105.5,percent of total billed charges,70% of total billed charges for outpatient setting,159.91,84.88,,127.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.2,50,,75.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.29,75,,113.03,percent of total billed charges,75% of total billed charges for outpatient setting,131.87,70,,105.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,12.84,,19.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.71,80,,120.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,12.84,,19.35,percent of total billed charges,12.84% of total billed charges,24.19,12.84,,19.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122.45,65,,97.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.94,35,,52.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.55,90,,135.64,percent of total billed charges,90% of total billed charges for outpatient setting,24.19,169.55,
GGT,200480,CDM,300,RC,82977,HCPCS,Outpatient,,,32.4,29.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,27.5,84.88,,22,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.3,75,,19.44,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,80,,20.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,100,,,Fee Schedule,100% of Custom Fee Schedule,29.16,90,,23.33,percent of total billed charges,90% of total billed charges for outpatient setting,7.2,29.16,
GI GENIUS,69161490,CDM,360,RC,,,Outpatient,,,84,84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,70,,47.04,percent of total billed charges,70% of total billed charges for outpatient setting,71.3,84.88,,57.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,42,50,,33.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,75,,50.4,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,70,,47.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,12.84,,8.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,80,,53.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,12.84,,8.63,percent of total billed charges,12.84% of total billed charges,10.79,12.84,,8.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,35,,23.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.6,90,,60.48,percent of total billed charges,90% of total billed charges for outpatient setting,10.79,75.6,
"GIARDIA ANTIBODY, SERUM",201066,CDM,302,RC,86674,HCPCS,Outpatient,,,66.24,59.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,56.22,84.88,,44.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.68,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,80,,42.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.5,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,100% of Custom Fee Schedule,59.62,90,,47.7,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,59.62,
GIARDIA IMMUNOASSAY,200816,CDM,300,RC,87328,HCPCS,Outpatient,,,62.19,55.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,52.79,84.88,,42.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.64,75,,37.31,percent of total billed charges,75% of total billed charges for outpatient setting,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.75,80,,39.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,55.97,90,,44.78,percent of total billed charges,90% of total billed charges for outpatient setting,13.82,55.97,
"GIARDIA LAMBLIA AG,STOOL",220836,CDM,300,RC,87328,HCPCS,Outpatient,,,62.19,55.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,52.79,84.88,,42.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.64,75,,37.31,percent of total billed charges,75% of total billed charges for outpatient setting,43.53,70,,34.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.75,80,,39.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,55.97,90,,44.78,percent of total billed charges,90% of total billed charges for outpatient setting,13.82,55.97,
GINSENG (GINSANA 60) CAP: 250MG,3301159,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GLASSCOCK EAR DRESSING // OTOS1000H,70000011,CDM,272,RC,,,Outpatient,,,122.84,122.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.99,70,,68.79,percent of total billed charges,70% of total billed charges for outpatient setting,104.27,84.88,,83.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.42,50,,49.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.13,75,,73.7,percent of total billed charges,75% of total billed charges for outpatient setting,85.99,70,,68.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,12.84,,12.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.27,80,,78.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,12.84,,12.62,percent of total billed charges,12.84% of total billed charges,15.77,12.84,,12.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.85,65,,63.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.99,35,,34.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.56,90,,88.45,percent of total billed charges,90% of total billed charges for outpatient setting,15.77,110.56,
GLENOID BASE / 113954,69161608,CDM,278,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
GLENOID BASE 4MM SMALL / 113952,69162549,CDM,278,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
GLENOID POST / PT-113950,69161607,CDM,278,RC,,,Outpatient,,,1892.63,1892.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,60,,908.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1606.46,84.88,,1285.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1419.47,75,,1135.58,percent of total billed charges,75% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.1,80,,1211.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1892.63,65,,1514.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.42,35,,529.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1135.58,60,,908.46,percent of total billed charges,60% of total billed charges for outpatient setting,243.01,1892.63,
GLENOSPHERE 25MM MINI BASE / 010000589,69161571,CDM,278,RC,C1776,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
GLENOSPHERE 36MM DIA CURVE STND / 115310,69161572,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
GLENOSPHERE 36MM STD / 115313,705701,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
GLENOSPHERE 40MM +3 / 110030777,69169790,CDM,278,RC,C1713,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
GLENOSPHERE 40MM +6 / 110030778,7079707,CDM,278,RC,C1713,HCPCS,Outpatient,,,3500,3500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,60,,1680,percent of total billed charges,60% of total Billed charges for outpatient setting,2970.8,84.88,,2376.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625,75,,2100,percent of total billed charges,75% of total billed charges for outpatient setting,1750,50,,1400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,80,,2240,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3675,105,,2940,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225,35,,980,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2100,60,,1680,percent of total billed charges,60% of total billed charges for outpatient setting,449.4,3675,
GLENOSPHERE 40MM STD / 110030776,69169615,CDM,278,RC,C1713,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
GLENOSPHERE 41MM STD / 115320,69162642,CDM,278,RC,C1776,HCPCS,Outpatient,,,2625,2625,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,60,,1260,percent of total billed charges,60% of total Billed charges for outpatient setting,2228.1,84.88,,1782.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968.75,75,,1575,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,50,,1050,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,80,,1680,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2756.25,105,,2205,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.75,35,,735,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1575,60,,1260,percent of total billed charges,60% of total billed charges for outpatient setting,337.05,2756.25,
GLIDE CATH STRAIGHT 5FR 65CM/CG505,69159964,CDM,272,RC,,,Outpatient,,,269.58,269.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.71,70,,150.97,percent of total billed charges,70% of total billed charges for outpatient setting,228.82,84.88,,183.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.79,50,,107.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.19,75,,161.75,percent of total billed charges,75% of total billed charges for outpatient setting,188.71,70,,150.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.61,12.84,,27.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.66,80,,172.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.61,12.84,,27.69,percent of total billed charges,12.84% of total billed charges,34.61,12.84,,27.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.23,65,,140.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.35,35,,75.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.62,90,,194.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.61,242.62,
GLIDECATH 4F STRAIGHT 120CM/CG414,69159967,CDM,272,RC,,,Outpatient,,,291.14,291.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.8,70,,163.04,percent of total billed charges,70% of total billed charges for outpatient setting,247.12,84.88,,197.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,145.57,50,,116.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.36,75,,174.69,percent of total billed charges,75% of total billed charges for outpatient setting,203.8,70,,163.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.91,80,,186.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.24,65,,151.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.9,35,,81.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,262.03,90,,209.62,percent of total billed charges,90% of total billed charges for outpatient setting,37.38,262.03,
GLIDECATH 5F ANGLED 65CM/CG507,69159963,CDM,272,RC,,,Outpatient,,,291.14,291.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.8,70,,163.04,percent of total billed charges,70% of total billed charges for outpatient setting,247.12,84.88,,197.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,145.57,50,,116.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.36,75,,174.69,percent of total billed charges,75% of total billed charges for outpatient setting,203.8,70,,163.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.91,80,,186.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.24,65,,151.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.9,35,,81.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,262.03,90,,209.62,percent of total billed charges,90% of total billed charges for outpatient setting,37.38,262.03,
GLIDECATH 5FR .038x65CM ANGLE TAPE/CG505,69159797,CDM,272,RC,,,Outpatient,,,312.8,312.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.96,70,,175.17,percent of total billed charges,70% of total billed charges for outpatient setting,265.5,84.88,,212.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.4,50,,125.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.6,75,,187.68,percent of total billed charges,75% of total billed charges for outpatient setting,218.96,70,,175.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.16,12.84,,32.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.24,80,,200.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.16,12.84,,32.13,percent of total billed charges,12.84% of total billed charges,40.16,12.84,,32.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.32,65,,162.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.48,35,,87.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.52,90,,225.22,percent of total billed charges,90% of total billed charges for outpatient setting,40.16,281.52,
GLIDECATH 5FR .038x65CM STRAIGHT/CG505,69159796,CDM,272,RC,,,Outpatient,,,312.8,312.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.96,70,,175.17,percent of total billed charges,70% of total billed charges for outpatient setting,265.5,84.88,,212.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.4,50,,125.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.6,75,,187.68,percent of total billed charges,75% of total billed charges for outpatient setting,218.96,70,,175.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.16,12.84,,32.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.24,80,,200.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.16,12.84,,32.13,percent of total billed charges,12.84% of total billed charges,40.16,12.84,,32.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.32,65,,162.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.48,35,,87.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.52,90,,225.22,percent of total billed charges,90% of total billed charges for outpatient setting,40.16,281.52,
GLIDESCOPE BFLEX 3.8 / 0570-0380,69169230,CDM,272,RC,,,Outpatient,,,1038,1038,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.6,70,,581.28,percent of total billed charges,70% of total billed charges for outpatient setting,881.05,84.88,,704.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,519,50,,415.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,778.5,75,,622.8,percent of total billed charges,75% of total billed charges for outpatient setting,726.6,70,,581.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.28,12.84,,106.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,830.4,80,,664.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.28,12.84,,106.62,percent of total billed charges,12.84% of total billed charges,133.28,12.84,,106.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,674.7,65,,539.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.3,35,,290.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,934.2,90,,747.36,percent of total billed charges,90% of total billed charges for outpatient setting,133.28,934.2,
GLIMEPIRIDE (AMARYL) TAB: 2 MG,3301160,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GLIMEPIRIDE (genAMARYL) 2 MG TAB,3301161,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
GLIMEPIRIDE (genericAMARYL) 4 MG TAB,3302864,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GLIPIZIDE (genGLUCOTROL) 10MG TAB,3301163,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLIPIZIDE (GLUCOTROL) TAB 5 MG   U/D,3301162,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GLIPIZIDE (GLUCOTROL) XL TAB  2.5 MG,3301164,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLIPIZIDE (GLUCOTROL) XL TAB  5 MG,3301165,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GLUCAGON HUMAN KIT 1 MG,3301166,CDM,250,RC,J1611,HCPCS,Outpatient,,,482,482,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.4,70,,269.92,percent of total billed charges,70% of total billed charges for outpatient setting,409.12,84.88,,327.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,241,50,,192.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.5,75,,289.2,percent of total billed charges,75% of total billed charges for outpatient setting,337.4,70,,269.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.89,12.84,,49.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.6,80,,308.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.89,12.84,,49.51,percent of total billed charges,12.84% of total billed charges,61.89,12.84,,49.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,313.3,65,,250.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.7,35,,134.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,433.8,90,,347.04,percent of total billed charges,90% of total billed charges for outpatient setting,61.89,433.8,
GLUCOSE,200170,CDM,300,RC,82947,HCPCS,Outpatient,,,17.69,15.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,84.88,,12.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.27,75,,10.62,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,80,,11.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of Custom Fee Schedule,15.92,90,,12.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,15.92,
GLUCOSE,5100502,CDM,301,RC,82947,HCPCS,Outpatient,,,40.44,36.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,70,,22.65,percent of total billed charges,70% of total billed charges for outpatient setting,34.33,84.88,,27.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.33,75,,24.26,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,70,,22.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.35,80,,25.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of Custom Fee Schedule,36.4,90,,29.12,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,36.4,
GLUCOSE  24 HR URINE,220092,CDM,301,RC,82945,HCPCS,Outpatient,,,17.69,15.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,84.88,,12.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.27,75,,10.62,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,70,,9.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,80,,11.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of Custom Fee Schedule,15.92,90,,12.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,15.92,
GLUCOSE 6 PHOSPHATE DEHYDROGENASE,220058,CDM,301,RC,82955,HCPCS,Outpatient,,,43.65,39.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,70,,24.45,percent of total billed charges,70% of total billed charges for outpatient setting,37.05,84.88,,29.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.74,75,,26.19,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,70,,24.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,80,,27.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.16,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,100,,,Fee Schedule,100% of Custom Fee Schedule,39.29,90,,31.43,percent of total billed charges,90% of total billed charges for outpatient setting,9.7,39.29,
GLUCOSE TOLERANCE TEST 1HR GTT,200172,CDM,301,RC,82951,HCPCS,Outpatient,,,57.92,52.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,49.16,84.88,,39.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.44,75,,34.75,percent of total billed charges,75% of total billed charges for outpatient setting,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,80,,37.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,100% of Custom Fee Schedule,52.13,90,,41.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,52.13,
GLUCOSE TOLERANCE TEST EA ADDITIONAL,220091,CDM,301,RC,82952,HCPCS,Outpatient,,,17.64,15.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,14.97,84.88,,11.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.23,75,,10.58,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,80,,11.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.72,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,100,,,Fee Schedule,100% of Custom Fee Schedule,15.88,90,,12.7,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.88,
GLUCOSE TOLERANCE TEST EACH ADDITIONAL,200173,CDM,301,RC,82952,HCPCS,Outpatient,,,17.64,15.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,14.97,84.88,,11.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.23,75,,10.58,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,70,,9.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,80,,11.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.72,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,100,,,Fee Schedule,100% of Custom Fee Schedule,15.88,90,,12.7,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.88,
"GLUCOSE, 2 HOUR POST PRANDIAL",200176,CDM,300,RC,82950,HCPCS,Outpatient,,,21.38,19.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.97,70,,11.98,percent of total billed charges,70% of total billed charges for outpatient setting,18.15,84.88,,14.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.04,75,,12.83,percent of total billed charges,75% of total billed charges for outpatient setting,14.97,70,,11.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,80,,13.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,100,,,Fee Schedule,100% of Custom Fee Schedule,19.24,90,,15.39,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,19.24,
GLUCOTROL XL: 10 MG,3302904,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLUCOVANCE 5/500:TAB,3302765,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLYBURIDE 2.5 MG TAB (DIABETA):,3301167,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GLYBURIDE 2.5 MG TAB (DIABETA): UD,3301170,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLYBURIDE 3 MG TAB (DIABETA): UD,3301172,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLYBURIDE 5 MG TAB (DIABETA):,3301171,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLYBURIDE 5 MG TAB (DIABETA): UD,3301168,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GLYBURIDE 5 MG TAB (DIABETA): UD,3301169,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GLYCERIN 2:1 LIDOCAINE/W EPI : UD,3303301,CDM,250,RC,,,Outpatient,,,73.02,73.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.11,70,,40.89,percent of total billed charges,70% of total billed charges for outpatient setting,61.98,84.88,,49.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.51,50,,29.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.77,75,,43.82,percent of total billed charges,75% of total billed charges for outpatient setting,51.11,70,,40.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,12.84,,7.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.42,80,,46.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,12.84,,7.5,percent of total billed charges,12.84% of total billed charges,9.38,12.84,,7.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.46,65,,37.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,35,,20.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.72,90,,52.58,percent of total billed charges,90% of total billed charges for outpatient setting,9.38,65.72,
GLYCERIN 72%: UD CHARGE,3303300,CDM,250,RC,,,Outpatient,,,46.47,46.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.53,70,,26.02,percent of total billed charges,70% of total billed charges for outpatient setting,39.44,84.88,,31.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.24,50,,18.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.85,75,,27.88,percent of total billed charges,75% of total billed charges for outpatient setting,32.53,70,,26.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.18,80,,29.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.21,65,,24.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.26,35,,13.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.82,90,,33.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,41.82,
GLYCERIN ADULT SUPP  12 EACH,3301173,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GLYCERIN SOL : 120ML,3301174,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
GLYCINE 3000ML BAG / 2B7317,6150080,CDM,272,RC,,,Outpatient,,,62.44,62.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.71,70,,34.97,percent of total billed charges,70% of total billed charges for outpatient setting,53,84.88,,42.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.22,50,,24.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.83,75,,37.46,percent of total billed charges,75% of total billed charges for outpatient setting,43.71,70,,34.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,12.84,,6.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.95,80,,39.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,12.84,,6.42,percent of total billed charges,12.84% of total billed charges,8.02,12.84,,6.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.59,65,,32.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.85,35,,17.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.2,90,,44.96,percent of total billed charges,90% of total billed charges for outpatient setting,8.02,56.2,
GLYCOPYRROLATE (ROBINUL)INJ 0.2MG/ML:5ML,3301176,CDM,250,RC,J3490,HCPCS,Outpatient,,,8.49,8.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.94,70,,4.75,percent of total billed charges,70% of total billed charges for outpatient setting,7.21,84.88,,5.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,6.37,75,,5.1,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,70,,4.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,80,,5.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.52,65,,4.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.97,35,,2.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.64,90,,6.11,percent of total billed charges,90% of total billed charges for outpatient setting,1.09,7.64,
GLYCOPYRROLATE 0.2MG/ML SYRINGE INJ  5ML,3308813,CDM,250,RC,,,Outpatient,,,64.05,64.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.84,70,,35.87,percent of total billed charges,70% of total billed charges for outpatient setting,54.37,84.88,,43.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.03,50,,25.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.04,75,,38.43,percent of total billed charges,75% of total billed charges for outpatient setting,44.84,70,,35.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.24,80,,40.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.63,65,,33.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.42,35,,17.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.65,90,,46.12,percent of total billed charges,90% of total billed charges for outpatient setting,8.22,57.65,
GLYCOPYRROLATE/ROBINUL INJ 0.2MG/ML 1ML,3301175,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
GLYCOSOLATED HEMOGLOBIN,220393,CDM,300,RC,83036,HCPCS,Outpatient,,,43.7,39.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,37.09,84.88,,29.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.78,75,,26.22,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,80,,27.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,100,,,Fee Schedule,100% of Custom Fee Schedule,39.33,90,,31.46,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,39.33,
GOLDBOND TOPICAL MEDICATED POWDER,3303334,CDM,259,RC,,,Outpatient,,,16.47,16.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,70,,9.22,percent of total billed charges,70% of total billed charges for outpatient setting,13.98,84.88,,11.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.24,50,,6.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.35,75,,9.88,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,70,,9.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,12.84,,1.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.18,80,,10.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,12.84,,1.69,percent of total billed charges,12.84% of total billed charges,2.11,12.84,,1.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.71,65,,8.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,35,,4.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.82,90,,11.86,percent of total billed charges,90% of total billed charges for outpatient setting,2.11,14.82,
GOLIMUMAB(SIMPONI ARIA)1MG/UNIT WASTAG,3306247,CDM,636,RC,J1602,HCPCS,Outpatient,,,90.03,90.03,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,70,,50.42,percent of total billed charges,70% of total billed charges for outpatient setting,76.42,84.88,,61.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.02,50,,36.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.52,75,,54.02,percent of total billed charges,75% of total billed charges for outpatient setting,63.02,70,,50.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.02,80,,57.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.52,65,,46.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.51,35,,25.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.03,90,,64.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.56,81.03,
GOLIMUMAB(SIMPONI ARIA)INJ 50MG(1MG/UNIT,3306246,CDM,636,RC,J1602,HCPCS,Outpatient,,,90.03,90.03,,22.52,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.02,70,,50.42,percent of total billed charges,70% of total billed charges for outpatient setting,76.42,84.88,,61.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,67.52,75,,54.02,percent of total billed charges,75% of total billed charges for outpatient setting,63.02,70,,50.42,percent of total billed charges,70% of total billed charges for outpatient setting,23.93,170,,,Fee Schedule,170% of Medicare OPPS rate,30.27,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.56,12.84,,9.248,percent of total billed charges,12.84% of total billed charges,24.64,175,,,Fee Schedule,175% of Medicare OPPS rate,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.02,80,,57.62,percent of total billed charges,80% of total billed charges for outpatient setting,19.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,17.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,11.56,12.84,,9.25,percent of total billed charges,12.84% of total billed charges,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,58.52,65,,46.82,percent of total billed charges,65% of total billed charges for outpatient setting,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,29,100,,,Fee Schedule,100% of Custom Fee Schedule,81.03,90,,64.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.56,81.03,
GRACILIS SGL STRD NON-BN TDN,69162037,CDM,278,RC,,,Outpatient,,,2420,2420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1452,60,,1161.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2054.1,84.88,,1643.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,1210,50,,968,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1815,75,,1452,percent of total billed charges,75% of total billed charges for outpatient setting,1210,50,,968,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.73,12.84,,248.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1936,80,,1548.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.73,12.84,,248.58,percent of total billed charges,12.84% of total billed charges,310.73,12.84,,248.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2541,105,,2032.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847,35,,677.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1452,60,,1161.6,percent of total billed charges,60% of total billed charges for outpatient setting,310.73,2541,
GRAFT 10ML BONE VITOSS / 2102-2210,71000830,CDM,278,RC,C9359,HCPCS,Outpatient,,,7411.94,7411.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4447.16,60,,3557.73,percent of total billed charges,60% of total Billed charges for outpatient setting,6291.25,84.88,,5033,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,5558.96,75,,4447.17,percent of total billed charges,75% of total billed charges for outpatient setting,3705.97,50,,2964.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.69,12.84,,761.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5929.55,80,,4743.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.69,12.84,,761.35,percent of total billed charges,12.84% of total billed charges,951.69,12.84,,761.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7782.54,105,,6226.03,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2594.18,35,,2075.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4447.16,60,,3557.73,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,7782.54,
GRAFT 2.5ML BONE VITOSS / 2102.2202,1226443,CDM,278,RC,C9359,HCPCS,Outpatient,,,2120.68,2120.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1272.41,60,,1017.93,percent of total billed charges,60% of total Billed charges for outpatient setting,1800.03,84.88,,1440.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1590.51,75,,1272.41,percent of total billed charges,75% of total billed charges for outpatient setting,1060.34,50,,848.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1696.54,80,,1357.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2226.71,105,,1781.37,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.24,35,,593.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1272.41,60,,1017.93,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2226.71,
GRAFT 4.0X230MM GRAFT SUTURE / FCON,69169893,CDM,278,RC,C1762,HCPCS,Outpatient,,,2444.6,2444.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1466.76,60,,1173.41,percent of total billed charges,60% of total Billed charges for outpatient setting,2074.98,84.88,,1659.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.45,75,,1466.76,percent of total billed charges,75% of total billed charges for outpatient setting,1222.3,50,,977.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.89,12.84,,251.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1955.68,80,,1564.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.89,12.84,,251.11,percent of total billed charges,12.84% of total billed charges,313.89,12.84,,251.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2566.83,105,,2053.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.61,35,,684.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1466.76,60,,1173.41,percent of total billed charges,60% of total billed charges for outpatient setting,313.89,2566.83,
GRAFT 6MM CERVICAL CORT / 3W3006,7562720,CDM,278,RC,C1821,HCPCS,Outpatient,,,3255,3255,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1953,60,,1562.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2762.84,84.88,,2210.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2441.25,75,,1953,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,50,,1302,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.94,12.84,,334.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2604,80,,2083.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.94,12.84,,334.35,percent of total billed charges,12.84% of total billed charges,417.94,12.84,,334.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3417.75,105,,2734.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.25,35,,911.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1953,60,,1562.4,percent of total billed charges,60% of total billed charges for outpatient setting,417.94,3417.75,
GRAFT 6MMX40CM STNDRD WALL / 22612,69160377,CDM,278,RC,C1768,HCPCS,Outpatient,,,1374.84,1374.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,824.9,60,,659.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1166.96,84.88,,933.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1031.13,75,,824.9,percent of total billed charges,75% of total billed charges for outpatient setting,687.42,50,,549.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.53,12.84,,141.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1099.87,80,,879.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.53,12.84,,141.22,percent of total billed charges,12.84% of total billed charges,176.53,12.84,,141.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1374.84,65,,1099.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.19,35,,384.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,824.9,60,,659.92,percent of total billed charges,60% of total billed charges for outpatient setting,176.53,1374.84,
GRAFT ACHILLES CALCANEAL BONE / 430200,69162439,CDM,278,RC,,,Outpatient,,,3820.5,3820.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.3,60,,1833.84,percent of total billed charges,60% of total Billed charges for outpatient setting,3242.84,84.88,,2594.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1910.25,50,,1528.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2865.38,75,,2292.3,percent of total billed charges,75% of total billed charges for outpatient setting,1910.25,50,,1528.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.55,12.84,,392.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3056.4,80,,2445.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.55,12.84,,392.44,percent of total billed charges,12.84% of total billed charges,490.55,12.84,,392.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4011.53,105,,3209.22,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1337.18,35,,1069.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2292.3,60,,1833.84,percent of total billed charges,60% of total billed charges for outpatient setting,490.55,4011.53,
GRAFT HIATAL HERNIA  7X10CM / G31455,69169427,CDM,278,RC,C1781,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2193.98,60,,1755.18,percent of total billed charges,60% of total Billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2193.98,60,,1755.18,percent of total billed charges,60% of total billed charges for outpatient setting,469.51,3839.46,
GRAFT TENDON    GRL-001,69162464,CDM,278,RC,,,Outpatient,,,4650,4650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2790,60,,2232,percent of total billed charges,60% of total Billed charges for outpatient setting,3946.92,84.88,,3157.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,2325,50,,1860,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3487.5,75,,2790,percent of total billed charges,75% of total billed charges for outpatient setting,2325,50,,1860,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.06,12.84,,477.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3720,80,,2976,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.06,12.84,,477.65,percent of total billed charges,12.84% of total billed charges,597.06,12.84,,477.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4882.5,105,,3906,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,35,,1302,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2790,60,,2232,percent of total billed charges,60% of total billed charges for outpatient setting,597.06,4882.5,
GRAFTLINK CONSTRUCT 9X65,69161878,CDM,278,RC,,,Outpatient,,,4132.5,4132.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2479.5,60,,1983.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3507.67,84.88,,2806.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,2066.25,50,,1653,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3099.38,75,,2479.5,percent of total billed charges,75% of total billed charges for outpatient setting,2066.25,50,,1653,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,12.84,,424.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3306,80,,2644.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,12.84,,424.49,percent of total billed charges,12.84% of total billed charges,530.61,12.84,,424.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4339.13,105,,3471.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.38,35,,1157.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2479.5,60,,1983.6,percent of total billed charges,60% of total billed charges for outpatient setting,530.61,4339.13,
GRAM STAIN,222033,CDM,306,RC,87205,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
GRANISETRON (KYTRIL)1MG/MLML:INJ,3304966,CDM,636,RC,J1626,HCPCS,Outpatient,,,137.64,137.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.35,70,,77.08,percent of total billed charges,70% of total billed charges for outpatient setting,116.83,84.88,,93.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,103.23,75,,82.58,percent of total billed charges,75% of total billed charges for outpatient setting,96.35,70,,77.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,12.84,,14.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.11,80,,88.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,17.67,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.47,65,,71.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,100,,,Fee Schedule,100% of Custom Fee Schedule,123.88,90,,99.1,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,123.88,
GRANULES CHRONS LG 2.8-5.6MM/710.026.97S,70000414,CDM,278,RC,,,Outpatient,,,3238.6,3238.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1943.16,60,,1554.53,percent of total billed charges,60% of total Billed charges for outpatient setting,2748.92,84.88,,2199.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1619.3,50,,1295.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2428.95,75,,1943.16,percent of total billed charges,75% of total billed charges for outpatient setting,1619.3,50,,1295.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.84,12.84,,332.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2590.88,80,,2072.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.84,12.84,,332.67,percent of total billed charges,12.84% of total billed charges,415.84,12.84,,332.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3400.53,105,,2720.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.51,35,,906.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1943.16,60,,1554.53,percent of total billed charges,60% of total billed charges for outpatient setting,415.84,3400.53,
GRASPER ENDOSCOPIC BABCOCK 10MM/10BB,6153236,CDM,272,RC,,,Outpatient,,,241.24,241.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.87,70,,135.1,percent of total billed charges,70% of total billed charges for outpatient setting,204.76,84.88,,163.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,120.62,50,,96.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.93,75,,144.74,percent of total billed charges,75% of total billed charges for outpatient setting,168.87,70,,135.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,12.84,,24.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,80,,154.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,12.84,,24.78,percent of total billed charges,12.84% of total billed charges,30.98,12.84,,24.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156.81,65,,125.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.43,35,,67.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,217.12,90,,173.7,percent of total billed charges,90% of total billed charges for outpatient setting,30.98,217.12,
GREAT WHITE SHAVER 4.2MM / 9299A,69160828,CDM,272,RC,,,Outpatient,,,277.76,277.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.43,70,,155.54,percent of total billed charges,70% of total billed charges for outpatient setting,235.76,84.88,,188.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.88,50,,111.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.32,75,,166.66,percent of total billed charges,75% of total billed charges for outpatient setting,194.43,70,,155.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.66,12.84,,28.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.21,80,,177.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.66,12.84,,28.53,percent of total billed charges,12.84% of total billed charges,35.66,12.84,,28.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.54,65,,144.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.22,35,,77.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.98,90,,199.98,percent of total billed charges,90% of total billed charges for outpatient setting,35.66,249.98,
GRID SPEE D GRID SGRID1,2750022,CDM,270,RC,,,Outpatient,,,41.78,41.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,70,,23.4,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,84.88,,28.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.89,50,,16.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.34,75,,25.07,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,70,,23.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.42,80,,26.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.16,65,,21.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,35,,11.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.6,90,,30.08,percent of total billed charges,90% of total billed charges for outpatient setting,5.36,37.6,
GROOVED ELECTRODE / VE-LG,6150863,CDM,272,RC,,,Outpatient,,,546.85,546.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.8,70,,306.24,percent of total billed charges,70% of total billed charges for outpatient setting,464.17,84.88,,371.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,273.43,50,,218.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.14,75,,328.11,percent of total billed charges,75% of total billed charges for outpatient setting,382.8,70,,306.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.22,12.84,,56.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.48,80,,349.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.22,12.84,,56.18,percent of total billed charges,12.84% of total billed charges,70.22,12.84,,56.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,355.45,65,,284.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.4,35,,153.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,492.17,90,,393.74,percent of total billed charges,90% of total billed charges for outpatient setting,70.22,492.17,
GROOVED VAPOR PROBE / VE-B,6150602,CDM,270,RC,,,Outpatient,,,495.94,495.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.16,70,,277.73,percent of total billed charges,70% of total billed charges for outpatient setting,420.95,84.88,,336.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,247.97,50,,198.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,371.96,75,,297.57,percent of total billed charges,75% of total billed charges for outpatient setting,347.16,70,,277.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.68,12.84,,50.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.75,80,,317.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.68,12.84,,50.94,percent of total billed charges,12.84% of total billed charges,63.68,12.84,,50.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,322.36,65,,257.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.58,35,,138.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.35,90,,357.08,percent of total billed charges,90% of total billed charges for outpatient setting,63.68,446.35,
GROUNDING PAD ADULT / WA99514C,7123121,CDM,272,RC,,,Outpatient,,,17.1,17.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,14.51,84.88,,11.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.55,50,,6.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.83,75,,10.26,percent of total billed charges,75% of total billed charges for outpatient setting,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,80,,10.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,65,,8.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,35,,4.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.39,90,,12.31,percent of total billed charges,90% of total billed charges for outpatient setting,2.2,15.39,
GROUNDING PAD ADULT AND PEDI / 9165,6150422,CDM,272,RC,,,Outpatient,,,19.8,19.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,16.81,84.88,,13.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.9,50,,7.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,75,,11.88,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,80,,12.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.87,65,,10.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.93,35,,5.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.82,90,,14.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,17.82,
GROUNDING PAD RADIOFR / RF-DGP-S,69169624,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,59.42,84.88,,47.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,35,50,,28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,75,,42,percent of total billed charges,75% of total billed charges for outpatient setting,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,80,,44.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.5,65,,36.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,35,,19.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63,90,,50.4,percent of total billed charges,90% of total billed charges for outpatient setting,8.99,63,
"GROUNDING PAD, PEDI  410-2000A",69159905,CDM,272,RC,,,Outpatient,,,34.26,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,70,,19.18,percent of total billed charges,70% of total billed charges for outpatient setting,29.08,84.88,,23.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.13,50,,13.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.7,75,,20.56,percent of total billed charges,75% of total billed charges for outpatient setting,23.98,70,,19.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.41,80,,21.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.27,65,,17.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,35,,9.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.83,90,,24.66,percent of total billed charges,90% of total billed charges for outpatient setting,4.4,30.83,
GROWTH HORMONE,220169,CDM,301,RC,83003,HCPCS,Outpatient,,,16.67,15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,70,,9.34,percent of total billed charges,70% of total billed charges for outpatient setting,14.15,84.88,,11.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.5,75,,10,percent of total billed charges,75% of total billed charges for outpatient setting,11.67,70,,9.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,80,,10.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,100% of Custom Fee Schedule,15,90,,12,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,31.64,
GUAIFEN (GUIATUSS AF) SYRUP 120 ML:,3301177,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
GUAIFEN (ROBITUSSIN) SYRP 100 MG/5ML,3301180,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GUAIFENESIN (MUCINEX) ER 600 MG TABLET,3301179,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GUAIFENESIN (ROBITUSSIN A-C) SYRUP:5MLUD,3301182,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
GUAIFENESIN (ROBITUSSIN DM) SYRUP 180ML:,3301185,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
GUAIFENESIN (TUSSIN DM) SYRUP 480 ML:,3301187,CDM,259,RC,,,Outpatient,,,15.42,15.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,70,,8.63,percent of total billed charges,70% of total billed charges for outpatient setting,13.09,84.88,,10.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.71,50,,6.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.57,75,,9.26,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,70,,8.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,80,,9.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.02,65,,8.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,35,,4.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.88,90,,11.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.98,13.88,
GUAIFENESIN (TUSSI-ORGANIDIN)SYRP:5ML UD,3301183,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
GUAIFENESIN DM 1200-60MG ER TAB,3313855,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
GUAIFENESIN DM 200MG/20MG/10ML U/D LIQ,3313856,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GUAIFENESIN DM(ROBITUSS DM GEN)LIQ118ML,3301184,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GUAIFENESIN ER (MUCINEX) 1200MG TAB,3303311,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
GUAIFENESIN SYRUP (DIABETIC-TUSS): 240ML,3301186,CDM,259,RC,,,Outpatient,,,13.22,13.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,70,,7.4,percent of total billed charges,70% of total billed charges for outpatient setting,11.22,84.88,,8.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.61,50,,5.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.92,75,,7.94,percent of total billed charges,75% of total billed charges for outpatient setting,9.25,70,,7.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,80,,8.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,1.7,12.84,,1.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.59,65,,6.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,35,,3.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.9,90,,9.52,percent of total billed charges,90% of total billed charges for outpatient setting,1.7,11.9,
GUAIFENESIN/CODEINE 100MG/10MG PER 5ML,3301181,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
GUAIFENEX DM 600-30MG:TAB,3302847,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GUANFACINE (TENEX) TAB : 1 MG,3301188,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
GUIDE 3.2MM DRILL AXSOS / 705036,1628327,CDM,272,RC,,,Outpatient,,,2134.44,2134.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1494.11,70,,1195.29,percent of total billed charges,70% of total billed charges for outpatient setting,1811.71,84.88,,1449.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1067.22,50,,853.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1600.83,75,,1280.66,percent of total billed charges,75% of total billed charges for outpatient setting,1494.11,70,,1195.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.06,12.84,,219.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.55,80,,1366.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.06,12.84,,219.25,percent of total billed charges,12.84% of total billed charges,274.06,12.84,,219.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1387.39,65,,1109.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.05,35,,597.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1921,90,,1536.8,percent of total billed charges,90% of total billed charges for outpatient setting,274.06,1921,
GUIDE AUG REAM SCREW / 110040300,2419555,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
GUIDE AUG RMR BUSHING / 110031869,2419552,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
GUIDE CUT LGNP KIT SZ F7/T6 / V0200023,69162392,CDM,272,RC,,,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1124.76,65,,899.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1557.36,90,,1245.89,percent of total billed charges,90% of total billed charges for outpatient setting,222.18,1557.36,
GUIDE GLENOID BONE MODEL / 110004347,69162388,CDM,272,RC,,,Outpatient,,,2750,2750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1925,70,,1540,percent of total billed charges,70% of total billed charges for outpatient setting,2334.2,84.88,,1867.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,1375,50,,1100,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2062.5,75,,1650,percent of total billed charges,75% of total billed charges for outpatient setting,1925,70,,1540,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2200,80,,1760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1787.5,65,,1430,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.5,35,,770,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2475,90,,1980,percent of total billed charges,90% of total billed charges for outpatient setting,353.1,2475,
GUIDE PIN 1.6MM / IO FIX / 101-00006,69161500,CDM,278,RC,,,Outpatient,,,93.58,93.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.15,60,,44.92,percent of total billed charges,60% of total Billed charges for outpatient setting,79.43,84.88,,63.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.79,50,,37.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.19,75,,56.15,percent of total billed charges,75% of total billed charges for outpatient setting,46.79,50,,37.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.86,80,,59.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.58,65,,74.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.75,35,,26.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.15,60,,44.92,percent of total billed charges,60% of total billed charges for outpatient setting,12.02,93.58,
GUIDE PIN 1.6MM 4.5 CANN SET / 292.27,6152471,CDM,278,RC,,,Outpatient,,,120.38,120.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.23,60,,57.78,percent of total billed charges,60% of total Billed charges for outpatient setting,102.18,84.88,,81.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.19,50,,48.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.29,75,,72.23,percent of total billed charges,75% of total billed charges for outpatient setting,60.19,50,,48.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,12.84,,12.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,80,,77.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,12.84,,12.37,percent of total billed charges,12.84% of total billed charges,15.46,12.84,,12.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.38,65,,96.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.13,35,,33.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.23,60,,57.78,percent of total billed charges,60% of total billed charges for outpatient setting,15.46,120.38,
GUIDE PIN 4.0 CANN / 900.721,69160847,CDM,278,RC,C1713,HCPCS,Outpatient,,,139.65,139.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.79,60,,67.03,percent of total billed charges,60% of total Billed charges for outpatient setting,118.53,84.88,,94.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.74,75,,83.79,percent of total billed charges,75% of total billed charges for outpatient setting,69.83,50,,55.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.93,12.84,,14.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.72,80,,89.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.93,12.84,,14.34,percent of total billed charges,12.84% of total billed charges,17.93,12.84,,14.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,139.65,65,,111.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.88,35,,39.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.79,60,,67.03,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,139.65,
GUIDE SET SIGMA KNEE // 420883,70000009,CDM,272,RC,,,Outpatient,,,2706.46,2706.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.52,70,,1515.62,percent of total billed charges,70% of total billed charges for outpatient setting,2297.24,84.88,,1837.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,1353.23,50,,1082.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2029.85,75,,1623.88,percent of total billed charges,75% of total billed charges for outpatient setting,1894.52,70,,1515.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.51,12.84,,278.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2165.17,80,,1732.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.51,12.84,,278.01,percent of total billed charges,12.84% of total billed charges,347.51,12.84,,278.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1759.2,65,,1407.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.26,35,,757.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2435.81,90,,1948.65,percent of total billed charges,90% of total billed charges for outpatient setting,347.51,2435.81,
GUIDE SET-SIGMA FEMORAL,69161982,CDM,272,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,70,,1695.79,percent of total billed charges,70% of total billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1968.33,65,,1574.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2725.38,90,,2180.3,percent of total billed charges,90% of total billed charges for outpatient setting,388.82,2725.38,
GUIDE SET-SIGMA FEMORAL RIGHT,69162108,CDM,272,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,70,,1695.79,percent of total billed charges,70% of total billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1968.33,65,,1574.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2725.38,90,,2180.3,percent of total billed charges,90% of total billed charges for outpatient setting,388.82,2725.38,
GUIDE WIRE 0.86 TROCAR TIP / AR-8737-89,69169660,CDM,278,RC,C1769,HCPCS,Outpatient,,,138.6,138.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,60,,66.53,percent of total billed charges,60% of total Billed charges for outpatient setting,117.64,84.88,,94.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,75,,83.16,percent of total billed charges,75% of total billed charges for outpatient setting,69.3,50,,55.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,80,,88.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,138.6,65,,110.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.51,35,,38.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.16,60,,66.53,percent of total billed charges,60% of total billed charges for outpatient setting,17.8,138.6,
GUIDE WIRE 1.1MM  292.623,69160011,CDM,278,RC,,,Outpatient,,,196.5,196.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.9,60,,94.32,percent of total billed charges,60% of total Billed charges for outpatient setting,166.79,84.88,,133.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.25,50,,78.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.38,75,,117.9,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,50,,78.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.23,12.84,,20.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.2,80,,125.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.23,12.84,,20.18,percent of total billed charges,12.84% of total billed charges,25.23,12.84,,20.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,196.5,65,,157.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.78,35,,55.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,117.9,60,,94.32,percent of total billed charges,60% of total billed charges for outpatient setting,25.23,196.5,
GUIDE WIRE 1.25X150MM THRD / 900.722,69159591,CDM,272,RC,C1713,HCPCS,Outpatient,,,178.26,178.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.78,70,,99.82,percent of total billed charges,70% of total billed charges for outpatient setting,151.31,84.88,,121.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.7,75,,106.96,percent of total billed charges,75% of total billed charges for outpatient setting,124.78,70,,99.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.89,12.84,,18.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.61,80,,114.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,22.89,12.84,,18.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.87,65,,92.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.39,35,,49.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.43,90,,128.34,percent of total billed charges,90% of total billed charges for outpatient setting,22.89,160.43,
GUIDE WIRE 1.6 X150MM THRDED / 292.72,69162363,CDM,272,RC,,,Outpatient,,,227.44,227.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.21,70,,127.37,percent of total billed charges,70% of total billed charges for outpatient setting,193.05,84.88,,154.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.72,50,,90.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.58,75,,136.46,percent of total billed charges,75% of total billed charges for outpatient setting,159.21,70,,127.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.95,80,,145.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.84,65,,118.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.6,35,,63.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.7,90,,163.76,percent of total billed charges,90% of total billed charges for outpatient setting,29.2,204.7,
GUIDE WIRE 1.6MM THRDED /02.226.000,69169421,CDM,272,RC,,,Outpatient,,,255.94,255.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.16,70,,143.33,percent of total billed charges,70% of total billed charges for outpatient setting,217.24,84.88,,173.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.97,50,,102.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.96,75,,153.57,percent of total billed charges,75% of total billed charges for outpatient setting,179.16,70,,143.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.86,12.84,,26.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,80,,163.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.86,12.84,,26.29,percent of total billed charges,12.84% of total billed charges,32.86,12.84,,26.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.36,65,,133.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.58,35,,71.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.35,90,,184.28,percent of total billed charges,90% of total billed charges for outpatient setting,32.86,230.35,
GUIDE WIRE THRDED 2.8MM (7.3 SET)/292.68,6152995,CDM,272,RC,C1769,HCPCS,Outpatient,,,255.45,255.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.82,70,,143.06,percent of total billed charges,70% of total billed charges for outpatient setting,216.83,84.88,,173.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.59,75,,153.27,percent of total billed charges,75% of total billed charges for outpatient setting,178.82,70,,143.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.8,12.84,,26.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.36,80,,163.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.8,12.84,,26.24,percent of total billed charges,12.84% of total billed charges,32.8,12.84,,26.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.04,65,,132.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.41,35,,71.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,229.91,90,,183.93,percent of total billed charges,90% of total billed charges for outpatient setting,32.8,229.91,
GUIDEWIRE .038 FLEXI TIP STIFF / G09957,69160873,CDM,272,RC,C1769,HCPCS,Outpatient,,,151.2,151.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.84,70,,84.67,percent of total billed charges,70% of total billed charges for outpatient setting,128.34,84.88,,102.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,75,,90.72,percent of total billed charges,75% of total billed charges for outpatient setting,105.84,70,,84.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,12.84,,15.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,80,,96.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,12.84,,15.53,percent of total billed charges,12.84% of total billed charges,19.41,12.84,,15.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.28,65,,78.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.08,90,,108.86,percent of total billed charges,90% of total billed charges for outpatient setting,19.41,136.08,
GUIDEWIRE .038 FLEXITIP / 638413,6150615,CDM,272,RC,C1769,HCPCS,Outpatient,,,149.58,149.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.71,70,,83.77,percent of total billed charges,70% of total billed charges for outpatient setting,126.96,84.88,,101.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.19,75,,89.75,percent of total billed charges,75% of total billed charges for outpatient setting,104.71,70,,83.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.21,12.84,,15.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.66,80,,95.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.21,12.84,,15.37,percent of total billed charges,12.84% of total billed charges,19.21,12.84,,15.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.23,65,,77.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.35,35,,41.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.62,90,,107.7,percent of total billed charges,90% of total billed charges for outpatient setting,19.21,134.62,
GUIDEWIRE .038 J TIP,6150616,CDM,272,RC,C1769,HCPCS,Outpatient,,,121.58,121.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.11,70,,68.09,percent of total billed charges,70% of total billed charges for outpatient setting,103.2,84.88,,82.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.19,75,,72.95,percent of total billed charges,75% of total billed charges for outpatient setting,85.11,70,,68.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.61,12.84,,12.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,80,,77.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.61,12.84,,12.49,percent of total billed charges,12.84% of total billed charges,15.61,12.84,,12.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.03,65,,63.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.55,35,,34.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,109.42,90,,87.54,percent of total billed charges,90% of total billed charges for outpatient setting,15.61,109.42,
GUIDEWIRE .038 STIFF/FIXED CORE  638455,69160866,CDM,272,RC,C1769,HCPCS,Outpatient,,,163.28,163.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.3,70,,91.44,percent of total billed charges,70% of total billed charges for outpatient setting,138.59,84.88,,110.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.46,75,,97.97,percent of total billed charges,75% of total billed charges for outpatient setting,114.3,70,,91.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,12.84,,16.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.62,80,,104.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,12.84,,16.78,percent of total billed charges,12.84% of total billed charges,20.97,12.84,,16.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.13,65,,84.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.15,35,,45.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.95,90,,117.56,percent of total billed charges,90% of total billed charges for outpatient setting,20.97,146.95,
GUIDEWIRE .038X50CM CURVED / G00524,69161027,CDM,272,RC,C1769,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,70,,70.56,percent of total billed charges,70% of total billed charges for outpatient setting,106.95,84.88,,85.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,75,,75.6,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,70,,70.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,80,,80.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.9,65,,65.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,35,,35.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.4,90,,90.72,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,113.4,
GUIDEWIRE .062 TROCAR TIP / AR-8941K,69162344,CDM,272,RC,,,Outpatient,,,97.34,97.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,84.88,,66.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.67,50,,38.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.01,75,,58.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.87,80,,62.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.27,65,,50.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.07,35,,27.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.61,90,,70.09,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,87.61,
GUIDEWIRE 0.038 STR / 082338,6152719,CDM,272,RC,C1769,HCPCS,Outpatient,,,67.48,67.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.28,84.88,,45.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.61,75,,40.49,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,12.84,,6.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.98,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,12.84,,6.93,percent of total billed charges,12.84% of total billed charges,8.66,12.84,,6.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.86,65,,35.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.62,35,,18.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.73,90,,48.58,percent of total billed charges,90% of total billed charges for outpatient setting,8.66,60.73,
GUIDEWIRE 0.045IN TRCR / AR-8737-41,70000535,CDM,272,RC,C1713,HCPCS,Outpatient,,,142.76,142.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.93,70,,79.94,percent of total billed charges,70% of total billed charges for outpatient setting,121.17,84.88,,96.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.07,75,,85.66,percent of total billed charges,75% of total billed charges for outpatient setting,99.93,70,,79.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.21,80,,91.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.79,65,,74.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.97,35,,39.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.48,90,,102.78,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,128.48,
GUIDEWIRE 0.86MM TRCR / AR-8737-39,71000809,CDM,272,RC,C1713,HCPCS,Outpatient,,,138.6,138.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,70,,77.62,percent of total billed charges,70% of total billed charges for outpatient setting,117.64,84.88,,94.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,75,,83.16,percent of total billed charges,75% of total billed charges for outpatient setting,97.02,70,,77.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,80,,88.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.09,65,,72.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.51,35,,38.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.74,90,,99.79,percent of total billed charges,90% of total billed charges for outpatient setting,17.8,124.74,
GUIDEWIRE 0.86MM TRCR / AR-8737-40,70000739,CDM,272,RC,C1713,HCPCS,Outpatient,,,136.5,136.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.55,70,,76.44,percent of total billed charges,70% of total billed charges for outpatient setting,115.86,84.88,,92.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,75,,81.9,percent of total billed charges,75% of total billed charges for outpatient setting,95.55,70,,76.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.53,12.84,,14.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.2,80,,87.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.53,12.84,,14.02,percent of total billed charges,12.84% of total billed charges,17.53,12.84,,14.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.73,65,,70.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.78,35,,38.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.85,90,,98.28,percent of total billed charges,90% of total billed charges for outpatient setting,17.53,122.85,
GUIDEWIRE 1.1X150MM / 03.333.001,7171133,CDM,278,RC,C1769,HCPCS,Outpatient,,,331.2,331.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.72,60,,158.98,percent of total billed charges,60% of total Billed charges for outpatient setting,281.12,84.88,,224.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.4,75,,198.72,percent of total billed charges,75% of total billed charges for outpatient setting,165.6,50,,132.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.53,12.84,,34.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.96,80,,211.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.53,12.84,,34.02,percent of total billed charges,12.84% of total billed charges,42.53,12.84,,34.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,331.2,65,,264.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,35,,92.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198.72,60,,158.98,percent of total billed charges,60% of total billed charges for outpatient setting,42.53,331.2,
GUIDEWIRE 1.2X100MM / AR-8005K,69162569,CDM,272,RC,,,Outpatient,,,142.76,142.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.93,70,,79.94,percent of total billed charges,70% of total billed charges for outpatient setting,121.17,84.88,,96.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.38,50,,57.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.07,75,,85.66,percent of total billed charges,75% of total billed charges for outpatient setting,99.93,70,,79.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.21,80,,91.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,18.33,12.84,,14.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.79,65,,74.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.97,35,,39.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.48,90,,102.78,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,128.48,
GUIDEWIRE 1.35MM DUAL TRCR / AR-5050-01,70000515,CDM,272,RC,C1769,HCPCS,Outpatient,,,215.25,215.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.68,70,,120.54,percent of total billed charges,70% of total billed charges for outpatient setting,182.7,84.88,,146.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.44,75,,129.15,percent of total billed charges,75% of total billed charges for outpatient setting,150.68,70,,120.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.64,12.84,,22.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.2,80,,137.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.64,12.84,,22.11,percent of total billed charges,12.84% of total billed charges,27.64,12.84,,22.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,139.91,65,,111.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.34,35,,60.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.73,90,,154.98,percent of total billed charges,90% of total billed charges for outpatient setting,27.64,193.73,
GUIDEWIRE 1.35MM TROCAR / AR-8943-01,70000543,CDM,278,RC,C1713,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,60,,60.48,percent of total billed charges,60% of total Billed charges for outpatient setting,106.95,84.88,,85.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,75,,75.6,percent of total billed charges,75% of total billed charges for outpatient setting,63,50,,50.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,80,,80.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,126,65,,100.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,35,,35.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.6,60,,60.48,percent of total billed charges,60% of total billed charges for outpatient setting,16.18,126,
GUIDEWIRE 1.6X150MM / 03.211.415,69169183,CDM,272,RC,C1769,HCPCS,Outpatient,,,269.94,269.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.96,70,,151.17,percent of total billed charges,70% of total billed charges for outpatient setting,229.13,84.88,,183.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.46,75,,161.97,percent of total billed charges,75% of total billed charges for outpatient setting,188.96,70,,151.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.66,12.84,,27.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.95,80,,172.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.66,12.84,,27.73,percent of total billed charges,12.84% of total billed charges,34.66,12.84,,27.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.46,65,,140.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.48,35,,75.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.95,90,,194.36,percent of total billed charges,90% of total billed charges for outpatient setting,34.66,242.95,
GUIDEWIRE 1.6X150MM THREAD / 03.211.430,337668,CDM,272,RC,C1713,HCPCS,Outpatient,,,239.64,239.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.75,70,,134.2,percent of total billed charges,70% of total billed charges for outpatient setting,203.41,84.88,,162.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.73,75,,143.78,percent of total billed charges,75% of total billed charges for outpatient setting,167.75,70,,134.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.77,12.84,,24.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.71,80,,153.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.77,12.84,,24.62,percent of total billed charges,12.84% of total billed charges,30.77,12.84,,24.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.77,65,,124.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.87,35,,67.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,215.68,90,,172.54,percent of total billed charges,90% of total billed charges for outpatient setting,30.77,215.68,
GUIDEWIRE 1.6X500MM / 685.007,69162301,CDM,272,RC,C1713,HCPCS,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390,65,,312,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540,90,,432,percent of total billed charges,90% of total billed charges for outpatient setting,77.04,540,
GUIDEWIRE 2.0X240MM / 03.010.25,69162057,CDM,272,RC,,,Outpatient,,,181.04,181.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.73,70,,101.38,percent of total billed charges,70% of total billed charges for outpatient setting,153.67,84.88,,122.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.52,50,,72.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.78,75,,108.62,percent of total billed charges,75% of total billed charges for outpatient setting,126.73,70,,101.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.83,80,,115.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,23.25,12.84,,18.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.68,65,,94.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.36,35,,50.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.94,90,,130.35,percent of total billed charges,90% of total billed charges for outpatient setting,23.25,162.94,
GUIDEWIRE 200CM ENDO FLEX / G57280,7081952,CDM,272,RC,,,Outpatient,,,820,820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574,70,,459.2,percent of total billed charges,70% of total billed charges for outpatient setting,696.02,84.88,,556.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,410,50,,328,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,615,75,,492,percent of total billed charges,75% of total billed charges for outpatient setting,574,70,,459.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.29,12.84,,84.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656,80,,524.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.29,12.84,,84.23,percent of total billed charges,12.84% of total billed charges,105.29,12.84,,84.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,533,65,,426.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,35,,229.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,738,90,,590.4,percent of total billed charges,90% of total billed charges for outpatient setting,105.29,738,
GUIDEWIRE 3.0X1000MM PRCN / 2351-3102S,71000832,CDM,272,RC,,,Outpatient,,,1809.5,1809.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1266.65,70,,1013.32,percent of total billed charges,70% of total billed charges for outpatient setting,1535.9,84.88,,1228.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,904.75,50,,723.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1357.13,75,,1085.7,percent of total billed charges,75% of total billed charges for outpatient setting,1266.65,70,,1013.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.34,12.84,,185.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1447.6,80,,1158.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.34,12.84,,185.87,percent of total billed charges,12.84% of total billed charges,232.34,12.84,,185.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1176.18,65,,940.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.33,35,,506.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1628.55,90,,1302.84,percent of total billed charges,90% of total billed charges for outpatient setting,232.34,1628.55,
GUIDEWIRE 3.2X400MM ORTH / 357.399,178218,CDM,272,RC,,,Outpatient,,,492.2,492.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.54,70,,275.63,percent of total billed charges,70% of total billed charges for outpatient setting,417.78,84.88,,334.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,246.1,50,,196.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.15,75,,295.32,percent of total billed charges,75% of total billed charges for outpatient setting,344.54,70,,275.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.2,12.84,,50.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.76,80,,315.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.2,12.84,,50.56,percent of total billed charges,12.84% of total billed charges,63.2,12.84,,50.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,319.93,65,,255.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.27,35,,137.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,442.98,90,,354.38,percent of total billed charges,90% of total billed charges for outpatient setting,63.2,442.98,
GUIDEWIRE 6X0.054IN ORTHO / WS-1406ST,733865,CDM,278,RC,C1769,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,60,,46.08,percent of total billed charges,60% of total Billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96,65,,76.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.6,60,,46.08,percent of total billed charges,60% of total billed charges for outpatient setting,12.33,96,
GUIDEWIRE MOVEABLE CORE .038/082438,6153070,CDM,272,RC,C1769,HCPCS,Outpatient,,,84.41,84.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.09,70,,47.27,percent of total billed charges,70% of total billed charges for outpatient setting,71.65,84.88,,57.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.31,75,,50.65,percent of total billed charges,75% of total billed charges for outpatient setting,59.09,70,,47.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,12.84,,8.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.53,80,,54.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,12.84,,8.67,percent of total billed charges,12.84% of total billed charges,10.84,12.84,,8.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.87,65,,43.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.54,35,,23.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.97,90,,60.78,percent of total billed charges,90% of total billed charges for outpatient setting,10.84,75.97,
GUIDEWIRE SPARTACORE .014x300/1005203,69159820,CDM,272,RC,,,Outpatient,,,431.94,431.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.36,70,,241.89,percent of total billed charges,70% of total billed charges for outpatient setting,366.63,84.88,,293.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,215.97,50,,172.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.96,75,,259.17,percent of total billed charges,75% of total billed charges for outpatient setting,302.36,70,,241.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.46,12.84,,44.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.55,80,,276.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.46,12.84,,44.37,percent of total billed charges,12.84% of total billed charges,55.46,12.84,,44.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,280.76,65,,224.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.18,35,,120.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.75,90,,311,percent of total billed charges,90% of total billed charges for outpatient setting,55.46,388.75,
GVL 3 STAT GLIDESCOPE / 0270-0626,69161687,CDM,272,RC,,,Outpatient,,,98.78,98.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.15,70,,55.32,percent of total billed charges,70% of total billed charges for outpatient setting,83.84,84.88,,67.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.39,50,,39.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.09,75,,59.27,percent of total billed charges,75% of total billed charges for outpatient setting,69.15,70,,55.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,12.84,,10.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.02,80,,63.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,12.84,,10.14,percent of total billed charges,12.84% of total billed charges,12.68,12.84,,10.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.21,65,,51.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.57,35,,27.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.9,90,,71.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.68,88.9,
GVL 4 STAT GLIDESCOPE / 0270-0628,69161688,CDM,272,RC,,,Outpatient,,,98.78,98.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.15,70,,55.32,percent of total billed charges,70% of total billed charges for outpatient setting,83.84,84.88,,67.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.39,50,,39.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.09,75,,59.27,percent of total billed charges,75% of total billed charges for outpatient setting,69.15,70,,55.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,12.84,,10.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.02,80,,63.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.68,12.84,,10.14,percent of total billed charges,12.84% of total billed charges,12.68,12.84,,10.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.21,65,,51.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.57,35,,27.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.9,90,,71.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.68,88.9,
GYN MALE UROLOGY LONESTAR / 3304G,6152340,CDM,270,RC,,,Outpatient,,,263.93,263.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,224.02,84.88,,179.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.97,50,,105.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.95,75,,158.36,percent of total billed charges,75% of total billed charges for outpatient setting,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.14,80,,168.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.55,65,,137.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,35,,73.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,237.54,90,,190.03,percent of total billed charges,90% of total billed charges for outpatient setting,33.89,237.54,
GYN RETRACTOR LONESTAR / 3301G,69162699,CDM,270,RC,,,Outpatient,,,264.6,264.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.22,70,,148.18,percent of total billed charges,70% of total billed charges for outpatient setting,224.59,84.88,,179.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,132.3,50,,105.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.45,75,,158.76,percent of total billed charges,75% of total billed charges for outpatient setting,185.22,70,,148.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.68,80,,169.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.99,65,,137.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.61,35,,74.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.14,90,,190.51,percent of total billed charges,90% of total billed charges for outpatient setting,33.97,238.14,
GYNECARE TVT ABBREVO / TVTOML,69161548,CDM,278,RC,C1771,HCPCS,Outpatient,,,2373.6,2373.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1424.16,60,,1139.33,percent of total billed charges,60% of total Billed charges for outpatient setting,2014.71,84.88,,1611.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.2,75,,1424.16,percent of total billed charges,75% of total billed charges for outpatient setting,1186.8,50,,949.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.77,12.84,,243.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1898.88,80,,1519.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.77,12.84,,243.82,percent of total billed charges,12.84% of total billed charges,304.77,12.84,,243.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2492.28,105,,1993.82,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,830.76,35,,664.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1424.16,60,,1139.33,percent of total billed charges,60% of total billed charges for outpatient setting,304.77,2492.28,
HAEMOPHILUS B POLYSAC CON3(ActHIB):0.5ML,3306496,CDM,636,RC,90648,HCPCS,Outpatient,,,117.97,117.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.58,70,,66.06,percent of total billed charges,70% of total billed charges for outpatient setting,100.13,84.88,,80.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,88.48,75,,70.78,percent of total billed charges,75% of total billed charges for outpatient setting,82.58,70,,66.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.15,12.84,,12.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.38,80,,75.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.15,12.84,,12.12,percent of total billed charges,12.84% of total billed charges,15.15,12.84,,12.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.68,65,,61.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.17,90,,84.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,106.17,
HALOBETASOL (ULTRAVATE) CRM : 50 GM,3301189,CDM,259,RC,,,Outpatient,,,218.47,218.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.93,70,,122.34,percent of total billed charges,70% of total billed charges for outpatient setting,185.44,84.88,,148.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.24,50,,87.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.85,75,,131.08,percent of total billed charges,75% of total billed charges for outpatient setting,152.93,70,,122.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.05,12.84,,22.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.78,80,,139.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.05,12.84,,22.44,percent of total billed charges,12.84% of total billed charges,28.05,12.84,,22.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.01,65,,113.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.46,35,,61.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.62,90,,157.3,percent of total billed charges,90% of total billed charges for outpatient setting,28.05,196.62,
HALOPERIDOL (genericHALDOL) 1 MG TAB,3301192,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HALOPERIDOL (genericHALDOL) 5MG TAB,3301194,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
HALOPERIDOL (HALDOL) INJ 2MG/ML : 15ML,3301195,CDM,250,RC,,,Outpatient,,,39.32,39.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.52,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,33.37,84.88,,26.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.66,50,,15.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.49,75,,23.59,percent of total billed charges,75% of total billed charges for outpatient setting,27.52,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,80,,25.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,5.05,12.84,,4.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.56,65,,20.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,35,,11.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.39,90,,28.31,percent of total billed charges,90% of total billed charges for outpatient setting,5.05,35.39,
HALOPERIDOL (HALDOL) INJ 5MG/ML : 1ML,3301196,CDM,250,RC,,,Outpatient,,,19.4,19.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,16.47,84.88,,13.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.7,50,,7.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.55,75,,11.64,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.49,12.84,,1.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.52,80,,12.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.49,12.84,,1.99,percent of total billed charges,12.84% of total billed charges,2.49,12.84,,1.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.61,65,,10.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,35,,5.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.46,90,,13.97,percent of total billed charges,90% of total billed charges for outpatient setting,2.49,17.46,
HALOPERIDOL (HALDOL) INJ 5MG/ML 1ML,3301197,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
HALOPERIDOL (HALDOL) TAB : 0.5 MG,3301191,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HALOPERIDOL (HALDOL) TAB : 2 MG   U/D,3301193,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HALOPERIDOL (HALDOL) TAB : 5 MG,3301190,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HAND 2 VWS BILATERAL,2400547,CDM,320,RC,73120,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HAND 2 VWS LEFT,2400546,CDM,320,RC,73120,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HAND 2 VWS RIGHT,2400545,CDM,320,RC,73120,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HAND 3 VWS BILATERAL,2400552,CDM,320,RC,73130,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
HAND 3 VWS LEFT,2400551,CDM,320,RC,73130,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HAND 3 VWS RIGHT,2400550,CDM,320,RC,73130,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HANDLE CANLTED PEDIGUARD  P2HE1000,69162315,CDM,272,RC,,,Outpatient,,,2900,2900,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2030,70,,1624,percent of total billed charges,70% of total billed charges for outpatient setting,2461.52,84.88,,1969.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,1450,50,,1160,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2175,75,,1740,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.36,12.84,,297.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2320,80,,1856,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.36,12.84,,297.89,percent of total billed charges,12.84% of total billed charges,372.36,12.84,,297.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1885,65,,1508,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015,35,,812,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2610,90,,2088,percent of total billed charges,90% of total billed charges for outpatient setting,372.36,2610,
HANDLE LARYNGOSCOPE BRITEPRO / 040-310U,1535410,CDM,272,RC,,,Outpatient,,,48.86,48.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.2,70,,27.36,percent of total billed charges,70% of total billed charges for outpatient setting,41.47,84.88,,33.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.43,50,,19.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.65,75,,29.32,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,70,,27.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,80,,31.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.76,65,,25.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,35,,13.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.97,90,,35.18,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,43.97,
HANDLE LRNGSCOPE BRITE PRO / 040-791U,1535449,CDM,272,RC,,,Outpatient,,,45.99,45.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.19,70,,25.75,percent of total billed charges,70% of total billed charges for outpatient setting,39.04,84.88,,31.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,23,50,,18.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.49,75,,27.59,percent of total billed charges,75% of total billed charges for outpatient setting,32.19,70,,25.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,12.84,,4.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.79,80,,29.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,12.84,,4.73,percent of total billed charges,12.84% of total billed charges,5.91,12.84,,4.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.89,65,,23.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,35,,12.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.39,90,,33.11,percent of total billed charges,90% of total billed charges for outpatient setting,5.91,41.39,
HAPTOGLOBIN,220328,CDM,300,RC,83010,HCPCS,Outpatient,,,56.61,50.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.63,70,,31.7,percent of total billed charges,70% of total billed charges for outpatient setting,48.05,84.88,,38.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.46,75,,33.97,percent of total billed charges,75% of total billed charges for outpatient setting,39.63,70,,31.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.29,80,,36.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,100% of Custom Fee Schedule,50.95,90,,40.76,percent of total billed charges,90% of total billed charges for outpatient setting,12.58,50.95,
HARMONIC ACE 23CM X 5MM/ HAR23,69161737,CDM,270,RC,,,Outpatient,,,1911.53,1911.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.07,70,,1070.46,percent of total billed charges,70% of total billed charges for outpatient setting,1622.51,84.88,,1298.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,955.77,50,,764.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1433.65,75,,1146.92,percent of total billed charges,75% of total billed charges for outpatient setting,1338.07,70,,1070.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.44,12.84,,196.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1529.22,80,,1223.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.44,12.84,,196.35,percent of total billed charges,12.84% of total billed charges,245.44,12.84,,196.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1242.49,65,,993.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.04,35,,535.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1720.38,90,,1376.3,percent of total billed charges,90% of total billed charges for outpatient setting,245.44,1720.38,
HARMONIC ACE 36CMX5MM / HARH36,69159328,CDM,270,RC,,,Outpatient,,,1820,1820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274,70,,1019.2,percent of total billed charges,70% of total billed charges for outpatient setting,1544.82,84.88,,1235.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,910,50,,728,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1365,75,,1092,percent of total billed charges,75% of total billed charges for outpatient setting,1274,70,,1019.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.69,12.84,,186.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456,80,,1164.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.69,12.84,,186.95,percent of total billed charges,12.84% of total billed charges,233.69,12.84,,186.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1183,65,,946.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637,35,,509.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1638,90,,1310.4,percent of total billed charges,90% of total billed charges for outpatient setting,233.69,1638,
HARMONIC ACE 45CM SHEARS / HARH45,69169322,CDM,270,RC,,,Outpatient,,,2805.86,2805.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1964.1,70,,1571.28,percent of total billed charges,70% of total billed charges for outpatient setting,2381.61,84.88,,1905.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,1402.93,50,,1122.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2104.4,75,,1683.52,percent of total billed charges,75% of total billed charges for outpatient setting,1964.1,70,,1571.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.27,12.84,,288.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2244.69,80,,1795.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.27,12.84,,288.22,percent of total billed charges,12.84% of total billed charges,360.27,12.84,,288.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1823.81,65,,1459.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.05,35,,785.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2525.27,90,,2020.22,percent of total billed charges,90% of total billed charges for outpatient setting,360.27,2525.27,
HARMONIC FOCUS / HAR9F,69160350,CDM,272,RC,,,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,70,,1008,percent of total billed charges,70% of total billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,1260,70,,1008,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1170,65,,936,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,90,,1296,percent of total billed charges,90% of total billed charges for outpatient setting,231.12,1620,
HARMONIC SCALPEL ADAPT  HSA06,69160218,CDM,271,RC,,,Outpatient,,,387.5,387.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.25,70,,217,percent of total billed charges,70% of total billed charges for outpatient setting,328.91,84.88,,263.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,193.75,50,,155,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.63,75,,232.5,percent of total billed charges,75% of total billed charges for outpatient setting,271.25,70,,217,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.76,12.84,,39.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310,80,,248,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.76,12.84,,39.81,percent of total billed charges,12.84% of total billed charges,49.76,12.84,,39.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,251.88,65,,201.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.63,35,,108.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348.75,90,,279,percent of total billed charges,90% of total billed charges for outpatient setting,49.76,348.75,
HCG BETA SUBUNIT QUANTITATIVE,220349,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
"HCG BETA,TUMOR MARKER QUANT",220350,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
HCG SERUM,200730,CDM,300,RC,84703,HCPCS,Outpatient,,,33.84,30.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.69,70,,18.95,percent of total billed charges,70% of total billed charges for outpatient setting,28.72,84.88,,22.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.38,75,,20.3,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,70,,18.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,80,,21.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.26,100,,,Fee Schedule,100% of Custom Fee Schedule,30.46,90,,24.37,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,30.46,
HCG SERUM,201230,CDM,300,RC,84702,HCPCS,Outpatient,,,67.73,60.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,57.49,84.88,,45.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.8,75,,40.64,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,70,,37.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,80,,43.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of Custom Fee Schedule,60.96,90,,48.77,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,60.96,
HCG URINE,200325,CDM,307,RC,81025,HCPCS,Outpatient,,,38.75,34.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,32.89,84.88,,26.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.06,75,,23.25,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,80,,24.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of Custom Fee Schedule,34.88,90,,27.9,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,34.88,
HCTZ (HYDRODIURIL) TAB : 25 MG,3301222,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HCTZ (HYDRODIURIL)50MG: TAB,3302902,CDM,259,RC,,,Outpatient,,,10.42,10.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,84.88,,7.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.21,50,,4.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.82,75,,6.26,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,80,,6.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.77,65,,5.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,35,,2.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.38,90,,7.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.38,
HCTZ BISOPROL (ZIAC) TAB : 5 MG,3301198,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HCTZ TRIAMT  50/75MG (genMAXZIDE)TAB,3301199,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HCTZ TRIAMT (MAXZIDE) 37.5/25MG TAB:,3301201,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HCTZ TRIAMT (TRIAMTERENE) 37.5MG CAP,3301200,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HDL,200690,CDM,300,RC,83718,HCPCS,Outpatient,,,36.86,33.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,31.29,84.88,,25.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.65,75,,22.12,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,80,,23.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.96,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,100,,,Fee Schedule,100% of Custom Fee Schedule,33.17,90,,26.54,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,33.17,
HEAD +1 32MM FEMORAL / 1365-32-310,69169888,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD +12 36MM FEMORAL / 1365-36-340,71000452,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD +5 36MM FEMORAL / 1365-36-320,71000444,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD +8.5 36MM FEMORAL / 1365-36-330,71000576,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD +9 32MM FEMORAL / 1365-32-330,71000914,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD 1.7MM MATCH / 5820-107-017,2327512,CDM,272,RC,C1776,HCPCS,Outpatient,,,401.28,401.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,340.61,84.88,,272.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.96,75,,240.77,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.02,80,,256.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.83,65,,208.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.45,35,,112.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.15,90,,288.92,percent of total billed charges,90% of total billed charges for outpatient setting,51.52,361.15,
HEAD 12/14 28MM FEM / 00-8018-028-01,71000231,CDM,278,RC,C1776,HCPCS,Outpatient,,,1700,1700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020,60,,816,percent of total billed charges,60% of total Billed charges for outpatient setting,1442.96,84.88,,1154.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275,75,,1020,percent of total billed charges,75% of total billed charges for outpatient setting,850,50,,680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360,80,,1088,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1700,65,,1360,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,35,,476,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1020,60,,816,percent of total billed charges,60% of total billed charges for outpatient setting,218.28,1700,
HEAD 13CM 2.5MM PRCSN / 8450-107-525,648217,CDM,272,RC,,,Outpatient,,,869.6,869.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.72,70,,486.98,percent of total billed charges,70% of total billed charges for outpatient setting,738.12,84.88,,590.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,434.8,50,,347.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,652.2,75,,521.76,percent of total billed charges,75% of total billed charges for outpatient setting,608.72,70,,486.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.66,12.84,,89.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.68,80,,556.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.66,12.84,,89.33,percent of total billed charges,12.84% of total billed charges,111.66,12.84,,89.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,565.24,65,,452.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.36,35,,243.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,782.64,90,,626.11,percent of total billed charges,90% of total billed charges for outpatient setting,111.66,782.64,
HEAD 2.5MM 13CM PRCSN / 8450-107-525L,2535246,CDM,272,RC,,,Outpatient,,,869.6,869.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.72,70,,486.98,percent of total billed charges,70% of total billed charges for outpatient setting,738.12,84.88,,590.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,434.8,50,,347.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,652.2,75,,521.76,percent of total billed charges,75% of total billed charges for outpatient setting,608.72,70,,486.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.66,12.84,,89.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.68,80,,556.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.66,12.84,,89.33,percent of total billed charges,12.84% of total billed charges,111.66,12.84,,89.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,565.24,65,,452.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.36,35,,243.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,782.64,90,,626.11,percent of total billed charges,90% of total billed charges for outpatient setting,111.66,782.64,
HEAD 28/+3MM FEM CER DELTA / 650-1157,71000279,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 28/0MM FEM CER DELTA / 650-1158,71000201,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 28/-3MM FEM CER DELTA / 650-1159,71000214,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 28/-6MM COCR MOD / 163660,71000334,CDM,278,RC,C1776,HCPCS,Outpatient,,,1700,1700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020,60,,816,percent of total billed charges,60% of total Billed charges for outpatient setting,1442.96,84.88,,1154.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275,75,,1020,percent of total billed charges,75% of total billed charges for outpatient setting,850,50,,680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360,80,,1088,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1700,65,,1360,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,35,,476,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1020,60,,816,percent of total billed charges,60% of total billed charges for outpatient setting,218.28,1700,
HEAD 28MM +3 FEMORAL CERAMIC / 12-115111,71000150,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 28MM +9MM COCR / 163665,71000893,CDM,278,RC,C1776,HCPCS,Outpatient,,,1700,1700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020,60,,816,percent of total billed charges,60% of total Billed charges for outpatient setting,1442.96,84.88,,1154.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275,75,,1020,percent of total billed charges,75% of total billed charges for outpatient setting,850,50,,680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360,80,,1088,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1700,65,,1360,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,35,,476,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1020,60,,816,percent of total billed charges,60% of total billed charges for outpatient setting,218.28,1700,
HEAD 28MM 12/14 COCR UNIV / 802202801,71000308,CDM,278,RC,C1776,HCPCS,Outpatient,,,1700,1700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020,60,,816,percent of total billed charges,60% of total Billed charges for outpatient setting,1442.96,84.88,,1154.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275,75,,1020,percent of total billed charges,75% of total billed charges for outpatient setting,850,50,,680,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360,80,,1088,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,218.28,12.84,,174.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1700,65,,1360,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,35,,476,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1020,60,,816,percent of total billed charges,60% of total billed charges for outpatient setting,218.28,1700,
HEAD 36 -3MM CERAMIC DELTA  / 650-0660,71000223,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 36/+6MM FEM CER DELTA / 650-0663,71000237,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 36MM +1.5 FEMORAL / 1365-36-310,69169751,CDM,278,RC,C1776,HCPCS,Outpatient,,,3157,3157,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.2,60,,1515.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2679.66,84.88,,2143.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.75,75,,1894.2,percent of total billed charges,75% of total billed charges for outpatient setting,1578.5,50,,1262.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.6,80,,2020.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,405.36,12.84,,324.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3314.85,105,,2651.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.95,35,,883.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1894.2,60,,1515.36,percent of total billed charges,60% of total billed charges for outpatient setting,405.36,3314.85,
HEAD 36MM +3 FEMORAL CERAMIC / 650-0662,71000110,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 36MM +6 FEMORAL CERAMIC / 12-115123,71000034,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD 36MM FEM MSPEC / 1365-55-000,71000707,CDM,278,RC,C1776,HCPCS,Outpatient,,,2100,2100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,60,,1008,percent of total billed charges,60% of total Billed charges for outpatient setting,1782.48,84.88,,1425.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,75,,1260,percent of total billed charges,75% of total billed charges for outpatient setting,1050,50,,840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,80,,1344,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,269.64,12.84,,215.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2205,105,,1764,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,35,,588,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1260,60,,1008,percent of total billed charges,60% of total billed charges for outpatient setting,269.64,2205,
HEAD 36MM FEMORAL / 1365-36-720,69162287,CDM,278,RC,C1776,HCPCS,Outpatient,,,4126.68,4126.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2476.01,60,,1980.81,percent of total billed charges,60% of total Billed charges for outpatient setting,3502.73,84.88,,2802.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3095.01,75,,2476.01,percent of total billed charges,75% of total billed charges for outpatient setting,2063.34,50,,1650.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.87,12.84,,423.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3301.34,80,,2641.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.87,12.84,,423.9,percent of total billed charges,12.84% of total billed charges,529.87,12.84,,423.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4333.01,105,,3466.41,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.34,35,,1155.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2476.01,60,,1980.81,percent of total billed charges,60% of total billed charges for outpatient setting,529.87,4333.01,
HEAD BIOLOX MODULAR / 650-0661,71000067,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
HEAD CRADLE / HR101,6150987,CDM,270,RC,,,Outpatient,,,13.95,13.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,11.84,84.88,,9.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.98,50,,5.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.46,75,,8.37,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,80,,8.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.07,65,,7.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,35,,3.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.56,90,,10.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.79,12.56,
HEAD HALTER DISKARD DLUX / 60383,69161695,CDM,272,RC,,,Outpatient,,,37.31,37.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,31.67,84.88,,25.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.66,50,,14.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.98,75,,22.38,percent of total billed charges,75% of total billed charges for outpatient setting,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,80,,23.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.25,65,,19.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,35,,10.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.58,90,,26.86,percent of total billed charges,90% of total billed charges for outpatient setting,4.79,33.58,
HEAD NECK RETRACTOR LONESTAR / 3309G,69162701,CDM,270,RC,,,Outpatient,,,263.93,263.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,224.02,84.88,,179.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.97,50,,105.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.95,75,,158.36,percent of total billed charges,75% of total billed charges for outpatient setting,184.75,70,,147.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.14,80,,168.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,33.89,12.84,,27.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.55,65,,137.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,35,,73.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,237.54,90,,190.03,percent of total billed charges,90% of total billed charges for outpatient setting,33.89,237.54,
HEAD RADIAL 10X24MM,69162322,CDM,278,RC,C1776,HCPCS,Outpatient,,,7483.44,7483.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4490.06,60,,3592.05,percent of total billed charges,60% of total Billed charges for outpatient setting,6351.94,84.88,,5081.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5612.58,75,,4490.06,percent of total billed charges,75% of total billed charges for outpatient setting,3741.72,50,,2993.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.87,12.84,,768.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5986.75,80,,4789.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.87,12.84,,768.7,percent of total billed charges,12.84% of total billed charges,960.87,12.84,,768.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7857.61,105,,6286.09,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2619.2,35,,2095.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4490.06,60,,3592.05,percent of total billed charges,60% of total billed charges for outpatient setting,960.87,7857.61,
HEAD REST LAMI / CF1007DH,6150683,CDM,270,RC,,,Outpatient,,,38.15,38.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,70,,21.37,percent of total billed charges,70% of total billed charges for outpatient setting,32.38,84.88,,25.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.08,50,,15.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.61,75,,22.89,percent of total billed charges,75% of total billed charges for outpatient setting,26.71,70,,21.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.52,80,,24.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.8,65,,19.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.35,35,,10.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.34,90,,27.47,percent of total billed charges,90% of total billed charges for outpatient setting,4.9,34.34,
"HELICOBACTER,STOOL ANTIGEN",222010,CDM,306,RC,87338,HCPCS,Outpatient,,,64.71,58.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.3,70,,36.24,percent of total billed charges,70% of total billed charges for outpatient setting,54.93,84.88,,43.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.53,75,,38.82,percent of total billed charges,75% of total billed charges for outpatient setting,45.3,70,,36.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.77,80,,41.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,58.24,90,,46.59,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,58.24,
HEMATINIC WITH FOLIC ACID: TABS,3303078,CDM,259,RC,,,Outpatient,,,12.05,12.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,10.23,84.88,,8.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.03,50,,4.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.04,75,,7.23,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.64,80,,7.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.83,65,,6.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,35,,3.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.85,90,,8.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,10.85,
HEMATOCRIT (Hct),200580,CDM,300,RC,85014,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMATOCRIT (Hct),5100504,CDM,300,RC,85014,HCPCS,Outpatient,,,24.08,21.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,20.44,84.88,,16.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.06,75,,14.45,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.26,80,,15.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,21.67,90,,17.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,21.67,
HEMATOCRIT HCT,201325,CDM,300,RC,85014,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMATOGEN CAP,3303289,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HEMATOGEN FORTE CAP,3302894,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HEMICAP ARTIC. COMP 35 X 8.5MM 8352-3585,69161537,CDM,278,RC,,,Outpatient,,,11176,11176,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.6,60,,5364.48,percent of total billed charges,60% of total Billed charges for outpatient setting,9486.19,84.88,,7588.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,5588,50,,4470.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8382,75,,6705.6,percent of total billed charges,75% of total billed charges for outpatient setting,5588,50,,4470.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,12.84,,1148,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8940.8,80,,7152.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,12.84,,1148,percent of total billed charges,12.84% of total billed charges,1435,12.84,,1148,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11734.8,105,,9387.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3911.6,35,,3129.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6705.6,60,,5364.48,percent of total billed charges,60% of total billed charges for outpatient setting,1435,11734.8,
HEMOBLAST BELLOWS / BQF02-US,69169738,CDM,270,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,891.24,84.88,,712.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,525,50,,420,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.5,75,,630,percent of total billed charges,75% of total billed charges for outpatient setting,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,80,,672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,682.5,65,,546,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,35,,294,percent of total billed charges,35% of total Billed charges for Outpatient Setting,945,90,,756,percent of total billed charges,90% of total billed charges for outpatient setting,134.82,945,
"HEMOCHROMATOSIS, HEREDITARY",220129,CDM,300,RC,81256,HCPCS,Outpatient,,,294.12,264.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.88,70,,164.7,percent of total billed charges,70% of total billed charges for outpatient setting,249.65,84.88,,199.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,220.59,75,,176.47,percent of total billed charges,75% of total billed charges for outpatient setting,205.88,70,,164.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.3,80,,188.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.95,100,,,Fee Schedule,100% of Custom Fee Schedule,264.71,90,,211.77,percent of total billed charges,90% of total billed charges for outpatient setting,37.77,264.71,
HEMOCYTE LIQUID : 30 ML,3302851,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HEMOCYTE PLUS: CAP,3303227,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
HEMOGLOBIN (Hgb),200575,CDM,300,RC,85018,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMOGLOBIN (HGB),201195,CDM,300,RC,85018,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMOGLOBIN (Hgb),5100503,CDM,300,RC,85018,HCPCS,Outpatient,,,24.08,21.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,20.44,84.88,,16.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.06,75,,14.45,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,70,,13.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.26,80,,15.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,21.67,90,,17.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,21.67,
HEMOGLOBIN HGB,201320,CDM,300,RC,85018,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMOGLOBIN HGB,5100049,CDM,300,RC,85018,HCPCS,Outpatient,,,10.67,9.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,9.06,84.88,,7.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8,75,,6.4,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,70,,5.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,80,,6.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,100,,,Fee Schedule,100% of Custom Fee Schedule,9.6,90,,7.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,9.6,
HEMOGLOBOIN ELECTROPORESIS,200920,CDM,300,RC,83020,HCPCS,Outpatient,,,57.92,52.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,49.16,84.88,,39.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.44,75,,34.75,percent of total billed charges,75% of total billed charges for outpatient setting,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,80,,37.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,100% of Custom Fee Schedule,52.13,90,,41.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,52.13,
HEM-O-LK LG POLYMER CLIP PURPLE / 544240,69161333,CDM,272,RC,,,Outpatient,,,149.53,149.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.67,70,,83.74,percent of total billed charges,70% of total billed charges for outpatient setting,126.92,84.88,,101.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.77,50,,59.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.15,75,,89.72,percent of total billed charges,75% of total billed charges for outpatient setting,104.67,70,,83.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.62,80,,95.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.19,65,,77.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.34,35,,41.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.58,90,,107.66,percent of total billed charges,90% of total billed charges for outpatient setting,19.2,134.58,
HEM-O-LOK MED/LG CLIPS GREEN / 544230,69161344,CDM,272,RC,,,Outpatient,,,149.5,149.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.65,70,,83.72,percent of total billed charges,70% of total billed charges for outpatient setting,126.9,84.88,,101.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.75,50,,59.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.13,75,,89.7,percent of total billed charges,75% of total billed charges for outpatient setting,104.65,70,,83.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.6,80,,95.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,19.2,12.84,,15.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.18,65,,77.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.33,35,,41.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.55,90,,107.64,percent of total billed charges,90% of total billed charges for outpatient setting,19.2,134.55,
HEMOPHILUS INFLUENZA VACCINE RESPONSE,200274,CDM,310,RC,86684,HCPCS,Outpatient,,,71.28,64.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.9,70,,39.92,percent of total billed charges,70% of total billed charges for outpatient setting,60.5,84.88,,48.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.2,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.46,75,,42.77,percent of total billed charges,75% of total billed charges for outpatient setting,49.9,70,,39.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.02,80,,45.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.13,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,100,,,Fee Schedule,100% of Custom Fee Schedule,64.15,90,,51.32,percent of total billed charges,90% of total billed charges for outpatient setting,15.84,64.15,
HEMOPHILUS INFLUENZA VACCINE RESPONSE,220148,CDM,310,RC,86684,HCPCS,Outpatient,,,71.28,64.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.9,70,,39.92,percent of total billed charges,70% of total billed charges for outpatient setting,60.5,84.88,,48.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.2,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.46,75,,42.77,percent of total billed charges,75% of total billed charges for outpatient setting,49.9,70,,39.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.02,80,,45.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.13,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,100,,,Fee Schedule,100% of Custom Fee Schedule,64.15,90,,51.32,percent of total billed charges,90% of total billed charges for outpatient setting,15.84,64.15,
HEMORRHOIDAL OINTMENT:30 G,3303169,CDM,259,RC,,,Outpatient,,,23.72,23.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.6,70,,13.28,percent of total billed charges,70% of total billed charges for outpatient setting,20.13,84.88,,16.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.86,50,,9.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.79,75,,14.23,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,70,,13.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,80,,15.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,65,,12.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,35,,6.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.35,90,,17.08,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,21.35,
HEP A AB TOTAL,220416,CDM,300,RC,86708,HCPCS,Outpatient,,,55.76,50.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.03,70,,31.22,percent of total billed charges,70% of total billed charges for outpatient setting,47.33,84.88,,37.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.82,75,,33.46,percent of total billed charges,75% of total billed charges for outpatient setting,39.03,70,,31.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.61,80,,35.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.09,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,50.18,90,,40.14,percent of total billed charges,90% of total billed charges for outpatient setting,12.39,50.18,
"HEP A AB, IGM",220417,CDM,300,RC,86709,HCPCS,Outpatient,,,50.67,45.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.47,70,,28.38,percent of total billed charges,70% of total billed charges for outpatient setting,43.01,84.88,,34.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38,75,,30.4,percent of total billed charges,75% of total billed charges for outpatient setting,35.47,70,,28.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.54,80,,32.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.35,100,,,Fee Schedule,100% of Custom Fee Schedule,45.6,90,,36.48,percent of total billed charges,90% of total billed charges for outpatient setting,11.26,45.6,
"HEP B CORE IGG, IGM DIFFERENTIATION",220909,CDM,300,RC,86705,HCPCS,Outpatient,,,52.97,47.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,44.96,84.88,,35.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.73,75,,31.78,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.38,80,,33.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,100,,,Fee Schedule,100% of Custom Fee Schedule,47.67,90,,38.14,percent of total billed charges,90% of total billed charges for outpatient setting,11.77,47.67,
HEP B CORE IGM,220428,CDM,300,RC,86705,HCPCS,Outpatient,,,52.97,47.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,44.96,84.88,,35.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.73,75,,31.78,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.38,80,,33.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,100,,,Fee Schedule,100% of Custom Fee Schedule,47.67,90,,38.14,percent of total billed charges,90% of total billed charges for outpatient setting,11.77,47.67,
HEP B CORE TOTAL,220425,CDM,300,RC,86704,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.85,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
HEP B SURF AB,220418,CDM,300,RC,86706,HCPCS,Outpatient,,,48.33,43.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,41.02,84.88,,32.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.25,75,,29,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,80,,30.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,100,,,Fee Schedule,100% of Custom Fee Schedule,43.5,90,,34.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,43.5,
HEP B SURF AB QUANT,220974,CDM,302,RC,86317,HCPCS,Outpatient,,,67.46,60.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.26,84.88,,45.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,100,,,Fee Schedule,100% of Custom Fee Schedule,60.71,90,,48.57,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,60.71,
HEP B SURF AG,220420,CDM,300,RC,87340,HCPCS,Outpatient,,,46.49,41.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.54,70,,26.03,percent of total billed charges,70% of total billed charges for outpatient setting,39.46,84.88,,31.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.87,75,,27.9,percent of total billed charges,75% of total billed charges for outpatient setting,32.54,70,,26.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.19,80,,29.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,100,,,Fee Schedule,100% of Custom Fee Schedule,41.84,90,,33.47,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,41.84,
HEP B VIRUS DNA QUANT,220854,CDM,300,RC,87517,HCPCS,Outpatient,,,192.78,173.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,163.63,84.88,,130.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,144.59,75,,115.67,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.22,80,,123.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,100,,,Fee Schedule,100% of Custom Fee Schedule,173.5,90,,138.8,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,173.5,
HEP BE AB,220419,CDM,302,RC,86707,HCPCS,Outpatient,,,52.07,46.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,70,,29.16,percent of total billed charges,70% of total billed charges for outpatient setting,44.2,84.88,,35.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.05,75,,31.24,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,70,,29.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,80,,33.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,100,,,Fee Schedule,100% of Custom Fee Schedule,46.86,90,,37.49,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,46.86,
HEP BE AG,220421,CDM,306,RC,87350,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.83,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
HEP C AB,220431,CDM,300,RC,86803,HCPCS,Outpatient,,,64.22,57.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.95,70,,35.96,percent of total billed charges,70% of total billed charges for outpatient setting,54.51,84.88,,43.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.17,75,,38.54,percent of total billed charges,75% of total billed charges for outpatient setting,44.95,70,,35.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.38,80,,41.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,100,,,Fee Schedule,100% of Custom Fee Schedule,57.8,90,,46.24,percent of total billed charges,90% of total billed charges for outpatient setting,14.27,57.8,
HEP C GENOTYPE,220503,CDM,300,RC,87902,HCPCS,Outpatient,,,1158.53,1042.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810.97,70,,648.78,percent of total billed charges,70% of total billed charges for outpatient setting,983.36,84.88,,786.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,442.05,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,868.9,75,,695.12,percent of total billed charges,75% of total billed charges for outpatient setting,810.97,70,,648.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.82,80,,741.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,375.88,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.2,100,,,Fee Schedule,100% of Custom Fee Schedule,1042.68,90,,834.14,percent of total billed charges,90% of total billed charges for outpatient setting,257.45,1042.68,
"HEP C RNA, NAA QUAL",220631,CDM,306,RC,87522,HCPCS,Outpatient,,,192.78,173.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,163.63,84.88,,130.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,144.59,75,,115.67,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.22,80,,123.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,100,,,Fee Schedule,100% of Custom Fee Schedule,173.5,90,,138.8,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,173.5,
HEP C RNA/PCR QUANT,220216,CDM,306,RC,87522,HCPCS,Outpatient,,,192.78,173.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,163.63,84.88,,130.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,144.59,75,,115.67,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.22,80,,123.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,100,,,Fee Schedule,100% of Custom Fee Schedule,173.5,90,,138.8,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,173.5,
HEP C VIRUS RNA QUAL W REFLEX TO QUANT,220927,CDM,306,RC,87521,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
HEP LOCK FLUSH SOLN 100UNTS/ML  1ML PF,3305740,CDM,250,RC,,,Outpatient,,,5.57,5.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,70,,3.12,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,84.88,,3.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.79,50,,2.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.18,75,,3.34,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,70,,3.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,80,,3.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.62,65,,2.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,35,,1.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.01,90,,4.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,5.01,
HEPARIN 1000 U/500 ML NS: IV BAG,3302664,CDM,250,RC,,,Outpatient,,,148.26,148.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,125.84,84.88,,100.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.13,50,,59.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.2,75,,88.96,percent of total billed charges,75% of total billed charges for outpatient setting,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.61,80,,94.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.37,65,,77.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,35,,41.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.43,90,,106.74,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,133.43,
"HEPARIN 25,000UNITS/250ML 0.45%NS",3302971,CDM,636,RC,J1644,HCPCS,Outpatient,,,43.16,43.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.21,70,,24.17,percent of total billed charges,70% of total billed charges for outpatient setting,36.63,84.88,,29.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.37,75,,25.9,percent of total billed charges,75% of total billed charges for outpatient setting,30.21,70,,24.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.54,12.84,,4.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.53,80,,27.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.54,12.84,,4.43,percent of total billed charges,12.84% of total billed charges,5.54,12.84,,4.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.05,65,,22.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,100,,,Fee Schedule,100% of Custom Fee Schedule,38.84,90,,31.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,38.84,
HEPARIN LOCK FLUSH 100U/ML 5ML SYRINGE,3301204,CDM,250,RC,J1642,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,2.92,
"HEPARIN SOD PORCINE INJ 10,000U/ML: 1ML",3301206,CDM,250,RC,,,Outpatient,,,142.15,142.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.51,70,,79.61,percent of total billed charges,70% of total billed charges for outpatient setting,120.66,84.88,,96.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.08,50,,56.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.61,75,,85.29,percent of total billed charges,75% of total billed charges for outpatient setting,99.51,70,,79.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.25,12.84,,14.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.72,80,,90.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.25,12.84,,14.6,percent of total billed charges,12.84% of total billed charges,18.25,12.84,,14.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.4,65,,73.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.75,35,,39.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.94,90,,102.35,percent of total billed charges,90% of total billed charges for outpatient setting,18.25,127.94,
HEPARIN SOD PORCINE INJ 10MU/ML: 1ML,3301207,CDM,250,RC,,,Outpatient,,,5.12,5.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,84.88,,3.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.56,50,,2.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.84,75,,3.07,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,80,,3.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.33,65,,2.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,35,,1.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.61,90,,3.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.61,
HEPARIN SOD PORCINE INJ 5000U/ML 1ML,3301202,CDM,250,RC,J1644,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,2.92,
HEPARIN SOD PORCINE INJ 5MU/ML: 1ML,3301205,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HEPARIN SOD PORCINE/D5W 50U SOL: 500ML,3301208,CDM,250,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
HEPARIN SODIUM INJ 1000U/ML 1ML,3301203,CDM,250,RC,J1644,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,2.92,
HEPATIC FUNCTION,201200,CDM,300,RC,80076,HCPCS,Outpatient,,,36.77,33.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,31.21,84.88,,24.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.58,75,,22.06,percent of total billed charges,75% of total billed charges for outpatient setting,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,80,,23.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of Custom Fee Schedule,33.09,90,,26.47,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,33.09,
HEPATITIS A VAC (HAVRIX) INJ 1440U: 1ML,3301209,CDM,250,RC,,,Outpatient,,,164.31,164.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.02,70,,92.02,percent of total billed charges,70% of total billed charges for outpatient setting,139.47,84.88,,111.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.16,50,,65.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.23,75,,98.58,percent of total billed charges,75% of total billed charges for outpatient setting,115.02,70,,92.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,12.84,,16.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.45,80,,105.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,12.84,,16.88,percent of total billed charges,12.84% of total billed charges,21.1,12.84,,16.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.8,65,,85.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.51,35,,46.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,147.88,90,,118.3,percent of total billed charges,90% of total billed charges for outpatient setting,21.1,147.88,
HEPATITIS ACUTE PANEL,220415,CDM,300,RC,80074,HCPCS,Outpatient,,,214.34,192.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.04,70,,120.03,percent of total billed charges,70% of total billed charges for outpatient setting,181.93,84.88,,145.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,160.76,75,,128.61,percent of total billed charges,75% of total billed charges for outpatient setting,150.04,70,,120.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.47,80,,137.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,69.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.34,100,,,Fee Schedule,100% of Custom Fee Schedule,192.91,90,,154.33,percent of total billed charges,90% of total billed charges for outpatient setting,47.63,192.91,
HEPATITIS B (BAYHEP B) INJ : 5ML,3301211,CDM,250,RC,,,Outpatient,,,1920.72,1920.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344.5,70,,1075.6,percent of total billed charges,70% of total billed charges for outpatient setting,1630.31,84.88,,1304.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,960.36,50,,768.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1440.54,75,,1152.43,percent of total billed charges,75% of total billed charges for outpatient setting,1344.5,70,,1075.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.62,12.84,,197.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.58,80,,1229.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.62,12.84,,197.3,percent of total billed charges,12.84% of total billed charges,246.62,12.84,,197.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1248.47,65,,998.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.25,35,,537.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1728.65,90,,1382.92,percent of total billed charges,90% of total billed charges for outpatient setting,246.62,1728.65,
HEPATITIS B (ENGERIX-B) INJ 20MCG/ML:1ML,3301213,CDM,250,RC,,,Outpatient,,,167.92,167.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.54,70,,94.03,percent of total billed charges,70% of total billed charges for outpatient setting,142.53,84.88,,114.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,83.96,50,,67.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.94,75,,100.75,percent of total billed charges,75% of total billed charges for outpatient setting,117.54,70,,94.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.56,12.84,,17.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.34,80,,107.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.56,12.84,,17.25,percent of total billed charges,12.84% of total billed charges,21.56,12.84,,17.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.15,65,,87.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.77,35,,47.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.13,90,,120.9,percent of total billed charges,90% of total billed charges for outpatient setting,21.56,151.13,
HEPATITIS B (NABI-HB IMMUNE) INJ 1560IU:,3301210,CDM,250,RC,,,Outpatient,,,2075.72,2075.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1453,70,,1162.4,percent of total billed charges,70% of total billed charges for outpatient setting,1761.87,84.88,,1409.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1037.86,50,,830.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1556.79,75,,1245.43,percent of total billed charges,75% of total billed charges for outpatient setting,1453,70,,1162.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.52,12.84,,213.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1660.58,80,,1328.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.52,12.84,,213.22,percent of total billed charges,12.84% of total billed charges,266.52,12.84,,213.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1349.22,65,,1079.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.5,35,,581.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1868.15,90,,1494.52,percent of total billed charges,90% of total billed charges for outpatient setting,266.52,1868.15,
HEPATITIS B VAC (ENEGERIX-B) SDV: 20 MCG,3301212,CDM,250,RC,,,Outpatient,,,163.26,163.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.28,70,,91.42,percent of total billed charges,70% of total billed charges for outpatient setting,138.58,84.88,,110.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.63,50,,65.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.45,75,,97.96,percent of total billed charges,75% of total billed charges for outpatient setting,114.28,70,,91.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.96,12.84,,16.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.61,80,,104.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.96,12.84,,16.77,percent of total billed charges,12.84% of total billed charges,20.96,12.84,,16.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.12,65,,84.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.14,35,,45.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.93,90,,117.54,percent of total billed charges,90% of total billed charges for outpatient setting,20.96,146.93,
HEPATITIS B VAC PED(ENGERIX-B) SDV 10MCG,3303338,CDM,250,RC,90744,HCPCS,Outpatient,,,163.26,163.26,,111.91,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,114.28,70,,91.42,percent of total billed charges,70% of total billed charges for outpatient setting,138.58,84.88,,110.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,122.45,75,,97.96,percent of total billed charges,75% of total billed charges for outpatient setting,114.28,70,,91.42,percent of total billed charges,70% of total billed charges for outpatient setting,113.42,170,,,Fee Schedule,170% of Medicare OPPS rate,120.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,20.96,12.84,,16.768,percent of total billed charges,12.84% of total billed charges,114.17,175,,,Fee Schedule,175% of Medicare OPPS rate,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.61,80,,104.49,percent of total billed charges,80% of total billed charges for outpatient setting,108.89,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,106.62,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,20.96,12.84,,16.77,percent of total billed charges,12.84% of total billed charges,20.96,12.84,,16.77,percent of total billed charges,12.84% of total billed charges,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,106.12,65,,84.9,percent of total billed charges,65% of total billed charges for outpatient setting,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.66,100,,,Fee Schedule,100% of Custom Fee Schedule,146.93,90,,117.54,percent of total billed charges,90% of total billed charges for outpatient setting,20.96,146.93,
HEPATITIS E ANTIBODY,220435,CDM,300,RC,86790,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
HERBAL PRODUCTS (SAM-E) CAP: 200 MG,3301214,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HERPES SIMPLEX VIRUS 1&2 IgG,220485,CDM,302,RC,86695,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
HET Bipolar Forcep  180-1022,69162100,CDM,272,RC,,,Outpatient,,,2138.67,2138.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.07,70,,1197.66,percent of total billed charges,70% of total billed charges for outpatient setting,1815.3,84.88,,1452.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,1069.34,50,,855.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1604,75,,1283.2,percent of total billed charges,75% of total billed charges for outpatient setting,1497.07,70,,1197.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.61,12.84,,219.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1710.94,80,,1368.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.61,12.84,,219.69,percent of total billed charges,12.84% of total billed charges,274.61,12.84,,219.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1390.14,65,,1112.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.53,35,,598.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1924.8,90,,1539.84,percent of total billed charges,90% of total billed charges for outpatient setting,274.61,1924.8,
HETASTARCH 6% (HESPAN) BAG 500 ML,3301215,CDM,258,RC,,,Outpatient,,,100.61,100.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.43,70,,56.34,percent of total billed charges,70% of total billed charges for outpatient setting,85.4,84.88,,68.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.31,50,,40.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.46,75,,60.37,percent of total billed charges,75% of total billed charges for outpatient setting,70.43,70,,56.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.92,12.84,,10.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.49,80,,64.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.92,12.84,,10.34,percent of total billed charges,12.84% of total billed charges,12.92,12.84,,10.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.4,65,,52.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.21,35,,28.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.55,90,,72.44,percent of total billed charges,90% of total billed charges for outpatient setting,12.92,90.55,
HETASTARCH/NSCL 6% SOLN: 500ML,3302505,CDM,258,RC,,,Outpatient,,,931.64,931.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.15,70,,521.72,percent of total billed charges,70% of total billed charges for outpatient setting,790.78,84.88,,632.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,465.82,50,,372.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.73,75,,558.98,percent of total billed charges,75% of total billed charges for outpatient setting,652.15,70,,521.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.62,12.84,,95.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.31,80,,596.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.62,12.84,,95.7,percent of total billed charges,12.84% of total billed charges,119.62,12.84,,95.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,605.57,65,,484.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.07,35,,260.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,838.48,90,,670.78,percent of total billed charges,90% of total billed charges for outpatient setting,119.62,838.48,
HETEROPHIL ANTIBODY TITER,220080,CDM,310,RC,86308,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
HGB ELECTROPHORESIS,200805,CDM,300,RC,83020,HCPCS,Outpatient,,,57.92,52.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,49.16,84.88,,39.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.44,75,,34.75,percent of total billed charges,75% of total billed charges for outpatient setting,40.54,70,,32.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,80,,37.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,100% of Custom Fee Schedule,52.13,90,,41.7,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,52.13,
"HGB, SERUM FREE",200532,CDM,300,RC,84311,HCPCS,Outpatient,,,36.45,32.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.52,70,,20.42,percent of total billed charges,70% of total billed charges for outpatient setting,30.94,84.88,,24.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.34,75,,21.87,percent of total billed charges,75% of total billed charges for outpatient setting,25.52,70,,20.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,80,,23.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.2,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.26,100,,,Fee Schedule,100% of Custom Fee Schedule,32.81,90,,26.25,percent of total billed charges,90% of total billed charges for outpatient setting,8.1,32.81,
HICKMAN 9.6FR SINGLE LUMEN / 0600560,6152749,CDM,272,RC,C1788,HCPCS,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,70,,278.59,percent of total billed charges,70% of total billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,348.24,70,,278.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323.37,65,,258.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,447.74,90,,358.19,percent of total billed charges,90% of total billed charges for outpatient setting,63.88,447.74,
HICKMAN 9FR 0600600,6150005,CDM,278,RC,C1788,HCPCS,Outpatient,,,1362.15,1362.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.29,60,,653.83,percent of total billed charges,60% of total Billed charges for outpatient setting,1156.19,84.88,,924.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.61,75,,817.29,percent of total billed charges,75% of total billed charges for outpatient setting,681.08,50,,544.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.9,12.84,,139.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.72,80,,871.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.9,12.84,,139.92,percent of total billed charges,12.84% of total billed charges,174.9,12.84,,139.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1362.15,65,,1089.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.75,35,,381.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,817.29,60,,653.83,percent of total billed charges,60% of total billed charges for outpatient setting,174.9,1362.15,
HIP ARTHROGRAPHY BILATERAL,2400328,CDM,322,RC,73525,HCPCS,Outpatient,,,1711.96,1283.97,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.37,70,,958.7,percent of total billed charges,70% of total billed charges for outpatient setting,1453.11,84.88,,1162.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,855.98,50,,684.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1283.97,75,,1027.18,percent of total billed charges,75% of total billed charges for outpatient setting,1198.37,70,,958.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,12.84,,175.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1369.57,80,,1095.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,12.84,,175.86,percent of total billed charges,12.84% of total billed charges,219.82,12.84,,175.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.19,35,,479.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1540.76,90,,1232.61,percent of total billed charges,90% of total billed charges for outpatient setting,128,1540.76,
HIP ARTHROGRAPHY LEFT,2400321,CDM,322,RC,73525,HCPCS,Outpatient,,,1141.31,855.98,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
HIP ARTHROGRAPHY RAD SUPERV,2400327,CDM,320,RC,73525,HCPCS,Outpatient,,,1141.31,855.98,,527.98,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,560.98,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,577.48,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,461.98,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,403.66,100,,,Fee Schedule,100% of Custom Fee Schedule,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
HIP ARTHROGRAPHY RIGHT,2400320,CDM,322,RC,73525,HCPCS,Outpatient,,,1141.31,855.98,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
HIP BIL 2 VW W/WO PELVIS,2400317,CDM,320,RC,73521,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.61,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,38.61,295.41,
HIP BIL MIN 5 VIEWS W/WO PELVIS,2400319,CDM,320,RC,73523,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.16,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HIP BILAT 2 VW W/WO PELVIS,2400308,CDM,320,RC,73521,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.61,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,38.61,295.41,
HIP BILAT 3-4 VW W/WOPELVIS,2400318,CDM,320,RC,73522,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.72,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HIP LEFT 1 VW  W/WO  PELVIS,2400312,CDM,320,RC,73501,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HIP LEFT 2-3 VW W/WO PELVIS,2400313,CDM,320,RC,73502,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HIP LEFT 4 VWS W/WO PELVIS,2400314,CDM,320,RC,73503,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
HIP RIGHT 1 VW W/WO PELVIS,2400322,CDM,320,RC,73501,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HIP RIGHT 2-3 VW W/WO PELVIS,2400323,CDM,320,RC,73502,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HIP RIGHT 4 VIEWS W/WO PELVIS,2400324,CDM,320,RC,73503,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
"HISTAMINE, URINE 24 HR",220876,CDM,301,RC,83088,HCPCS,Outpatient,,,132.89,119.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.02,70,,74.42,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,84.88,,90.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.67,75,,79.74,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,70,,74.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.31,80,,85.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of Custom Fee Schedule,119.6,90,,95.68,percent of total billed charges,90% of total billed charges for outpatient setting,29.53,119.6,
HISTOPLASMA AB,220846,CDM,302,RC,86698,HCPCS,Outpatient,,,86.81,78.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,73.68,84.88,,58.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.11,75,,52.09,percent of total billed charges,75% of total billed charges for outpatient setting,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.45,80,,55.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,100,,,Fee Schedule,100% of Custom Fee Schedule,78.13,90,,62.5,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,78.13,
HISTOPLASMA ANTIGEN  SERUM,220919,CDM,306,RC,87385,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
HISTOPLASMA ANTIGEN  URINE,220864,CDM,306,RC,87385,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
HISTOPLASMA CAPSULATUM AB,220931,CDM,302,RC,86698,HCPCS,Outpatient,,,86.81,78.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,73.68,84.88,,58.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.11,75,,52.09,percent of total billed charges,75% of total billed charges for outpatient setting,60.77,70,,48.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.45,80,,55.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,100,,,Fee Schedule,100% of Custom Fee Schedule,78.13,90,,62.5,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,78.13,
HIV 1/2 AB PROFICIENCY,201913,CDM,300,RC,82272,HCPCS,Outpatient,,,19.04,17.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,16.16,84.88,,12.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.28,75,,11.42,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,80,,12.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.14,90,,13.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,17.14,
HIV 1/2 AG/AB COMBO,220905,CDM,300,RC,87389,HCPCS,Outpatient,,,108.36,97.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.85,70,,60.68,percent of total billed charges,70% of total billed charges for outpatient setting,91.98,84.88,,73.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,81.27,75,,65.02,percent of total billed charges,75% of total billed charges for outpatient setting,75.85,70,,60.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.69,80,,69.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,34.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,100,,,Fee Schedule,100% of Custom Fee Schedule,97.52,90,,78.02,percent of total billed charges,90% of total billed charges for outpatient setting,24.08,97.52,
HIV RNA QUANTITATIVE,220868,CDM,300,RC,87535,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
HIV-1,220436,CDM,300,RC,86701,HCPCS,Outpatient,,,40.01,36.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.01,70,,22.41,percent of total billed charges,70% of total billed charges for outpatient setting,33.96,84.88,,27.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.01,75,,24.01,percent of total billed charges,75% of total billed charges for outpatient setting,28.01,70,,22.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.01,80,,25.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,100% of Custom Fee Schedule,36.01,90,,28.81,percent of total billed charges,90% of total billed charges for outpatient setting,8.89,36.01,
HIV-1 RNA QUANTITATIVE BY PCR,220867,CDM,300,RC,87536,HCPCS,Outpatient,,,382.95,344.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.07,70,,214.46,percent of total billed charges,70% of total billed charges for outpatient setting,325.05,84.88,,260.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,287.21,75,,229.77,percent of total billed charges,75% of total billed charges for outpatient setting,268.07,70,,214.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.36,80,,245.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,124.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.37,100,,,Fee Schedule,100% of Custom Fee Schedule,344.66,90,,275.73,percent of total billed charges,90% of total billed charges for outpatient setting,84.91,344.66,
HIV-2 ANTIBODIES,220457,CDM,300,RC,86702,HCPCS,Outpatient,,,60.84,54.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.59,70,,34.07,percent of total billed charges,70% of total billed charges for outpatient setting,51.64,84.88,,41.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.63,75,,36.5,percent of total billed charges,75% of total billed charges for outpatient setting,42.59,70,,34.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.67,80,,38.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of Custom Fee Schedule,54.76,90,,43.81,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,54.76,
HLA B27,220439,CDM,301,RC,86812,HCPCS,Outpatient,,,116.15,104.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,84.88,,78.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,87.11,75,,69.69,percent of total billed charges,75% of total billed charges for outpatient setting,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.92,80,,74.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.94,100,,,Fee Schedule,100% of Custom Fee Schedule,104.54,90,,83.63,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,104.54,
HLA-A29,220873,CDM,300,RC,81381,HCPCS,Outpatient,,,764.55,688.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.19,70,,428.15,percent of total billed charges,70% of total billed charges for outpatient setting,648.95,84.88,,519.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,236.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,573.41,75,,458.73,percent of total billed charges,75% of total billed charges for outpatient setting,535.19,70,,428.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.17,12.84,,78.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.64,80,,489.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.17,12.84,,78.54,percent of total billed charges,12.84% of total billed charges,98.17,12.84,,78.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.35,100,,,Fee Schedule,100% of Custom Fee Schedule,688.1,90,,550.48,percent of total billed charges,90% of total billed charges for outpatient setting,98.17,688.1,
HMRL BEARING 44-36MM +3 / XL-115364,69162897,CDM,278,RC,C1776,HCPCS,Outpatient,,,2894.06,2894.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.44,60,,1389.15,percent of total billed charges,60% of total Billed charges for outpatient setting,2456.48,84.88,,1965.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170.55,75,,1736.44,percent of total billed charges,75% of total billed charges for outpatient setting,1447.03,50,,1157.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,80,,1852.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3038.76,105,,2431.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.92,35,,810.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1736.44,60,,1389.15,percent of total billed charges,60% of total billed charges for outpatient setting,371.6,3038.76,
HMRL BEARING 44-36MM DIA CRV / XL-115363,69161573,CDM,278,RC,,,Outpatient,,,2894.06,2894.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.44,60,,1389.15,percent of total billed charges,60% of total Billed charges for outpatient setting,2456.48,84.88,,1965.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,1447.03,50,,1157.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2170.55,75,,1736.44,percent of total billed charges,75% of total billed charges for outpatient setting,1447.03,50,,1157.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,80,,1852.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3038.76,105,,2431.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.92,35,,810.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1736.44,60,,1389.15,percent of total billed charges,60% of total billed charges for outpatient setting,371.6,3038.76,
HMRL TRAY 44MM STANDARD / 115370,69161574,CDM,278,RC,,,Outpatient,,,2835,2835,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,60,,1360.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2406.35,84.88,,1925.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1417.5,50,,1134,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2126.25,75,,1701,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,50,,1134,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2268,80,,1814.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2976.75,105,,2381.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.25,35,,793.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,60,,1360.8,percent of total billed charges,60% of total billed charges for outpatient setting,364.01,2976.75,
HOLTER MONITOR HOOKUP,2600106,CDM,731,RC,93225,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
HOLTER MONITOR TECH COMP,2600107,CDM,731,RC,93226,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
HOMATROPINE (ISOPTO) OPTH SOL 5% : 5ML,3301216,CDM,259,RC,,,Outpatient,,,34.23,34.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.96,70,,19.17,percent of total billed charges,70% of total billed charges for outpatient setting,29.05,84.88,,23.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.12,50,,13.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.67,75,,20.54,percent of total billed charges,75% of total billed charges for outpatient setting,23.96,70,,19.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.38,80,,21.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,4.4,12.84,,3.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.25,65,,17.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,35,,9.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.81,90,,24.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.4,30.81,
HOMATROPINE (ISOPTO) OPTH SOL 5% : 5ML,3301217,CDM,259,RC,,,Outpatient,,,48.73,48.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.11,70,,27.29,percent of total billed charges,70% of total billed charges for outpatient setting,41.36,84.88,,33.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.37,50,,19.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.55,75,,29.24,percent of total billed charges,75% of total billed charges for outpatient setting,34.11,70,,27.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.26,12.84,,5.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.98,80,,31.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.26,12.84,,5.01,percent of total billed charges,12.84% of total billed charges,6.26,12.84,,5.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.67,65,,25.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.06,35,,13.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.86,90,,35.09,percent of total billed charges,90% of total billed charges for outpatient setting,6.26,43.86,
HOME HEALTH CARE PRODUCTS (BBRAUN) DP:50,3301218,CDM,259,RC,,,Outpatient,,,7.09,7.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,70,,3.97,percent of total billed charges,70% of total billed charges for outpatient setting,6.02,84.88,,4.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.55,50,,2.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.32,75,,4.26,percent of total billed charges,75% of total billed charges for outpatient setting,4.96,70,,3.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,80,,4.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.61,65,,3.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,35,,1.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.38,90,,5.1,percent of total billed charges,90% of total billed charges for outpatient setting,0.91,6.38,
HOMOCYSTEINE,220370,CDM,300,RC,82131,HCPCS,Outpatient,,,103.41,93.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.39,70,,57.91,percent of total billed charges,70% of total billed charges for outpatient setting,87.77,84.88,,70.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.56,75,,62.05,percent of total billed charges,75% of total billed charges for outpatient setting,72.39,70,,57.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.73,80,,66.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.98,100,,,Fee Schedule,100% of Custom Fee Schedule,93.07,90,,74.46,percent of total billed charges,90% of total billed charges for outpatient setting,21.58,93.07,
HOOD FLYTE PEELAWAY / 0408-801-500,6152152,CDM,272,RC,,,Outpatient,,,155.75,155.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.03,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,132.2,84.88,,105.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.88,50,,62.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.81,75,,93.45,percent of total billed charges,75% of total billed charges for outpatient setting,109.03,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.6,80,,99.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.24,65,,80.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,35,,43.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.18,90,,112.14,percent of total billed charges,90% of total billed charges for outpatient setting,20,140.18,
HOOK 50 DEG APOLLO RF / AR-9815,71000320,CDM,272,RC,,,Outpatient,,,835.8,835.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.06,70,,468.05,percent of total billed charges,70% of total billed charges for outpatient setting,709.43,84.88,,567.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,417.9,50,,334.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,626.85,75,,501.48,percent of total billed charges,75% of total billed charges for outpatient setting,585.06,70,,468.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.32,12.84,,85.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.64,80,,534.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.32,12.84,,85.86,percent of total billed charges,12.84% of total billed charges,107.32,12.84,,85.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,543.27,65,,434.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.53,35,,234.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,752.22,90,,601.78,percent of total billed charges,90% of total billed charges for outpatient setting,107.32,752.22,
HOOK 90 DEG APOLLO RF / AR-9825,69169343,CDM,272,RC,,,Outpatient,,,777,777,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.9,70,,435.12,percent of total billed charges,70% of total billed charges for outpatient setting,659.52,84.88,,527.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,388.5,50,,310.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,582.75,75,,466.2,percent of total billed charges,75% of total billed charges for outpatient setting,543.9,70,,435.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.77,12.84,,79.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.6,80,,497.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.77,12.84,,79.82,percent of total billed charges,12.84% of total billed charges,99.77,12.84,,79.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.05,65,,404.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.95,35,,217.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,699.3,90,,559.44,percent of total billed charges,90% of total billed charges for outpatient setting,99.77,699.3,
HOOK CAUTERY 5MM TIP / 400156,69161354,CDM,272,RC,,,Outpatient,,,409.05,409.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.34,70,,229.07,percent of total billed charges,70% of total billed charges for outpatient setting,347.2,84.88,,277.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,204.53,50,,163.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.79,75,,245.43,percent of total billed charges,75% of total billed charges for outpatient setting,286.34,70,,229.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.52,12.84,,42.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.24,80,,261.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.52,12.84,,42.02,percent of total billed charges,12.84% of total billed charges,52.52,12.84,,42.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,265.88,65,,212.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.17,35,,114.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,368.15,90,,294.52,percent of total billed charges,90% of total billed charges for outpatient setting,52.52,368.15,
HOOKS 12MM BLUNT / 3350-8G,69162704,CDM,272,RC,,,Outpatient,,,56.86,56.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.8,70,,31.84,percent of total billed charges,70% of total billed charges for outpatient setting,48.26,84.88,,38.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.43,50,,22.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.65,75,,34.12,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,70,,31.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.49,80,,36.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.96,65,,29.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,35,,15.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.17,90,,40.94,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,51.17,
HOOKS 5MM SEMI BLUNT / 3205-8G,69162849,CDM,272,RC,,,Outpatient,,,56.86,56.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.8,70,,31.84,percent of total billed charges,70% of total billed charges for outpatient setting,48.26,84.88,,38.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.43,50,,22.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.65,75,,34.12,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,70,,31.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.49,80,,36.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.96,65,,29.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,35,,15.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.17,90,,40.94,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,51.17,
HOOKS 5MM SHARP / 3311-8G,69161255,CDM,272,RC,,,Outpatient,,,56.96,56.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,70,,31.9,percent of total billed charges,70% of total billed charges for outpatient setting,48.35,84.88,,38.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.48,50,,22.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.72,75,,34.18,percent of total billed charges,75% of total billed charges for outpatient setting,39.87,70,,31.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,12.84,,5.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.57,80,,36.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,12.84,,5.85,percent of total billed charges,12.84% of total billed charges,7.31,12.84,,5.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.02,65,,29.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,35,,15.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.26,90,,41.01,percent of total billed charges,90% of total billed charges for outpatient setting,7.31,51.26,
HUMALOG 75/25(INSULIN MIX)INJ 10ML,3301291,CDM,259,RC,,,Outpatient,,,226.25,226.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.38,70,,126.7,percent of total billed charges,70% of total billed charges for outpatient setting,192.04,84.88,,153.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.13,50,,90.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.69,75,,135.75,percent of total billed charges,75% of total billed charges for outpatient setting,158.38,70,,126.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.05,12.84,,23.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181,80,,144.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.05,12.84,,23.24,percent of total billed charges,12.84% of total billed charges,29.05,12.84,,23.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.06,65,,117.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.19,35,,63.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,203.63,90,,162.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.05,203.63,
HUMALOG INSULIN  3ML,3302823,CDM,250,RC,,,Outpatient,,,101.75,101.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.23,70,,56.98,percent of total billed charges,70% of total billed charges for outpatient setting,86.37,84.88,,69.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.88,50,,40.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.31,75,,61.05,percent of total billed charges,75% of total billed charges for outpatient setting,71.23,70,,56.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,12.84,,10.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.4,80,,65.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,12.84,,10.45,percent of total billed charges,12.84% of total billed charges,13.06,12.84,,10.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.14,65,,52.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.61,35,,28.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.58,90,,73.26,percent of total billed charges,90% of total billed charges for outpatient setting,13.06,91.58,
HUMERAL  TRAY 44MM +5MM / 115375,69169354,CDM,278,RC,C1713,HCPCS,Outpatient,,,2835,2835,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,60,,1360.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2406.35,84.88,,1925.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2126.25,75,,1701,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,50,,1134,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2268,80,,1814.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,364.01,12.84,,291.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2976.75,105,,2381.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.25,35,,793.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,60,,1360.8,percent of total billed charges,60% of total billed charges for outpatient setting,364.01,2976.75,
HUMERAL BEARING ARCOMXL / XL-115366,69162643,CDM,278,RC,C1776,HCPCS,Outpatient,,,2894.06,2894.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.44,60,,1389.15,percent of total billed charges,60% of total Billed charges for outpatient setting,2456.48,84.88,,1965.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170.55,75,,1736.44,percent of total billed charges,75% of total billed charges for outpatient setting,1447.03,50,,1157.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,80,,1852.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,371.6,12.84,,297.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3038.76,105,,2431.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.92,35,,810.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1736.44,60,,1389.15,percent of total billed charges,60% of total billed charges for outpatient setting,371.6,3038.76,
HUMERAL CANN NAIL 7X240MM / 04.001.228S,70000413,CDM,278,RC,C1776,HCPCS,Outpatient,,,4229.62,4229.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2537.77,60,,2030.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3590.1,84.88,,2872.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3172.22,75,,2537.78,percent of total billed charges,75% of total billed charges for outpatient setting,2114.81,50,,1691.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.08,12.84,,434.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3383.7,80,,2706.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.08,12.84,,434.46,percent of total billed charges,12.84% of total billed charges,543.08,12.84,,434.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4441.1,105,,3552.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.37,35,,1184.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2537.77,60,,2030.22,percent of total billed charges,60% of total billed charges for outpatient setting,543.08,4441.1,
HUMERAL CANN NAIL PROX 9X150MM,69162058,CDM,278,RC,C1776,HCPCS,Outpatient,,,4571.98,4571.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2743.19,60,,2194.55,percent of total billed charges,60% of total Billed charges for outpatient setting,3880.7,84.88,,3104.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3428.99,75,,2743.19,percent of total billed charges,75% of total billed charges for outpatient setting,2285.99,50,,1828.79,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.04,12.84,,469.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3657.58,80,,2926.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.04,12.84,,469.63,percent of total billed charges,12.84% of total billed charges,587.04,12.84,,469.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4800.58,105,,3840.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600.19,35,,1280.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2743.19,60,,2194.55,percent of total billed charges,60% of total billed charges for outpatient setting,587.04,4800.58,
HUMERAL TRAY 40MM +0MM / 110031399,69169585,CDM,278,RC,C1776,HCPCS,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
HUMERAL TRAY 40MM +10MM / 110031401,69169788,CDM,278,RC,C1713,HCPCS,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
HUMERAL TRAY 40MM +3MM / 110031400,69169628,CDM,278,RC,C1713,HCPCS,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,60,,1200,percent of total billed charges,60% of total Billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2625,105,,2100,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1500,60,,1200,percent of total billed charges,60% of total billed charges for outpatient setting,321,2625,
HUMERAL TRAY 40MM +3MM / 110031429,69169787,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
HUMERUS BILATERAL,2400502,CDM,320,RC,73060,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
HUMERUS LEFT,2400501,CDM,320,RC,73060,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HUMERUS RIGHT,2400500,CDM,320,RC,73060,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
HUMIDIFIER KIT 500ML / 002620,5050008,CDM,270,RC,,,Outpatient,,,22.68,22.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,19.25,84.88,,15.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.34,50,,9.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.01,75,,13.61,percent of total billed charges,75% of total billed charges for outpatient setting,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,80,,14.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.74,65,,11.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,35,,6.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.41,90,,16.33,percent of total billed charges,90% of total billed charges for outpatient setting,2.91,20.41,
HUMIDVENT / 11112,6151098,CDM,270,RC,,,Outpatient,,,8.91,8.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,70,,4.99,percent of total billed charges,70% of total billed charges for outpatient setting,7.56,84.88,,6.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.46,50,,3.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.68,75,,5.34,percent of total billed charges,75% of total billed charges for outpatient setting,6.24,70,,4.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,80,,5.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.79,65,,4.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.02,90,,6.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,8.02,
HUMULIN N INSULIN 10 ML,3302881,CDM,250,RC,,,Outpatient,,,102.75,102.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.93,70,,57.54,percent of total billed charges,70% of total billed charges for outpatient setting,87.21,84.88,,69.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.38,50,,41.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.06,75,,61.65,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,70,,57.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,12.84,,10.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.2,80,,65.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,12.84,,10.55,percent of total billed charges,12.84% of total billed charges,13.19,12.84,,10.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.79,65,,53.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.96,35,,28.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.48,90,,73.98,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,92.48,
HYALOURONIDASE(HYLENEX) 150UNITS/ML 1ML,3309937,CDM,636,RC,J3473,HCPCS,Outpatient,,,216.6,216.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.62,70,,121.3,percent of total billed charges,70% of total billed charges for outpatient setting,183.85,84.88,,147.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,162.45,75,,129.96,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,70,,121.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,12.84,,22.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.28,80,,138.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,12.84,,22.25,percent of total billed charges,12.84% of total billed charges,27.81,12.84,,22.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.79,65,,112.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,100,,,Fee Schedule,100% of Custom Fee Schedule,194.94,90,,155.95,percent of total billed charges,90% of total billed charges for outpatient setting,0.38,194.94,
HYDRALAZINE (APRESOLINE) TAB : 10 MG,3301219,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HYDRALAZINE (APRESOLINE) TAB 25 MG  U/D,3301220,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDRALAZINE (genAPRESOLINE) 20MG/ML 1ML,3301221,CDM,636,RC,J0360,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,4.88,
HYDROCHLOROTHIAZIDE 25 MG TAB,3302804,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCHLOROTHIAZIDE TAB : 25 MG U/D,3301223,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
HYDROCOD (HYDROCO COMPD)SR 5-1.5/5:480ML,3301229,CDM,259,RC,,,Outpatient,,,62,62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.4,70,,34.72,percent of total billed charges,70% of total billed charges for outpatient setting,52.63,84.88,,42.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,31,50,,24.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.5,75,,37.2,percent of total billed charges,75% of total billed charges for outpatient setting,43.4,70,,34.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.96,12.84,,6.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.6,80,,39.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.96,12.84,,6.37,percent of total billed charges,12.84% of total billed charges,7.96,12.84,,6.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.3,65,,32.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,35,,17.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,90% of total billed charges for outpatient setting,7.96,55.8,
HYDROCOD (LORTAB 5) TAB : 5 - 500MG U/D,3301228,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCOD (VICODIN) TAB : 500 MG,3301225,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCOD (VICODIN) TAB : 5-500 MG  U/D,3301226,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCODONE (VICODIN) 500MG TAB:,3302584,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCODONE (VICODIN)5-500MG TAB:UD,3302583,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCODONE 10MG/325MG APAP (NORCO),3304465,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCODONE 2.5MG/108MG APAP PER 5ML LIQ,3302620,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCODONE 5/325MG APAP(NORCO GEN) TAB,3304464,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCODONE 7.5MG/325MG APAP (NORCO),3305843,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCODONE(VICODIN) TAB: 5/500MG UD,3302580,CDM,259,RC,,,Outpatient,,,5.33,5.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,84.88,,3.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.67,50,,2.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4,75,,3.2,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,80,,3.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.46,65,,2.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,35,,1.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.8,90,,3.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.8,
HYDROCODONE7.5MG/APAP 325MG:ANEXSIA,3302750,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
HYDROCORT (HEMORRHOIDAL) SUPP : 25 MG,3301242,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROCORTISONE (ANUSOL) CRM 2.5%: 30GM,3302816,CDM,259,RC,,,Outpatient,,,126.49,126.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.54,70,,70.83,percent of total billed charges,70% of total billed charges for outpatient setting,107.36,84.88,,85.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.25,50,,50.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.87,75,,75.9,percent of total billed charges,75% of total billed charges for outpatient setting,88.54,70,,70.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.24,12.84,,12.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.19,80,,80.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.24,12.84,,12.99,percent of total billed charges,12.84% of total billed charges,16.24,12.84,,12.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.22,65,,65.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.27,35,,35.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.84,90,,91.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.24,113.84,
HYDROCORTISONE (COLOCORT) ENEMA : 100MG,3301237,CDM,259,RC,,,Outpatient,,,26.36,26.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,70,,14.76,percent of total billed charges,70% of total billed charges for outpatient setting,22.37,84.88,,17.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.18,50,,10.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.77,75,,15.82,percent of total billed charges,75% of total billed charges for outpatient setting,18.45,70,,14.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,12.84,,2.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.09,80,,16.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,3.38,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.13,65,,13.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,35,,7.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.72,90,,18.98,percent of total billed charges,90% of total billed charges for outpatient setting,3.38,23.72,
HYDROCORTISONE (genANUSOL HC)SUPP  25 MG,3301241,CDM,259,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.5,70,,14,percent of total billed charges,70% of total billed charges for outpatient setting,21.22,84.88,,16.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.5,50,,10,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.75,75,,15,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,70,,14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,12.84,,2.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,80,,16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,12.84,,2.57,percent of total billed charges,12.84% of total billed charges,3.21,12.84,,2.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.25,65,,13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.75,35,,7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.5,90,,18,percent of total billed charges,90% of total billed charges for outpatient setting,3.21,22.5,
HYDROCORTISONE (PROCTOSOL) CRM : 30 GM,3301239,CDM,259,RC,,,Outpatient,,,67.26,67.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,57.09,84.88,,45.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.63,50,,26.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.45,75,,40.36,percent of total billed charges,75% of total billed charges for outpatient setting,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.81,80,,43.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.72,65,,34.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.54,35,,18.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.53,90,,48.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.64,60.53,
HYDROCORTISONE (PROCTOZONE-HC) CRM: 2.5,3301232,CDM,259,RC,,,Outpatient,,,67.26,67.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,57.09,84.88,,45.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.63,50,,26.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.45,75,,40.36,percent of total billed charges,75% of total billed charges for outpatient setting,47.08,70,,37.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.81,80,,43.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,8.64,12.84,,6.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.72,65,,34.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.54,35,,18.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.53,90,,48.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.64,60.53,
HYDROCORTISONE (SOLU CORTEF) INJ:100MG,3301244,CDM,250,RC,,,Outpatient,,,15.31,15.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.72,70,,8.58,percent of total billed charges,70% of total billed charges for outpatient setting,13,84.88,,10.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.66,50,,6.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,75,,9.18,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,70,,8.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,80,,9.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.95,65,,7.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,35,,4.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.78,90,,11.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.97,13.78,
HYDROCORTISONE (SOLU-CORTEF) 100MG INJ,3301243,CDM,636,RC,J1720,HCPCS,Outpatient,,,96.2,96.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.34,70,,53.87,percent of total billed charges,70% of total billed charges for outpatient setting,81.65,84.88,,65.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,72.15,75,,57.72,percent of total billed charges,75% of total billed charges for outpatient setting,67.34,70,,53.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.96,80,,61.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,12.35,12.84,,9.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.53,65,,50.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.7,100,,,Fee Schedule,100% of Custom Fee Schedule,86.58,90,,69.26,percent of total billed charges,90% of total billed charges for outpatient setting,12.35,86.58,
HYDROCORTISONE 0.5%OINTMENT:,3301240,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
HYDROCORTISONE CREAM 1% 28GM,3302977,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROCORTISONE ENEMA : 100MG/60ML,3301235,CDM,259,RC,,,Outpatient,,,32.7,32.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.89,70,,18.31,percent of total billed charges,70% of total billed charges for outpatient setting,27.76,84.88,,22.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.35,50,,13.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.53,75,,19.62,percent of total billed charges,75% of total billed charges for outpatient setting,22.89,70,,18.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,80,,20.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.26,65,,17.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,35,,9.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.43,90,,23.54,percent of total billed charges,90% of total billed charges for outpatient setting,4.2,29.43,
HYDROCORTISONE POWDER : 25GM,3301234,CDM,259,RC,,,Outpatient,,,83.97,83.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.78,70,,47.02,percent of total billed charges,70% of total billed charges for outpatient setting,71.27,84.88,,57.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.99,50,,33.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.98,75,,50.38,percent of total billed charges,75% of total billed charges for outpatient setting,58.78,70,,47.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,12.84,,8.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.18,80,,53.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,12.84,,8.62,percent of total billed charges,12.84% of total billed charges,10.78,12.84,,8.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.58,65,,43.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,35,,23.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.57,90,,60.46,percent of total billed charges,90% of total billed charges for outpatient setting,10.78,75.57,
HYDROCORTISONE POWDER: 10 GM,3301236,CDM,259,RC,,,Outpatient,,,103.46,103.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.42,70,,57.94,percent of total billed charges,70% of total billed charges for outpatient setting,87.82,84.88,,70.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.73,50,,41.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.6,75,,62.08,percent of total billed charges,75% of total billed charges for outpatient setting,72.42,70,,57.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,12.84,,10.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.77,80,,66.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,12.84,,10.62,percent of total billed charges,12.84% of total billed charges,13.28,12.84,,10.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.25,65,,53.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.21,35,,28.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,93.11,90,,74.49,percent of total billed charges,90% of total billed charges for outpatient setting,13.28,93.11,
HYDROCORTISONE POWDER: 25 GM,3301238,CDM,259,RC,,,Outpatient,,,199.63,199.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.74,70,,111.79,percent of total billed charges,70% of total billed charges for outpatient setting,169.45,84.88,,135.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.82,50,,79.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.72,75,,119.78,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,70,,111.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,12.84,,20.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.7,80,,127.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.63,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.76,65,,103.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.87,35,,55.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.67,90,,143.74,percent of total billed charges,90% of total billed charges for outpatient setting,25.63,179.67,
HYDROCORTISONE PREPARATION H CR 26GM,3301231,CDM,259,RC,,,Outpatient,,,51.89,51.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.95,50,,20.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,12.84,,5.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,12.84,,5.33,percent of total billed charges,12.84% of total billed charges,6.66,12.84,,5.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.73,65,,26.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.16,35,,14.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,6.66,46.7,
HYDROCORTISONE TAB: 20 MG,3301233,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HYDROCORTISONE/PRAMOXINE:10 G(PROCTOFOAM,3302789,CDM,259,RC,,,Outpatient,,,210.07,210.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.05,70,,117.64,percent of total billed charges,70% of total billed charges for outpatient setting,178.31,84.88,,142.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.04,50,,84.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.55,75,,126.04,percent of total billed charges,75% of total billed charges for outpatient setting,147.05,70,,117.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.97,12.84,,21.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.06,80,,134.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.97,12.84,,21.58,percent of total billed charges,12.84% of total billed charges,26.97,12.84,,21.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.55,65,,109.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,35,,58.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.06,90,,151.25,percent of total billed charges,90% of total billed charges for outpatient setting,26.97,189.06,
HYDRODISSECTION CANNULA 27G / 8065441720,6150516,CDM,272,RC,,,Outpatient,,,36.4,36.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.48,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,84.88,,24.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.2,50,,14.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.3,75,,21.84,percent of total billed charges,75% of total billed charges for outpatient setting,25.48,70,,20.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.12,80,,23.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.66,65,,18.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,35,,10.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.76,90,,26.21,percent of total billed charges,90% of total billed charges for outpatient setting,4.67,32.76,
HYDROGEN PEROXIDE 3% 16OZ / D0012,5050127,CDM,270,RC,,,Outpatient,,,6.57,6.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.6,70,,3.68,percent of total billed charges,70% of total billed charges for outpatient setting,5.58,84.88,,4.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.29,50,,2.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.93,75,,3.94,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,70,,3.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,80,,4.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.27,65,,3.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,35,,1.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.91,90,,4.73,percent of total billed charges,90% of total billed charges for outpatient setting,0.84,5.91,
HYDROGEN PEROXIDE 473 ML,3302758,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROMORPHONE (DILAUDID) TAB : 2 MG,3301248,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROMORPHONE (DILAUDID) TAB : 4 MG,3301250,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROMORPHONE (DILAUDID) TAB: 4 MG,3301249,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROMORPHONE (DILAUDID)INJ 0.5MG/0.5ML,3309352,CDM,636,RC,J1170,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,3.26,
HYDROMORPHONE (DILAUDID)INJ 1MG/ML 1ML,3306421,CDM,636,RC,J1170,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,3.26,
HYDROMORPHONE (DILAUDID)INJ 2mg/ml 1ml,3301247,CDM,636,RC,J1170,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,3.26,
HYDROMORPHONE (genericDILAUDID) TAB 2MG,3301246,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROMORPHONE(DILAUDID)PCA 0.2MG/ML 50ML,3302747,CDM,250,RC,,,Outpatient,,,113.43,113.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,96.28,84.88,,77.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.72,50,,45.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.07,75,,68.06,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,70,,63.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,80,,72.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.73,65,,58.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,35,,31.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.09,90,,81.67,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.09,
HYDROSET XT 3CC BONE SUBSTITUTE/897003,69162935,CDM,278,RC,C1713,HCPCS,Outpatient,,,3600.23,3600.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160.14,60,,1728.11,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.88,84.88,,2444.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700.17,75,,2160.14,percent of total billed charges,75% of total billed charges for outpatient setting,1800.12,50,,1440.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.27,12.84,,369.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880.18,80,,2304.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.27,12.84,,369.82,percent of total billed charges,12.84% of total billed charges,462.27,12.84,,369.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780.24,105,,3024.19,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260.08,35,,1008.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160.14,60,,1728.11,percent of total billed charges,60% of total billed charges for outpatient setting,462.27,3780.24,
HYDROSET XT 5CC BONE SUBSTITUTE/897005,69169231,CDM,278,RC,C1713,HCPCS,Outpatient,,,2863.6,2863.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1718.16,60,,1374.53,percent of total billed charges,60% of total Billed charges for outpatient setting,2430.62,84.88,,1944.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2147.7,75,,1718.16,percent of total billed charges,75% of total billed charges for outpatient setting,1431.8,50,,1145.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.69,12.84,,294.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2290.88,80,,1832.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.69,12.84,,294.15,percent of total billed charges,12.84% of total billed charges,367.69,12.84,,294.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3006.78,105,,2405.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.26,35,,801.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1718.16,60,,1374.53,percent of total billed charges,60% of total billed charges for outpatient setting,367.69,3006.78,
HYDROXYCHLOROQUINE (PLAQUENIL) TAB : 200,3301251,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYCHLOROQUINE (PLAQUENIL) TAB 200MG,3301252,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
HYDROXYZINE (ATARAX) INJ 50MG/ML :1ML,3301259,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) INJ: 25MG,3301258,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) TAB : 10 MG,3301255,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) TAB : 25 MG,3301254,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) TAB : 25 MG,3301257,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) TAB : 25MG U/D,3301261,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HYDROXYZINE (ATARAX) TAB :10MG,3301253,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDROXYZINE (ATARAX) TAB 10 MG  U/D,3301256,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HYDROXYZINE (VISTARIL)  CAP 25MG,3309135,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROXYZINE 50MG PER ML  INJ  1ML,3302624,CDM,636,RC,J3410,HCPCS,Outpatient,,,103.71,103.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.6,70,,58.08,percent of total billed charges,70% of total billed charges for outpatient setting,88.03,84.88,,70.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.78,75,,62.22,percent of total billed charges,75% of total billed charges for outpatient setting,72.6,70,,58.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,12.84,,10.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.97,80,,66.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,13.32,12.84,,10.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.41,65,,53.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.37,100,,,Fee Schedule,100% of Custom Fee Schedule,93.34,90,,74.67,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,93.34,
HYDROXYZINE genericVISTARIL 50MG CAP,3302626,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYDROXYZINE INJ 25MG/ML: 1ML,3302625,CDM,250,RC,,,Outpatient,,,43.67,43.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,37.07,84.88,,29.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.84,50,,17.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.75,75,,26.2,percent of total billed charges,75% of total billed charges for outpatient setting,30.57,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.94,80,,27.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.39,65,,22.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,35,,12.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.3,90,,31.44,percent of total billed charges,90% of total billed charges for outpatient setting,5.61,39.3,
HYDROXYZINE INJ 50MG/ML :1ML,3301260,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
HYDRUS MICROSTENT / F00022,69169723,CDM,278,RC,C1783,HCPCS,Outpatient,,,3604,3604,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2162.4,60,,1729.92,percent of total billed charges,60% of total Billed charges for outpatient setting,3059.08,84.88,,2447.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2703,75,,2162.4,percent of total billed charges,75% of total billed charges for outpatient setting,1802,50,,1441.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.75,12.84,,370.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2883.2,80,,2306.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.75,12.84,,370.2,percent of total billed charges,12.84% of total billed charges,462.75,12.84,,370.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3784.2,105,,3027.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.4,35,,1009.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2162.4,60,,1729.92,percent of total billed charges,60% of total billed charges for outpatient setting,462.75,3784.2,
HYOSCYAMINE  0.375MG (LEVBID):TAB,3302853,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
HYOSCYAMINE 0.125 MG TAB,3302807,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
HYPERTONIC SALINE:3% SODIUM CL,3303230,CDM,250,RC,,,Outpatient,,,174.41,174.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.09,70,,97.67,percent of total billed charges,70% of total billed charges for outpatient setting,148.04,84.88,,118.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,87.21,50,,69.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.81,75,,104.65,percent of total billed charges,75% of total billed charges for outpatient setting,122.09,70,,97.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.39,12.84,,17.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.53,80,,111.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.39,12.84,,17.91,percent of total billed charges,12.84% of total billed charges,22.39,12.84,,17.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,113.37,65,,90.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,35,,48.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,156.97,90,,125.58,percent of total billed charges,90% of total billed charges for outpatient setting,22.39,156.97,
HYPROMELLOSE OPTH(GONAK)  2.5% 15ML,3302672,CDM,259,RC,,,Outpatient,,,108.17,108.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.72,70,,60.58,percent of total billed charges,70% of total billed charges for outpatient setting,91.81,84.88,,73.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.09,50,,43.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.13,75,,64.9,percent of total billed charges,75% of total billed charges for outpatient setting,75.72,70,,60.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.89,12.84,,11.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.54,80,,69.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.89,12.84,,11.11,percent of total billed charges,12.84% of total billed charges,13.89,12.84,,11.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.31,65,,56.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.86,35,,30.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.35,90,,77.88,percent of total billed charges,90% of total billed charges for outpatient setting,13.89,97.35,
HYROCORTISONE(SOLU-CORTEF):250 MG,3302781,CDM,250,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
HYZAAR (LOSARTAN/HYDROCHLOR)50-12.5:TAB,3302947,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
HYZAAR 100/25: TAB,3302888,CDM,259,RC,,,Outpatient,,,11.87,11.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.9,75,,7.12,percent of total billed charges,75% of total billed charges for outpatient setting,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,35,,3.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.68,90,,8.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,10.68,
I/A 0.3MM TRNSFRMR INTREPID / 8065752885,69169896,CDM,272,RC,,,Outpatient,,,125.4,125.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.78,70,,70.22,percent of total billed charges,70% of total billed charges for outpatient setting,106.44,84.88,,85.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.7,50,,50.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.05,75,,75.24,percent of total billed charges,75% of total billed charges for outpatient setting,87.78,70,,70.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,12.84,,12.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.32,80,,80.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,12.84,,12.88,percent of total billed charges,12.84% of total billed charges,16.1,12.84,,12.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.51,65,,65.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.89,35,,35.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.86,90,,90.29,percent of total billed charges,90% of total billed charges for outpatient setting,16.1,112.86,
IA-2 ANITBODY,203260,CDM,310,RC,86341,HCPCS,Outpatient,,,106.07,95.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,90.03,84.88,,72.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.55,75,,63.64,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.86,80,,67.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.52,100,,,Fee Schedule,100% of Custom Fee Schedule,95.46,90,,76.37,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,95.46,
IBUPROFEN (genericMOTRIN) 800MG TAB,3313445,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
IBUPROFEN (MOTRIN) LIQ : 100 MG,3301276,CDM,259,RC,,,Outpatient,,,5.19,5.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,70,,2.9,percent of total billed charges,70% of total billed charges for outpatient setting,4.41,84.88,,3.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.6,50,,2.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.89,75,,3.11,percent of total billed charges,75% of total billed charges for outpatient setting,3.63,70,,2.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,80,,3.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.67,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.37,65,,2.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,35,,1.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.67,90,,3.74,percent of total billed charges,90% of total billed charges for outpatient setting,0.67,4.67,
IBUPROFEN (MOTRIN) TAB : 400 MG,3301264,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 400 MG,3301266,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 600 MG,3301263,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 600 MG,3301265,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 800 MG,3301269,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 800 MG,3301272,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB : 800 MG   U/D,3301270,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB 200 MG,3301262,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
IBUPROFEN (MOTRIN) TAB 400 MG,3301268,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
IBUPROFEN (MOTRIN) TAB: 200 MG,3301267,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB: 600 MG,3301274,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
IBUPROFEN (MOTRIN) TAB: 800 MG,3301275,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN (MOTRIN) TAB:800MG UD,3301273,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IBUPROFEN MOTRIN 100MG PER 5ML 120ML,3301271,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
I-CAR C TAB,3302952,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ICD BATTERY D224VRC,69161443,CDM,275,RC,C1722,HCPCS,Outpatient,,,33000,33000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23100,70,,18480,percent of total billed charges,70% of total billed charges for outpatient setting,28010.4,84.88,,22408.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24750,75,,19800,percent of total billed charges,75% of total billed charges for outpatient setting,16500,50,,13200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26400,80,,21120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34650,105,,27720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11550,35,,9240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29700,90,,23760,percent of total billed charges,90% of total billed charges for outpatient setting,4237.2,34650,
ICD GENERATOR  D274DRG,69161295,CDM,275,RC,C1721,HCPCS,Outpatient,,,40560,40560,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28392,70,,22713.6,percent of total billed charges,70% of total billed charges for outpatient setting,34427.33,84.88,,27541.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30420,75,,24336,percent of total billed charges,75% of total billed charges for outpatient setting,20280,50,,16224,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5207.9,12.84,,4166.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32448,80,,25958.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5207.9,12.84,,4166.32,percent of total billed charges,12.84% of total billed charges,5207.9,12.84,,4166.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42588,105,,34070.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14196,35,,11356.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36504,90,,29203.2,percent of total billed charges,90% of total billed charges for outpatient setting,5207.9,42588,
ICD-DR GENERATOR EVERA XT DDBB1D4,69162205,CDM,275,RC,C1721,HCPCS,Outpatient,,,38413.28,38413.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26889.3,70,,21511.44,percent of total billed charges,70% of total billed charges for outpatient setting,32605.19,84.88,,26084.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28809.96,75,,23047.97,percent of total billed charges,75% of total billed charges for outpatient setting,19206.64,50,,15365.31,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4932.27,12.84,,3945.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30730.62,80,,24584.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4932.27,12.84,,3945.82,percent of total billed charges,12.84% of total billed charges,4932.27,12.84,,3945.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40333.94,105,,32267.15,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13444.65,35,,10755.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34571.95,90,,27657.56,percent of total billed charges,90% of total billed charges for outpatient setting,4932.27,40333.94,
IDRIVE ADAPTER STANDARD / EGIAADAPT,69161919,CDM,272,RC,,,Outpatient,,,259.56,259.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.69,70,,145.35,percent of total billed charges,70% of total billed charges for outpatient setting,220.31,84.88,,176.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.67,75,,155.74,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,70,,145.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,80,,166.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.71,65,,134.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,35,,72.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.6,90,,186.88,percent of total billed charges,90% of total billed charges for outpatient setting,33.33,233.6,
IDRIVE ADAPTER XL / EGIAADAPTXL,69161918,CDM,272,RC,,,Outpatient,,,311.47,311.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.03,70,,174.42,percent of total billed charges,70% of total billed charges for outpatient setting,264.38,84.88,,211.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,155.74,50,,124.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,233.6,75,,186.88,percent of total billed charges,75% of total billed charges for outpatient setting,218.03,70,,174.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.99,12.84,,31.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.18,80,,199.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.99,12.84,,31.99,percent of total billed charges,12.84% of total billed charges,39.99,12.84,,31.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,202.46,65,,161.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.01,35,,87.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,280.32,90,,224.26,percent of total billed charges,90% of total billed charges for outpatient setting,39.99,280.32,
IDRIVE BATTERY PACK / INTB100,69161920,CDM,271,RC,,,Outpatient,,,12.17,12.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.52,70,,6.82,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,84.88,,8.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.09,50,,4.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.13,75,,7.3,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,70,,6.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.56,12.84,,1.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.74,80,,7.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.56,12.84,,1.25,percent of total billed charges,12.84% of total billed charges,1.56,12.84,,1.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.91,65,,6.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,35,,3.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.95,90,,8.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.56,10.95,
IDRIVE ULTRA HANDLE / IDRVULTRA,69161917,CDM,272,RC,,,Outpatient,,,389.34,389.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,330.47,84.88,,264.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.67,50,,155.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.01,75,,233.61,percent of total billed charges,75% of total billed charges for outpatient setting,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,80,,249.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,35,,109.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.41,90,,280.33,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,350.41,
IGA QUANT,220314,CDM,301,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
IGE QUANT,220295,CDM,300,RC,82785,HCPCS,Outpatient,,,74.07,66.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.85,70,,41.48,percent of total billed charges,70% of total billed charges for outpatient setting,62.87,84.88,,50.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.55,75,,44.44,percent of total billed charges,75% of total billed charges for outpatient setting,51.85,70,,41.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.26,80,,47.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.05,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,100,,,Fee Schedule,100% of Custom Fee Schedule,66.66,90,,53.33,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,66.66,
IGF-1 INSULIN GROWTH FACTOR 1,220311,CDM,300,RC,84305,HCPCS,Outpatient,,,95.67,86.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.97,70,,53.58,percent of total billed charges,70% of total billed charges for outpatient setting,81.2,84.88,,64.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.75,75,,57.4,percent of total billed charges,75% of total billed charges for outpatient setting,66.97,70,,53.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.54,80,,61.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.24,100,,,Fee Schedule,100% of Custom Fee Schedule,86.1,90,,68.88,percent of total billed charges,90% of total billed charges for outpatient setting,21.26,86.1,
"IGF-BP3, IGF BNDNG PRTN 3",220312,CDM,300,RC,82397,HCPCS,Outpatient,,,63.54,57.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,53.93,84.88,,43.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.66,75,,38.13,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,80,,40.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,57.19,90,,45.75,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,57.19,
IGG QUANT,220313,CDM,301,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
"IgG SYNTHESIS RATE,CSF",202370,CDM,310,RC,,,Outpatient,,,64.47,58.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.13,70,,36.1,percent of total billed charges,70% of total billed charges for outpatient setting,54.72,84.88,,43.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.24,50,,25.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.35,75,,38.68,percent of total billed charges,75% of total billed charges for outpatient setting,45.13,70,,36.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,12.84,,6.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.58,80,,41.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,8.28,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,35,,18.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.02,90,,46.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.28,58.02,
IGM QUANT,220310,CDM,301,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
ILOPAN (DEXPANTHENOL)250 MG/ML:2 ML,3302744,CDM,250,RC,,,Outpatient,,,19.53,19.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.67,70,,10.94,percent of total billed charges,70% of total billed charges for outpatient setting,16.58,84.88,,13.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.77,50,,7.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.65,75,,11.72,percent of total billed charges,75% of total billed charges for outpatient setting,13.67,70,,10.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.62,80,,12.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.69,65,,10.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,35,,5.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.58,90,,14.06,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,17.58,
IM INJECTION,6000030,CDM,260,RC,96372,HCPCS,Outpatient,,,293.1,293.1,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,205.17,70,,164.14,percent of total billed charges,70% of total billed charges for outpatient setting,248.78,84.88,,199.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,219.83,75,,175.86,percent of total billed charges,75% of total billed charges for outpatient setting,205.17,70,,164.14,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,37.63,12.84,,30.104,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,234.48,80,,187.58,percent of total billed charges,80% of total billed charges for outpatient setting,77.78,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,37.63,12.84,,30.1,percent of total billed charges,12.84% of total billed charges,37.63,12.84,,30.1,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,263.79,90,,211.03,percent of total billed charges,90% of total billed charges for outpatient setting,37.63,263.79,
IM or SUBCUTANEOUS INJECTION,5100015,CDM,260,RC,96372,HCPCS,Outpatient,,,298.96,298.96,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,253.76,84.88,,203.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,224.22,75,,179.38,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.39,12.84,,30.712,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239.17,80,,191.34,percent of total billed charges,80% of total billed charges for outpatient setting,77.78,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,269.06,90,,215.25,percent of total billed charges,90% of total billed charges for outpatient setting,38.39,269.06,
IMIPENEM & CILASTATIN (PRIMAXIN):250MG,3303194,CDM,636,RC,J0740,HCPCS,Outpatient,,,1496.1,1496.1,,988.11,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1047.27,70,,837.82,percent of total billed charges,70% of total billed charges for outpatient setting,1269.89,84.88,,1015.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,600.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.08,75,,897.66,percent of total billed charges,75% of total billed charges for outpatient setting,1047.27,70,,837.82,percent of total billed charges,70% of total billed charges for outpatient setting,1049.84,170,,,Fee Schedule,170% of Medicare OPPS rate,1327.77,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.1,12.84,,153.68,percent of total billed charges,12.84% of total billed charges,1080.74,175,,,Fee Schedule,175% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1196.88,80,,957.5,percent of total billed charges,80% of total billed charges for outpatient setting,864.59,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,771.96,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.1,12.84,,153.68,percent of total billed charges,12.84% of total billed charges,192.1,12.84,,153.68,percent of total billed charges,12.84% of total billed charges,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,972.47,65,,777.98,percent of total billed charges,65% of total billed charges for outpatient setting,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,777.02,100,,,Fee Schedule,100% of Custom Fee Schedule,1346.49,90,,1077.19,percent of total billed charges,90% of total billed charges for outpatient setting,192.1,1346.49,
IMIPENEM (PRIMAXIN) INJ : 250 MG,3301277,CDM,250,RC,,,Outpatient,,,112.55,112.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.79,70,,63.03,percent of total billed charges,70% of total billed charges for outpatient setting,95.53,84.88,,76.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.28,50,,45.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.41,75,,67.53,percent of total billed charges,75% of total billed charges for outpatient setting,78.79,70,,63.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,12.84,,11.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.04,80,,72.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,12.84,,11.56,percent of total billed charges,12.84% of total billed charges,14.45,12.84,,11.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.16,65,,58.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.39,35,,31.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.3,90,,81.04,percent of total billed charges,90% of total billed charges for outpatient setting,14.45,101.3,
IMIPENEM (PRIMAXIN)/NS IVPB: 500MG/100ML,3303350,CDM,636,RC,J0740,HCPCS,Outpatient,,,158.41,158.41,,988.11,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,110.89,70,,88.71,percent of total billed charges,70% of total billed charges for outpatient setting,134.46,84.88,,107.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,600.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,118.81,75,,95.05,percent of total billed charges,75% of total billed charges for outpatient setting,110.89,70,,88.71,percent of total billed charges,70% of total billed charges for outpatient setting,1049.84,170,,,Fee Schedule,170% of Medicare OPPS rate,1327.77,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,20.34,12.84,,16.272,percent of total billed charges,12.84% of total billed charges,1080.74,175,,,Fee Schedule,175% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.73,80,,101.38,percent of total billed charges,80% of total billed charges for outpatient setting,864.59,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,771.96,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,20.34,12.84,,16.27,percent of total billed charges,12.84% of total billed charges,20.34,12.84,,16.27,percent of total billed charges,12.84% of total billed charges,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,102.97,65,,82.38,percent of total billed charges,65% of total billed charges for outpatient setting,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,617.57,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,777.02,100,,,Fee Schedule,100% of Custom Fee Schedule,142.57,90,,114.06,percent of total billed charges,90% of total billed charges for outpatient setting,20.34,1327.77,
IMIPENEM (PRIMAXIN)500MG: VIAL,3301278,CDM,636,RC,J0743,HCPCS,Outpatient,,,158.41,158.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.89,70,,88.71,percent of total billed charges,70% of total billed charges for outpatient setting,134.46,84.88,,107.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.81,75,,95.05,percent of total billed charges,75% of total billed charges for outpatient setting,110.89,70,,88.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.34,12.84,,16.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.73,80,,101.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.34,12.84,,16.27,percent of total billed charges,12.84% of total billed charges,20.34,12.84,,16.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.97,65,,82.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,100,,,Fee Schedule,100% of Custom Fee Schedule,142.57,90,,114.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,142.57,
IMIPRAMINE (TOFRANIL) TAB : 10 MG,3301279,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
IMIPRAMINE (TOFRANIL) TAB : 25 MG,3301280,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IMIPRAMINE (TOFRANIL) TAB : 25 MG  U/D,3301281,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
IMMOBILIZER 20IN KNEE / 79-80020,6150168,CDM,270,RC,,,Outpatient,,,95.34,95.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.74,70,,53.39,percent of total billed charges,70% of total billed charges for outpatient setting,80.92,84.88,,64.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.67,50,,38.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.51,75,,57.21,percent of total billed charges,75% of total billed charges for outpatient setting,66.74,70,,53.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,12.84,,9.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,80,,61.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,12.84,,9.79,percent of total billed charges,12.84% of total billed charges,12.24,12.84,,9.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.97,65,,49.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.37,35,,26.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.81,90,,68.65,percent of total billed charges,90% of total billed charges for outpatient setting,12.24,85.81,
IMMUNIZATION ADM IM SQ EA ADDITIONAL,5100024,CDM,771,RC,90472,HCPCS,Outpatient,,,42.74,42.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.92,70,,23.94,percent of total billed charges,70% of total billed charges for outpatient setting,36.28,84.88,,29.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.06,75,,25.65,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,70,,23.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.19,80,,27.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.78,65,,22.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.47,90,,30.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,38.47,
IMMUNIZATION ADMINISTRATION IM SQ,5100020,CDM,771,RC,90471,HCPCS,Outpatient,,,88.63,88.63,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,62.04,70,,49.63,percent of total billed charges,70% of total billed charges for outpatient setting,75.23,84.88,,60.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.47,75,,53.18,percent of total billed charges,75% of total billed charges for outpatient setting,62.04,70,,49.63,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.38,12.84,,9.104,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,70.9,80,,56.72,percent of total billed charges,80% of total billed charges for outpatient setting,77.78,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.38,12.84,,9.1,percent of total billed charges,12.84% of total billed charges,11.38,12.84,,9.1,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,57.61,65,,46.09,percent of total billed charges,65% of total billed charges for outpatient setting,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,79.77,90,,63.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.38,119.45,
IMMUNIZATION VACC ADMIN IM SQ EA ADDTL,5100023,CDM,771,RC,90472,HCPCS,Outpatient,,,88.63,88.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.04,70,,49.63,percent of total billed charges,70% of total billed charges for outpatient setting,75.23,84.88,,60.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.47,75,,53.18,percent of total billed charges,75% of total billed charges for outpatient setting,62.04,70,,49.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,12.84,,9.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.9,80,,56.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,12.84,,9.1,percent of total billed charges,12.84% of total billed charges,11.38,12.84,,9.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.61,65,,46.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.77,90,,63.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.38,79.77,
"IMMUNOASSAY,ANALYTE,QUANTITATIVE;NOS",200966,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
IMMUNOASSAY/ANALYTE,200244,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
IMMUNOBLOT,200464,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
IMMUNOELECTROPHORESIS,200983,CDM,300,RC,86334,HCPCS,Outpatient,,,100.53,90.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.37,70,,56.3,percent of total billed charges,70% of total billed charges for outpatient setting,85.33,84.88,,68.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,75.4,75,,60.32,percent of total billed charges,75% of total billed charges for outpatient setting,70.37,70,,56.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.42,80,,64.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.37,100,,,Fee Schedule,100% of Custom Fee Schedule,90.48,90,,72.38,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,90.48,
IMMUNOELECTROPHORESIS  CSF,200982,CDM,300,RC,86325,HCPCS,Outpatient,,,104.09,93.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,88.35,84.88,,70.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.07,75,,62.46,percent of total billed charges,75% of total billed charges for outpatient setting,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.27,80,,66.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.41,100,,,Fee Schedule,100% of Custom Fee Schedule,93.68,90,,74.94,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,93.68,
IMMUNOELECTROPHORESIS  SERUM,220409,CDM,300,RC,86320,HCPCS,Outpatient,,,134.64,121.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.25,70,,75.4,percent of total billed charges,70% of total billed charges for outpatient setting,114.28,84.88,,91.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,100.98,75,,80.78,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,70,,75.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.71,80,,86.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.72,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.51,100,,,Fee Schedule,100% of Custom Fee Schedule,121.18,90,,96.94,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,121.18,
IMMUNOELECTROPHORESIS URINE,220410,CDM,300,RC,86325,HCPCS,Outpatient,,,104.09,93.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,88.35,84.88,,70.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.07,75,,62.46,percent of total billed charges,75% of total billed charges for outpatient setting,72.86,70,,58.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.27,80,,66.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.41,100,,,Fee Schedule,100% of Custom Fee Schedule,93.68,90,,74.94,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,93.68,
IMMUNOFIXATION ELECTROPHORESIS SERUM,220832,CDM,300,RC,86334,HCPCS,Outpatient,,,100.53,90.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.37,70,,56.3,percent of total billed charges,70% of total billed charges for outpatient setting,85.33,84.88,,68.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,75.4,75,,60.32,percent of total billed charges,75% of total billed charges for outpatient setting,70.37,70,,56.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.42,80,,64.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.37,100,,,Fee Schedule,100% of Custom Fee Schedule,90.48,90,,72.38,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,90.48,
IMMUNOFIXATION ELECTROPHORESIS URINE,200776,CDM,300,RC,86335,HCPCS,Outpatient,,,132.08,118.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,112.11,84.88,,89.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.06,75,,79.25,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.66,80,,84.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.66,100,,,Fee Schedule,100% of Custom Fee Schedule,118.87,90,,95.1,percent of total billed charges,90% of total billed charges for outpatient setting,16.96,118.87,
"IMMUNOFIXATION ELECTROPHORESIS, CSF",200777,CDM,300,RC,86335,HCPCS,Outpatient,,,132.08,118.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,112.11,84.88,,89.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.06,75,,79.25,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.66,80,,84.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.66,100,,,Fee Schedule,100% of Custom Fee Schedule,118.87,90,,95.1,percent of total billed charges,90% of total billed charges for outpatient setting,16.96,118.87,
"IMMUNOFIXATION ELECTROPHORESIS, URINE",220897,CDM,300,RC,86335,HCPCS,Outpatient,,,132.08,118.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,112.11,84.88,,89.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.06,75,,79.25,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,70,,73.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.66,80,,84.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,16.96,12.84,,13.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.66,100,,,Fee Schedule,100% of Custom Fee Schedule,118.87,90,,95.1,percent of total billed charges,90% of total billed charges for outpatient setting,16.96,118.87,
IMMUNOFLUORESCENT STUDY 1ST AB,200401,CDM,310,RC,88346,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,1044.92,
IMMUNOFLUORESCENT STUDY DIRECT METHOD,900036,CDM,310,RC,88346,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,1044.92,
IMMUNOGLOBULIN SUBCLASSES IGG 1 2 3 4 EA,200897,CDM,300,RC,82787,HCPCS,Outpatient,,,36.09,32.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.26,70,,20.21,percent of total billed charges,70% of total billed charges for outpatient setting,30.63,84.88,,24.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.07,75,,21.66,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,70,,20.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.87,80,,23.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.71,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,100,,,Fee Schedule,100% of Custom Fee Schedule,32.48,90,,25.98,percent of total billed charges,90% of total billed charges for outpatient setting,6.75,32.48,
IMMUNOGLOBULINS G A M E,200985,CDM,300,RC,82784,HCPCS,Outpatient,,,41.85,37.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,35.52,84.88,,28.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.39,75,,25.11,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,70,,23.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.48,80,,26.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.58,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,100,,,Fee Schedule,100% of Custom Fee Schedule,37.67,90,,30.14,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,37.67,
IMMUNOGLOBULINS G A M E,200987,CDM,300,RC,82785,HCPCS,Outpatient,,,74.07,66.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.85,70,,41.48,percent of total billed charges,70% of total billed charges for outpatient setting,62.87,84.88,,50.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.55,75,,44.44,percent of total billed charges,75% of total billed charges for outpatient setting,51.85,70,,41.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.26,80,,47.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.05,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,100,,,Fee Schedule,100% of Custom Fee Schedule,66.66,90,,53.33,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,66.66,
IMMUNOHISTOCHEMISTRY EA ADDTL ANTIBODY,900046,CDM,310,RC,88341,HCPCS,Outpatient,,,77.62,69.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,70,,43.46,percent of total billed charges,70% of total billed charges for outpatient setting,65.88,84.88,,52.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.22,75,,46.58,percent of total billed charges,75% of total billed charges for outpatient setting,54.33,70,,43.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.1,80,,49.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.86,90,,55.89,percent of total billed charges,90% of total billed charges for outpatient setting,54.33,69.86,
IMMUNOHISTOCHEMISTRY EA MULTIPLEX STAIN,900047,CDM,310,RC,88344,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,134.72,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,103.69,1044.92,
IMMUNOHISTOCHEMISTRY EACH ANTIBODY,900035,CDM,310,RC,88342,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.41,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,49.84,535.12,
IMPLANT 160CC BREAST / 10610-160LP,1816836,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 310CC BREAST / 10610-310LP,2169366,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 320CC LUXE BREAST / 10610-320LPP,7670528,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 340CC BREAST / 10610-340LP,2241565,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 370CC BREAST / 10610-370LP,2241566,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 375CC NATRELLE / SRM375,1758438,CDM,278,RC,C1789,HCPCS,Outpatient,,,3307.5,3307.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,60,,1587.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2807.41,84.88,,2245.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2480.63,75,,1984.5,percent of total billed charges,75% of total billed charges for outpatient setting,1653.75,50,,1323,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2646,80,,2116.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3472.88,105,,2778.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.63,35,,926.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1984.5,60,,1587.6,percent of total billed charges,60% of total billed charges for outpatient setting,424.68,3472.88,
IMPLANT 400CC BREAST / 10610-400LP,2241567,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 435CC BREAST / 10621-435MP,1665178,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 475CC BREAST / 10610-475LP,7210498,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 485CC BREAST / 10621-485MP,1738764,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 500CC BREAST / 10610-500LP,2241569,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT 590CC BREAST / 10621-590MP,2143335,CDM,278,RC,C1789,HCPCS,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,60,,924,percent of total billed charges,60% of total Billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1925,65,,1540,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1155,60,,924,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,1925,
IMPLANT BENGAL 4MM 7DEG / 1873-01-104,70000352,CDM,278,RC,C1713,HCPCS,Outpatient,,,2620,2620,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572,60,,1257.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2223.86,84.88,,1779.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965,75,,1572,percent of total billed charges,75% of total billed charges for outpatient setting,1310,50,,1048,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096,80,,1676.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2751,105,,2200.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917,35,,733.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1572,60,,1257.6,percent of total billed charges,60% of total billed charges for outpatient setting,336.41,2751,
IMPLANT BENGAL 5MM 7DEG / 1873-01-105,70000481,CDM,278,RC,C1713,HCPCS,Outpatient,,,2620,2620,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572,60,,1257.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2223.86,84.88,,1779.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965,75,,1572,percent of total billed charges,75% of total billed charges for outpatient setting,1310,50,,1048,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096,80,,1676.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2751,105,,2200.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917,35,,733.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1572,60,,1257.6,percent of total billed charges,60% of total billed charges for outpatient setting,336.41,2751,
IMPLANT BENGAL 6MM 7DEG / 1873-01-106,69169133,CDM,278,RC,C1713,HCPCS,Outpatient,,,2620,2620,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572,60,,1257.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2223.86,84.88,,1779.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965,75,,1572,percent of total billed charges,75% of total billed charges for outpatient setting,1310,50,,1048,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096,80,,1676.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,336.41,12.84,,269.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2751,105,,2200.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917,35,,733.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1572,60,,1257.6,percent of total billed charges,60% of total billed charges for outpatient setting,336.41,2751,
IMPLANT FINGER JOINT SWANSON / 4700001,71000032,CDM,278,RC,C1776,HCPCS,Outpatient,,,3352,3352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.2,60,,1608.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2845.18,84.88,,2276.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2514,75,,2011.2,percent of total billed charges,75% of total billed charges for outpatient setting,1676,50,,1340.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2681.6,80,,2145.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3519.6,105,,2815.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1173.2,35,,938.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2011.2,60,,1608.96,percent of total billed charges,60% of total billed charges for outpatient setting,430.4,3519.6,
IMPLANT FINGER JOINT SWANSON / 4700002,71000031,CDM,278,RC,C1776,HCPCS,Outpatient,,,3352,3352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.2,60,,1608.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2845.18,84.88,,2276.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2514,75,,2011.2,percent of total billed charges,75% of total billed charges for outpatient setting,1676,50,,1340.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2681.6,80,,2145.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3519.6,105,,2815.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1173.2,35,,938.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2011.2,60,,1608.96,percent of total billed charges,60% of total billed charges for outpatient setting,430.4,3519.6,
IMPLANT FINGER JOINT SWANSON / 4700010,71000030,CDM,278,RC,C1776,HCPCS,Outpatient,,,3352,3352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.2,60,,1608.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2845.18,84.88,,2276.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2514,75,,2011.2,percent of total billed charges,75% of total billed charges for outpatient setting,1676,50,,1340.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2681.6,80,,2145.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,430.4,12.84,,344.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3519.6,105,,2815.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1173.2,35,,938.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2011.2,60,,1608.96,percent of total billed charges,60% of total billed charges for outpatient setting,430.4,3519.6,
IMPLANT SYS PARS SUTURE / AR-8860DS,69162518,CDM,272,RC,,,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.26,70,,1589.81,percent of total billed charges,70% of total billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1987.26,70,,1589.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1845.31,65,,1476.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.63,35,,794.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2555.05,90,,2044.04,percent of total billed charges,90% of total billed charges for outpatient setting,364.52,2555.05,
IMPLANTED VAD FLUSH,5100021,CDM,260,RC,96523,HCPCS,Outpatient,,,180,180,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,96.33,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IMPLANTS TOTAL KNEE,69162641,CDM,278,RC,C1776,HCPCS,Outpatient,,,7275,7275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4365,60,,3492,percent of total billed charges,60% of total Billed charges for outpatient setting,6175.02,84.88,,4940.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456.25,75,,4365,percent of total billed charges,75% of total billed charges for outpatient setting,3637.5,50,,2910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.11,12.84,,747.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5820,80,,4656,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.11,12.84,,747.29,percent of total billed charges,12.84% of total billed charges,934.11,12.84,,747.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7638.75,105,,6111,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2546.25,35,,2037,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4365,60,,3492,percent of total billed charges,60% of total billed charges for outpatient setting,934.11,7638.75,
IN SITU HYBRIDIZATION SPECIMEN,900042,CDM,310,RC,88364,HCPCS,Outpatient,,,102.46,92.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.72,70,,57.38,percent of total billed charges,70% of total billed charges for outpatient setting,86.97,84.88,,69.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.85,75,,61.48,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,70,,57.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.97,80,,65.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.21,90,,73.77,percent of total billed charges,90% of total billed charges for outpatient setting,71.72,92.21,
INCENTIVE SPIROMETRY,1300100,CDM,460,RC,94664,HCPCS,Outpatient,,,332.86,332.86,,269.5,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,282.53,84.88,,226.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,249.65,75,,199.72,percent of total billed charges,75% of total billed charges for outpatient setting,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,286.34,170,,,Fee Schedule,170% of Medicare OPPS rate,362.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.74,12.84,,34.192,percent of total billed charges,12.84% of total billed charges,294.76,175,,,Fee Schedule,175% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.29,80,,213.03,percent of total billed charges,80% of total billed charges for outpatient setting,235.81,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,210.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,143,100,,,Case rate,pays based on fixed rate ,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.01,100,,,Fee Schedule,100% of Custom Fee Schedule,299.57,90,,239.66,percent of total billed charges,90% of total billed charges for outpatient setting,42.74,362.14,
INCENTIVE SPROMETRG,1300040,CDM,410,RC,94664,HCPCS,Outpatient,,,332.86,332.86,,269.5,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,282.53,84.88,,226.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,249.65,75,,199.72,percent of total billed charges,75% of total billed charges for outpatient setting,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,286.34,170,,,Fee Schedule,170% of Medicare OPPS rate,362.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.74,12.84,,34.192,percent of total billed charges,12.84% of total billed charges,294.76,175,,,Fee Schedule,175% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.29,80,,213.03,percent of total billed charges,80% of total billed charges for outpatient setting,235.81,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,210.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181,100,,,Case rate,pays based on fixed rate ,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.01,100,,,Fee Schedule,100% of Custom Fee Schedule,299.57,90,,239.66,percent of total billed charges,90% of total billed charges for outpatient setting,42.74,362.14,
INCLISIRAN (LEQVIO) 284MG/1.5ML INJ,3314045,CDM,636,RC,J1306,HCPCS,Outpatient,,,11661.16,11661.16,,19.28,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8162.81,70,,6530.25,percent of total billed charges,70% of total billed charges for outpatient setting,9897.99,84.88,,7918.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,5830.58,50,,4664.46,percent of total billed charges,50% of total Billed charges for outpatient setting,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8745.87,75,,6996.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,20.48,170,,,Fee Schedule,170% of Medicare OPPS rate,25.9,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,1497.29,12.84,,1197.832,percent of total billed charges,12.84% of total billed charges,21.08,175,,,Fee Schedule,175% of Medicare OPPS rate,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,9328.93,80,,7463.14,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,15.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,1497.29,12.84,,1197.83,percent of total billed charges,12.84% of total billed charges,1497.29,12.84,,1197.83,percent of total billed charges,12.84% of total billed charges,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7579.75,65,,6063.8,percent of total billed charges,65% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.05,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4081.41,35,,3265.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10495.04,90,,8396.03,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,10495.04,
INDAPAMIDE (LOZOL) 1.25MG: TAB,3303044,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
INDERAL 160 MG (PROPRANOLOL),3303165,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
INDIA INK PREPARATION,201069,CDM,300,RC,87210,HCPCS,Outpatient,,,26.19,23.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,22.23,84.88,,17.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.64,75,,15.71,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.95,80,,16.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,23.57,90,,18.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,23.57,
INDIGO CARMINE:0.8%,3302772,CDM,259,RC,,,Outpatient,,,94.64,94.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.25,70,,53,percent of total billed charges,70% of total billed charges for outpatient setting,80.33,84.88,,64.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.32,50,,37.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.98,75,,56.78,percent of total billed charges,75% of total billed charges for outpatient setting,66.25,70,,53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,80,,60.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.52,65,,49.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,35,,26.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.18,90,,68.14,percent of total billed charges,90% of total billed charges for outpatient setting,12.15,85.18,
INDIGOTINDSULFTE (INDIGO) 0.8% INJ: 5ML,3301282,CDM,250,RC,,,Outpatient,,,24.26,24.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.59,84.88,,16.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.13,50,,9.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.2,75,,14.56,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,80,,15.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.77,65,,12.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,35,,6.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.83,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,21.83,
INDINAVIR (CRIXIVAN) CAP : 400 MG,3301283,CDM,259,RC,,,Outpatient,,,7.89,7.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,70,,4.42,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,84.88,,5.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.95,50,,3.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.92,75,,4.74,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,70,,4.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.31,80,,5.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.13,65,,4.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,35,,2.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.1,90,,5.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.01,7.1,
INDOCIN VIAL : 1 MG,3302712,CDM,250,RC,,,Outpatient,,,152.87,152.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.01,70,,85.61,percent of total billed charges,70% of total billed charges for outpatient setting,129.76,84.88,,103.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.44,50,,61.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.65,75,,91.72,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,70,,85.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,12.84,,15.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.3,80,,97.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,12.84,,15.7,percent of total billed charges,12.84% of total billed charges,19.63,12.84,,15.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.37,65,,79.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.5,35,,42.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.58,90,,110.06,percent of total billed charges,90% of total billed charges for outpatient setting,19.63,137.58,
INDOCYANINE GREEN  (ICG) 25 MG INJ,3302723,CDM,250,RC,,,Outpatient,,,543.33,543.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.33,70,,304.26,percent of total billed charges,70% of total billed charges for outpatient setting,461.18,84.88,,368.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,271.67,50,,217.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,407.5,75,,326,percent of total billed charges,75% of total billed charges for outpatient setting,380.33,70,,304.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.76,12.84,,55.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.66,80,,347.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.76,12.84,,55.81,percent of total billed charges,12.84% of total billed charges,69.76,12.84,,55.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,353.16,65,,282.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.17,35,,152.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,489,90,,391.2,percent of total billed charges,90% of total billed charges for outpatient setting,69.76,489,
INDOCYANINE GREEN (IC) INJ: 25 MG,3301284,CDM,250,RC,,,Outpatient,,,207.24,207.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.07,70,,116.06,percent of total billed charges,70% of total billed charges for outpatient setting,175.91,84.88,,140.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.62,50,,82.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.43,75,,124.34,percent of total billed charges,75% of total billed charges for outpatient setting,145.07,70,,116.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.61,12.84,,21.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.79,80,,132.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.61,12.84,,21.29,percent of total billed charges,12.84% of total billed charges,26.61,12.84,,21.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.71,65,,107.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.53,35,,58.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,186.52,90,,149.22,percent of total billed charges,90% of total billed charges for outpatient setting,26.61,186.52,
INDOMETHACIN (INDOCIN) CAP : 25 MG,3301285,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
INDOMETHACIN (INDOCIN) CAP : 75 MG,3301286,CDM,259,RC,,,Outpatient,,,4.92,4.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,84.88,,3.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.46,50,,1.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.69,75,,2.95,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,80,,3.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.2,65,,2.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.43,90,,3.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.63,4.43,
INDOMETHACIN 25MG: CAP,3303262,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
INFECTIOUS AGENT ANTIGEN;NOT SPECIFIED,200258,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
INFECTIOUS AGENT ANTIGEN;STREP GRP B,200257,CDM,310,RC,87802,HCPCS,Outpatient,,,57.29,51.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.1,70,,32.08,percent of total billed charges,70% of total billed charges for outpatient setting,48.63,84.88,,38.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.97,75,,34.38,percent of total billed charges,75% of total billed charges for outpatient setting,40.1,70,,32.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.83,80,,36.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,51.56,90,,41.25,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,51.56,
INFINITI  ULTRASOUND FMS / 8065741080,69160690,CDM,272,RC,,,Outpatient,,,227.12,227.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,192.78,84.88,,154.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.56,50,,90.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.34,75,,136.27,percent of total billed charges,75% of total billed charges for outpatient setting,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.7,80,,145.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.63,65,,118.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.49,35,,63.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.41,90,,163.53,percent of total billed charges,90% of total billed charges for outpatient setting,29.16,204.41,
INFLATION SYSTEM / 5060-05,6051164,CDM,272,RC,,,Outpatient,,,157.9,157.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.53,70,,88.42,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.95,50,,63.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.53,70,,88.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.27,12.84,,16.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.32,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.27,12.84,,16.22,percent of total billed charges,12.84% of total billed charges,20.27,12.84,,16.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.64,65,,82.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.27,35,,44.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,142.11,90,,113.69,percent of total billed charges,90% of total billed charges for outpatient setting,20.27,142.11,
INFLATOR KIT BALLOON SINUPLAS / 18INFKIT,69161895,CDM,272,RC,,,Outpatient,,,606.48,606.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.54,70,,339.63,percent of total billed charges,70% of total billed charges for outpatient setting,514.78,84.88,,411.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,303.24,50,,242.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.86,75,,363.89,percent of total billed charges,75% of total billed charges for outpatient setting,424.54,70,,339.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.87,12.84,,62.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.18,80,,388.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.87,12.84,,62.3,percent of total billed charges,12.84% of total billed charges,77.87,12.84,,62.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,394.21,65,,315.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.27,35,,169.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.83,90,,436.66,percent of total billed charges,90% of total billed charges for outpatient setting,77.87,545.83,
INFLIXIMAB (REMICADE)INJ 100MG (10MG/UN),3302965,CDM,636,RC,J1745,HCPCS,Outpatient,,,328.88,328.88,,56.03,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,230.22,70,,184.18,percent of total billed charges,70% of total billed charges for outpatient setting,279.15,84.88,,223.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.66,75,,197.33,percent of total billed charges,75% of total billed charges for outpatient setting,230.22,70,,184.18,percent of total billed charges,70% of total billed charges for outpatient setting,59.53,170,,,Fee Schedule,170% of Medicare OPPS rate,75.29,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.23,12.84,,33.784,percent of total billed charges,12.84% of total billed charges,61.28,175,,,Fee Schedule,175% of Medicare OPPS rate,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,263.1,80,,210.48,percent of total billed charges,80% of total billed charges for outpatient setting,49.02,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,43.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.77,65,,171.02,percent of total billed charges,65% of total billed charges for outpatient setting,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.4,100,,,Fee Schedule,100% of Custom Fee Schedule,295.99,90,,236.79,percent of total billed charges,90% of total billed charges for outpatient setting,35.02,295.99,
INFLIXIMAB(REMICADE) 10MG/UNIT (WASTAGE),3305387,CDM,636,RC,J1745,HCPCS,Outpatient,,,328.88,328.88,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.22,70,,184.18,percent of total billed charges,70% of total billed charges for outpatient setting,279.15,84.88,,223.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.44,50,,131.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.66,75,,197.33,percent of total billed charges,75% of total billed charges for outpatient setting,230.22,70,,184.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.23,12.84,,33.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.1,80,,210.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,213.77,65,,171.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.11,35,,92.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.99,90,,236.79,percent of total billed charges,90% of total billed charges for outpatient setting,42.23,295.99,
INFLOW TUBING SET (MYOSURE),69161784,CDM,272,RC,,,Outpatient,,,490.14,490.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.1,70,,274.48,percent of total billed charges,70% of total billed charges for outpatient setting,416.03,84.88,,332.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,245.07,50,,196.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.61,75,,294.09,percent of total billed charges,75% of total billed charges for outpatient setting,343.1,70,,274.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.93,12.84,,50.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.11,80,,313.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.93,12.84,,50.34,percent of total billed charges,12.84% of total billed charges,62.93,12.84,,50.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,318.59,65,,254.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.55,35,,137.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,441.13,90,,352.9,percent of total billed charges,90% of total billed charges for outpatient setting,62.93,441.13,
INFLUENZA A AND B ANTIBODIES,202149,CDM,302,RC,86710,HCPCS,Outpatient,,,60.98,54.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.69,70,,34.15,percent of total billed charges,70% of total billed charges for outpatient setting,51.76,84.88,,41.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.74,75,,36.59,percent of total billed charges,75% of total billed charges for outpatient setting,42.69,70,,34.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.78,80,,39.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.88,90,,43.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.55,54.88,
INFLUENZA A AND B BY DIRECT EIA,201562,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
INFLUENZA VIRUS VACCINE (FLUZONE) 0.5ML,3303109,CDM,250,RC,90656,HCPCS,Outpatient,,,110.43,110.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.3,70,,61.84,percent of total billed charges,70% of total billed charges for outpatient setting,93.73,84.88,,74.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.82,75,,66.26,percent of total billed charges,75% of total billed charges for outpatient setting,77.3,70,,61.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.34,80,,70.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.78,65,,57.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,100,,,Fee Schedule,100% of Custom Fee Schedule,99.39,90,,79.51,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,99.39,
INFUSE BONE GRAFT SMALL / 7510200,69162270,CDM,278,RC,L8699,HCPCS,Outpatient,,,6500,6500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3900,60,,3120,percent of total billed charges,60% of total Billed charges for outpatient setting,5517.2,84.88,,4413.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,3250,50,,2600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4875,75,,3900,percent of total billed charges,75% of total billed charges for outpatient setting,3250,50,,2600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5200,80,,4160,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,834.6,12.84,,667.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6825,105,,5460,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,35,,1820,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3900,60,,3120,percent of total billed charges,60% of total billed charges for outpatient setting,834.6,6825,
INFUSE BONE GRAFT XSMALL / 7510100,69162265,CDM,278,RC,L8699,HCPCS,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
INFUSION ALBUMIN 25% 10ML,1000115,CDM,386,RC,,,Outpatient,,,119.35,119.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.55,70,,66.84,percent of total billed charges,70% of total billed charges for outpatient setting,101.3,84.88,,81.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.68,50,,47.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.51,75,,71.61,percent of total billed charges,75% of total billed charges for outpatient setting,83.55,70,,66.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.48,80,,76.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.58,65,,62.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.77,35,,33.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,107.42,90,,85.94,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,107.42,
INFUSION ALBUMIN 25% 20ML,1000135,CDM,386,RC,P9046,HCPCS,Outpatient,,,50.97,50.97,,33.56,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.68,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,43.26,84.88,,34.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.23,75,,30.58,percent of total billed charges,75% of total billed charges for outpatient setting,35.68,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,35.65,170,,,Fee Schedule,170% of Medicare OPPS rate,45.1,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,36.71,175,,,Fee Schedule,175% of Medicare OPPS rate,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,40.78,80,,32.62,percent of total billed charges,80% of total billed charges for outpatient setting,29.37,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,26.22,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.13,65,,26.5,percent of total billed charges,65% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,20.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,40.6,100,,,Fee Schedule,100% of Custom Fee Schedule,45.87,90,,36.7,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.87,
INFUSION ALBUMIN 25% 50ML,1000140,CDM,386,RC,P9047,HCPCS,Outpatient,,,140.63,140.63,,83.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,98.44,70,,78.75,percent of total billed charges,70% of total billed charges for outpatient setting,119.37,84.88,,95.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,105.47,75,,84.38,percent of total billed charges,75% of total billed charges for outpatient setting,98.44,70,,78.75,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,170,,,Fee Schedule,170% of Medicare OPPS rate,112.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,18.06,12.84,,14.448,percent of total billed charges,12.84% of total billed charges,91.78,175,,,Fee Schedule,175% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,112.5,80,,90,percent of total billed charges,80% of total billed charges for outpatient setting,73.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,65.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,18.06,12.84,,14.45,percent of total billed charges,12.84% of total billed charges,18.06,12.84,,14.45,percent of total billed charges,12.84% of total billed charges,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.41,65,,73.13,percent of total billed charges,65% of total billed charges for outpatient setting,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.76,100,,,Fee Schedule,100% of Custom Fee Schedule,126.57,90,,101.26,percent of total billed charges,90% of total billed charges for outpatient setting,18.06,126.57,
INFUSION ALBUMIN 5% 250ML,1000130,CDM,386,RC,P9045,HCPCS,Outpatient,,,135.96,135.96,,83.92,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.17,70,,76.14,percent of total billed charges,70% of total billed charges for outpatient setting,115.4,84.88,,92.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.97,75,,81.58,percent of total billed charges,75% of total billed charges for outpatient setting,95.17,70,,76.14,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,170,,,Fee Schedule,170% of Medicare OPPS rate,112.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,17.46,12.84,,13.968,percent of total billed charges,12.84% of total billed charges,91.78,175,,,Fee Schedule,175% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.77,80,,87.02,percent of total billed charges,80% of total billed charges for outpatient setting,73.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,65.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,17.46,12.84,,13.97,percent of total billed charges,12.84% of total billed charges,17.46,12.84,,13.97,percent of total billed charges,12.84% of total billed charges,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,88.37,65,,70.7,percent of total billed charges,65% of total billed charges for outpatient setting,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,81.15,100,,,Fee Schedule,100% of Custom Fee Schedule,122.36,90,,97.89,percent of total billed charges,90% of total billed charges for outpatient setting,17.46,122.36,
INFUSION ALBUMIN 5% 50 ML,1000110,CDM,386,RC,P9041,HCPCS,Outpatient,,,238.71,238.71,,16.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,167.1,70,,133.68,percent of total billed charges,70% of total billed charges for outpatient setting,202.62,84.88,,162.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.03,75,,143.22,percent of total billed charges,75% of total billed charges for outpatient setting,167.1,70,,133.68,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,170,,,Fee Schedule,170% of Medicare OPPS rate,22.55,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,30.65,12.84,,24.52,percent of total billed charges,12.84% of total billed charges,18.35,175,,,Fee Schedule,175% of Medicare OPPS rate,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,190.97,80,,152.78,percent of total billed charges,80% of total billed charges for outpatient setting,14.68,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,13.11,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,30.65,12.84,,24.52,percent of total billed charges,12.84% of total billed charges,30.65,12.84,,24.52,percent of total billed charges,12.84% of total billed charges,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.16,65,,124.13,percent of total billed charges,65% of total billed charges for outpatient setting,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,10.49,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,24.91,100,,,Fee Schedule,100% of Custom Fee Schedule,214.84,90,,171.87,percent of total billed charges,90% of total billed charges for outpatient setting,10.49,214.84,
INFUSION PLASMA PROTEIN 5% 250ML,1000145,CDM,386,RC,P9048,HCPCS,Outpatient,,,418.19,418.19,,261.95,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,292.73,70,,234.18,percent of total billed charges,70% of total billed charges for outpatient setting,354.96,84.88,,283.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,313.64,75,,250.91,percent of total billed charges,75% of total billed charges for outpatient setting,292.73,70,,234.18,percent of total billed charges,70% of total billed charges for outpatient setting,278.32,170,,,Fee Schedule,170% of Medicare OPPS rate,351.99,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,53.7,12.84,,42.96,percent of total billed charges,12.84% of total billed charges,286.51,175,,,Fee Schedule,175% of Medicare OPPS rate,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,334.55,80,,267.64,percent of total billed charges,80% of total billed charges for outpatient setting,229.2,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,204.65,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,53.7,12.84,,42.96,percent of total billed charges,12.84% of total billed charges,53.7,12.84,,42.96,percent of total billed charges,12.84% of total billed charges,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.82,65,,217.46,percent of total billed charges,65% of total billed charges for outpatient setting,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,163.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.05,100,,,Fee Schedule,100% of Custom Fee Schedule,376.37,90,,301.1,percent of total billed charges,90% of total billed charges for outpatient setting,44.05,376.37,
INFUSION PLASMA PROTEIN FRACTION 5% 50ML,1000120,CDM,386,RC,P9043,HCPCS,Outpatient,,,182.42,182.42,,13.07,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,127.69,70,,102.15,percent of total billed charges,70% of total billed charges for outpatient setting,154.84,84.88,,123.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,136.82,75,,109.46,percent of total billed charges,75% of total billed charges for outpatient setting,127.69,70,,102.15,percent of total billed charges,70% of total billed charges for outpatient setting,13.88,170,,,Fee Schedule,170% of Medicare OPPS rate,17.55,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.42,12.84,,18.736,percent of total billed charges,12.84% of total billed charges,14.29,175,,,Fee Schedule,175% of Medicare OPPS rate,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,145.94,80,,116.75,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,10.21,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.42,12.84,,18.74,percent of total billed charges,12.84% of total billed charges,23.42,12.84,,18.74,percent of total billed charges,12.84% of total billed charges,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,118.57,65,,94.86,percent of total billed charges,65% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,19.95,100,,,Fee Schedule,100% of Custom Fee Schedule,164.18,90,,131.34,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,164.18,
INFUSION THERAPY  EACH ADD UP TO 8HRS,6000021,CDM,262,RC,96361,HCPCS,Outpatient,,,368.3,368.3,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.81,70,,206.25,percent of total billed charges,70% of total billed charges for outpatient setting,312.61,84.88,,250.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,276.23,75,,220.98,percent of total billed charges,75% of total billed charges for outpatient setting,257.81,70,,206.25,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,47.29,12.84,,37.832,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,294.64,80,,235.71,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,47.29,12.84,,37.83,percent of total billed charges,12.84% of total billed charges,47.29,12.84,,37.83,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239.4,65,,191.52,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,331.47,90,,265.18,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,331.47,
INFUSION; MONOCLONAL ANTIB; EA ADDTL HR,5100027,CDM,260,RC,96366,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
INFUSION; MONOCLONAL ANTIBODY UP TO 1HR,5100026,CDM,260,RC,96365,HCPCS,Outpatient,,,489.98,489.98,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,415.9,84.88,,332.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.49,75,,293.99,percent of total billed charges,75% of total billed charges for outpatient setting,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,62.91,12.84,,50.328,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,391.98,80,,313.58,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,440.98,90,,352.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.91,440.98,
INHALATION STRL WATER AIRLIFE / CN0010,70000215,CDM,270,RC,,,Outpatient,,,25.8,25.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,21.9,84.88,,17.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.9,50,,10.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.35,75,,15.48,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,80,,16.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.77,65,,13.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,35,,7.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.22,90,,18.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.31,23.22,
INHIBIN A,220020,CDM,302,RC,86336,HCPCS,Outpatient,,,70.16,63.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.11,70,,39.29,percent of total billed charges,70% of total billed charges for outpatient setting,59.55,84.88,,47.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,52.62,75,,42.1,percent of total billed charges,75% of total billed charges for outpatient setting,49.11,70,,39.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.13,80,,44.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.55,100,,,Fee Schedule,100% of Custom Fee Schedule,63.14,90,,50.51,percent of total billed charges,90% of total billed charges for outpatient setting,15.59,63.14,
INHIBIN B,220019,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
INJ MAJOR JOINT OR ARTHROCENT ASPIRATION,2401025,CDM,360,RC,20610,HCPCS,Outpatient,,,455.91,455.91,,374.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,319.14,70,,255.31,percent of total billed charges,70% of total billed charges for outpatient setting,386.98,84.88,,309.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,340.33,50,,272.26,percent of total billed charges,50% of total Billed charges for outpatient setting,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,341.93,75,,273.54,percent of total billed charges,75% of total billed charges for outpatient setting,319.14,70,,255.31,percent of total billed charges,70% of total billed charges for outpatient setting,398,170,,,Fee Schedule,170% of Medicare OPPS rate,503.35,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,58.54,12.84,,46.832,percent of total billed charges,12.84% of total billed charges,409.71,175,,,Fee Schedule,175% of Medicare OPPS rate,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,364.73,80,,291.78,percent of total billed charges,80% of total billed charges for outpatient setting,327.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,292.64,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,58.54,12.84,,46.83,percent of total billed charges,12.84% of total billed charges,58.54,12.84,,46.83,percent of total billed charges,12.84% of total billed charges,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,234.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,240.55,100,,,Fee Schedule,100% of Custom Fee Schedule,410.32,90,,328.26,percent of total billed charges,90% of total billed charges for outpatient setting,58.54,503.35,
INJECTAFER (FerricCarb) 50mg/ml 1MG UNIT,3313929,CDM,636,RC,J1439,HCPCS,Outpatient,,,3.24,3.24,,1.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,1.93,170,,,Fee Schedule,170% of Medicare OPPS rate,2.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,1.99,175,,,Fee Schedule,175% of Medicare OPPS rate,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,1.59,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1.42,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.12,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1.12,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
INJECTION  PNEUMONIA VACC ADMIN,5000018,CDM,771,RC,G0009,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION FLU VACCINE ADMINISTRATION,5000017,CDM,771,RC,G0008,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION FLU VACCINE ADMINISTRATION,5100017,CDM,771,RC,G0008,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION FOR HIP XRAY BIL,2401029,CDM,360,RC,27093,HCPCS,Outpatient,,,898.47,898.47,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,762.62,84.88,,610.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,449.24,50,,359.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.85,75,,539.08,percent of total billed charges,75% of total billed charges for outpatient setting,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.78,80,,575.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.46,35,,251.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,808.62,90,,646.9,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,808.62,
INJECTION FOR HIP XRAY BILATERAL,2401030,CDM,360,RC,27093,HCPCS,Outpatient,,,1347.72,1347.72,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.4,70,,754.72,percent of total billed charges,70% of total billed charges for outpatient setting,1143.94,84.88,,915.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,673.86,50,,539.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1010.79,75,,808.63,percent of total billed charges,75% of total billed charges for outpatient setting,943.4,70,,754.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.05,12.84,,138.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1078.18,80,,862.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.05,12.84,,138.44,percent of total billed charges,12.84% of total billed charges,173.05,12.84,,138.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.7,35,,377.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1212.95,90,,970.36,percent of total billed charges,90% of total billed charges for outpatient setting,173.05,1212.95,
INJECTION FOR HIP XRAY LT,2401026,CDM,360,RC,27093,HCPCS,Outpatient,,,898.47,898.47,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,762.62,84.88,,610.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,50,,507.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.85,75,,539.08,percent of total billed charges,75% of total billed charges for outpatient setting,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.78,80,,575.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.46,35,,251.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,808.62,90,,646.9,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,808.62,
INJECTION FOR HIP XRAY RT,2401028,CDM,360,RC,27093,HCPCS,Outpatient,,,898.47,898.47,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,762.62,84.88,,610.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,50,,507.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.85,75,,539.08,percent of total billed charges,75% of total billed charges for outpatient setting,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.78,80,,575.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.46,35,,251.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,808.62,90,,646.9,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,808.62,
INJECTION FOR SHOULDER XRAY,2401027,CDM,360,RC,23350,HCPCS,Outpatient,,,497.58,497.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.31,70,,278.65,percent of total billed charges,70% of total billed charges for outpatient setting,422.35,84.88,,337.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,50,,281.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.19,75,,298.55,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,70,,278.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.89,12.84,,51.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.06,80,,318.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.89,12.84,,51.11,percent of total billed charges,12.84% of total billed charges,63.89,12.84,,51.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.82,90,,358.26,percent of total billed charges,90% of total billed charges for outpatient setting,63.89,490,
INJECTION FOR WRIST XRAY LT,2401031,CDM,360,RC,25246,HCPCS,Outpatient,,,898.47,898.47,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,762.62,84.88,,610.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,50,,281.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.85,75,,539.08,percent of total billed charges,75% of total billed charges for outpatient setting,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.78,80,,575.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.46,35,,251.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,808.62,90,,646.9,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,808.62,
INJECTION FOR WRIST XRAY RT,2401032,CDM,360,RC,25246,HCPCS,Outpatient,,,898.47,898.47,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,762.62,84.88,,610.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,50,,281.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.85,75,,539.08,percent of total billed charges,75% of total billed charges for outpatient setting,628.93,70,,503.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.78,80,,575.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,115.36,12.84,,92.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.46,35,,251.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,808.62,90,,646.9,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,808.62,
INJECTION HEPATITIS VACC ADMIN,5000019,CDM,771,RC,G0010,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION HEPATITIS VACCINE ADMIN,5100019,CDM,771,RC,G0010,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION INTRAOCULAR,5100029,CDM,940,RC,96379,HCPCS,Outpatient,,,328.86,328.86,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,230.2,70,,184.16,percent of total billed charges,70% of total billed charges for outpatient setting,279.14,84.88,,223.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.65,75,,197.32,percent of total billed charges,75% of total billed charges for outpatient setting,230.2,70,,184.16,percent of total billed charges,70% of total billed charges for outpatient setting,60.96,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.23,12.84,,33.784,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,263.09,80,,210.47,percent of total billed charges,80% of total billed charges for outpatient setting,50.2,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226,100,,,Case rate,pays based on fixed rate ,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,295.97,90,,236.78,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,295.97,
INJECTION IV  EA ADDTL SEQ NEW DRUG/SUB,5100011,CDM,260,RC,96375,HCPCS,Outpatient,,,298.96,298.96,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,253.76,84.88,,203.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,224.22,75,,179.38,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.39,12.84,,30.712,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,239.17,80,,191.34,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,269.06,90,,215.25,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,269.06,
INJECTION IV EA  ADDTL SEQ SAME DRUG/SUB,5100010,CDM,260,RC,96376,HCPCS,Outpatient,,,298.96,298.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,253.76,84.88,,203.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.22,75,,179.38,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,70,,167.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,12.84,,30.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.17,80,,191.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,38.39,12.84,,30.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.06,90,,215.25,percent of total billed charges,90% of total billed charges for outpatient setting,38.39,269.06,
INJECTION IV PUSH,5000008,CDM,260,RC,96374,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
INJECTION IV PUSH,6000008,CDM,260,RC,96374,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
INJECTION IV PUSH,6110008,CDM,260,RC,96374,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
INJECTION IV PUSH THx/PROPH 1ST SUBSTAN,5100008,CDM,260,RC,96374,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
INJECTION IVP THx PRO EA ADDTL NEW MED,5100028,CDM,260,RC,96375,HCPCS,Outpatient,,,328.86,328.86,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,230.2,70,,184.16,percent of total billed charges,70% of total billed charges for outpatient setting,279.14,84.88,,223.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.65,75,,197.32,percent of total billed charges,75% of total billed charges for outpatient setting,230.2,70,,184.16,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.23,12.84,,33.784,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,263.09,80,,210.47,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,42.23,12.84,,33.78,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,295.97,90,,236.78,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,295.97,
INJECTION PNEUMONIA VACCINE ADMIN,5100018,CDM,771,RC,G0009,HCPCS,Outpatient,,,67.49,67.49,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,57.29,84.88,,45.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,50.62,75,,40.5,percent of total billed charges,75% of total billed charges for outpatient setting,47.24,70,,37.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.67,12.84,,6.936,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.99,80,,43.19,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,8.67,12.84,,6.94,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.87,65,,35.1,percent of total billed charges,65% of total billed charges for outpatient setting,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,60.74,90,,48.59,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,77.09,
INJECTION SALINE 25ML / 2B1300,70000551,CDM,271,RC,,,Outpatient,,,13.04,13.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.13,70,,7.3,percent of total billed charges,70% of total billed charges for outpatient setting,11.07,84.88,,8.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.52,50,,5.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.78,75,,7.82,percent of total billed charges,75% of total billed charges for outpatient setting,9.13,70,,7.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,80,,8.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.48,65,,6.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,35,,3.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.74,90,,9.39,percent of total billed charges,90% of total billed charges for outpatient setting,1.67,11.74,
INJECTION SALINE BRAUN 1L / E8000,70000555,CDM,271,RC,,,Outpatient,,,26.19,26.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,22.23,84.88,,17.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.1,50,,10.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.64,75,,15.71,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.95,80,,16.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.02,65,,13.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,35,,7.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.57,90,,18.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,23.57,
INNOVAMATRIX 2X2CM / IMX-0202-01,71000056,CDM,272,RC,,,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1251.25,65,,1001,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1732.5,90,,1386,percent of total billed charges,90% of total billed charges for outpatient setting,247.17,1732.5,
INNOVAMATRIX 5X5CM / IMX-0505-01,71000026,CDM,272,RC,,,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,70,,1512,percent of total billed charges,70% of total billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1890,70,,1512,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1755,65,,1404,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2430,90,,1944,percent of total billed charges,90% of total billed charges for outpatient setting,346.68,2430,
INSERT 10MM SZ 3 TIB / 5530-G-410-E,71000235,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 3 TIB / 5531-G-310-E,71000708,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 3 TIB BEAR / 5530-G-310-E,71000118,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 4 TIB / 5531-G-410-E,71000445,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 5 TIB / 5531-G-510-E,71000403,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 6 TIB / 5531-G-610-E,71000570,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 7 TIB / 5531-G-710-E,71000814,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 10MM SZ 7 TIB / 5531-P-710,71000604,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 3 TIB / 5531-G-311-E,71000424,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 3 TIB / 5537-G-311-E,71000592,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 11MM SZ 3 TIB BEAR / 5530-G-311-E,71000011,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 3 TIB BEAR / 5530-G-311-E,71000120,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 4 TIB / 5531-G-411-E,71000823,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 5 TIB / 5531-G-511-E,71000582,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 5 TIB / 5532-G-511-E,71000488,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 5 TIB / 5537-G-511-E,71000839,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 11MM SZ 6 TIB / 5531-G-611-E,71000384,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 7 TIB / 5531-G-711-E,71000544,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 11MM SZ 8 TIB / 5531-G-811-E,71000654,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 12MM SZ 5 TIB / 5531-G-512-E,71000482,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 12MM SZ 6 TIB / 5531-G-612-E,71000691,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 13MM SZ 4 TIB / 5531-G-413-E,71000827,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 13MM SZ 4 TIB / 5537-G-511-E,71000869,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 13MM SZ 5 TIB / 5531-G-513-E,71000655,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 13MM SZ 5 TIB / 5537-G-513-E,71000816,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 13MM SZ 6 TIB / 5531-G-613-E,71000673,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 13MM SZ 6 TIB / 5537-G-613-E,71000423,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 13MM SZ 8 TIB / 5531-G-809-E,71000672,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 14MM SZ 4 TIB X3 / 5531-G-414-E,71000463,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 16MM SZ 2 TIB / 5537-G-216-E,71000520,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 16MM SZ 3 TIB / 5532-G-316-E,71000860,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 16MM SZ 4 TIB / 5537-G-416-E,71000923,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 16MM SZ 5 TIB / 5537-G-516-E,71000468,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 19MM SZ 2 TIB / 5537-G-219-E,75000002,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 19MM SZ 5 TIB / 5537-G-519-E,71000375,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 19MM SZ 6 TIB / 5532-G-619-E,71000881,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 19MM SZ 6 TIB / 5537-G-619-E,71000581,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 19MM SZ 7 TIB / 5537-G-719-E,71000890,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 22MM SZ 3 TIB / 5537-G-322-E,71000844,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 22MM SZ 6 TIB / 5537-G-622-E,71000648,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 28MM SZ 3 TIB / 5537-G-328-E,71000593,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 5MM SZ 8 TIB / 1516-30-805,71000935,CDM,278,RC,C1776,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
INSERT 5MM SZ 9 TIB / 1516-30-905,71000855,CDM,278,RC,C1776,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
INSERT 8MM SZ 7 TIB / 1516-30-708,71000932,CDM,278,RC,C1776,HCPCS,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,60,,1075.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2352,105,,1881.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1344,60,,1075.2,percent of total billed charges,60% of total billed charges for outpatient setting,287.62,2352,
INSERT 9MM SZ 2 TIB / 5531-G-209-E,71000396,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 3 TIB / 5531-G-309-E,71000385,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 3 TIB BEAR / 5530-G-309-E,71000176,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 4 TIB / 5531-G-409-E,71000364,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 4 TIB / 5537-G-409-E,71000953,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 9MM SZ 4 TIB BEAR / 5530-G-409-E,71000126,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 5 TIB / 5531-G-509-E,71000556,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 5 TIB / 5532-G-509-E,71000572,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 5-6 ARTCLR GII / 71420830,71000659,CDM,278,RC,C1776,HCPCS,Outpatient,,,2029.24,2029.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1217.54,60,,974.03,percent of total billed charges,60% of total Billed charges for outpatient setting,1722.42,84.88,,1377.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1521.93,75,,1217.54,percent of total billed charges,75% of total billed charges for outpatient setting,1014.62,50,,811.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1623.39,80,,1298.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,260.55,12.84,,208.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2029.24,65,,1623.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.23,35,,568.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1217.54,60,,974.03,percent of total billed charges,60% of total billed charges for outpatient setting,260.55,2029.24,
INSERT 9MM SZ 6 TIB / 5531-G-609-E,71000352,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 6 TIB / 5537-G-609-E,71000902,CDM,278,RC,C1776,HCPCS,Outpatient,,,4660.88,4660.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.53,60,,2237.22,percent of total billed charges,60% of total Billed charges for outpatient setting,3956.15,84.88,,3164.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3495.66,75,,2796.53,percent of total billed charges,75% of total billed charges for outpatient setting,2330.44,50,,1864.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3728.7,80,,2982.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,598.46,12.84,,478.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4893.92,105,,3915.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.31,35,,1305.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2796.53,60,,2237.22,percent of total billed charges,60% of total billed charges for outpatient setting,598.46,4893.92,
INSERT 9MM SZ 7 TIB / 5531-G-709-E,71000381,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 7 TIB / 5532-G-709,69169801,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
INSERT 9MM SZ 8 TIB / 5531-G-809-E,71000395,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
"INSERTION OF CATHETER, VENOUS",5100016,CDM,360,RC,,,Outpatient,,,4079.4,4079.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2855.58,70,,2284.46,percent of total billed charges,70% of total billed charges for outpatient setting,3462.59,84.88,,2770.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,2039.7,50,,1631.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3059.55,75,,2447.64,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.79,12.84,,419.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3263.52,80,,2610.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.79,12.84,,419.03,percent of total billed charges,12.84% of total billed charges,523.79,12.84,,419.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1427.79,35,,1142.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3671.46,90,,2937.17,percent of total billed charges,90% of total billed charges for outpatient setting,523.79,3671.46,
INSERTION OF NON-INDWELLING URINARY CATH,5150216,CDM,360,RC,51701,HCPCS,Outpatient,,,227.24,227.24,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,192.88,84.88,,154.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,170.43,75,,136.34,percent of total billed charges,75% of total billed charges for outpatient setting,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,29.18,12.84,,23.344,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181.79,80,,145.43,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,204.52,90,,163.62,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,490,
INSERTION OF TEMP INDWELLING CATHETER,5150213,CDM,360,RC,51702,HCPCS,Outpatient,,,227.24,227.24,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,192.88,84.88,,154.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,170.43,75,,136.34,percent of total billed charges,75% of total billed charges for outpatient setting,159.07,70,,127.26,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,29.18,12.84,,23.344,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181.79,80,,145.43,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,29.18,12.84,,23.34,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,490,65,,392,percent of total billed charges,65% of total billed charges for outpatient setting,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,204.52,90,,163.62,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,490,
INSTRUMENT TRACKER FUSION / 9733533XOM,69161833,CDM,272,RC,,,Outpatient,,,634,634,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.8,70,,355.04,percent of total billed charges,70% of total billed charges for outpatient setting,538.14,84.88,,430.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,317,50,,253.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,475.5,75,,380.4,percent of total billed charges,75% of total billed charges for outpatient setting,443.8,70,,355.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.41,12.84,,65.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.2,80,,405.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.41,12.84,,65.13,percent of total billed charges,12.84% of total billed charges,81.41,12.84,,65.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,412.1,65,,329.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.9,35,,177.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,570.6,90,,456.48,percent of total billed charges,90% of total billed charges for outpatient setting,81.41,570.6,
INSUFFLATION TUBING / 37-2003-S,6150586,CDM,270,RC,,,Outpatient,,,39.76,39.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.83,70,,22.26,percent of total billed charges,70% of total billed charges for outpatient setting,33.75,84.88,,27,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.88,50,,15.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.82,75,,23.86,percent of total billed charges,75% of total billed charges for outpatient setting,27.83,70,,22.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,12.84,,4.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,80,,25.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,12.84,,4.09,percent of total billed charges,12.84% of total billed charges,5.11,12.84,,4.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.84,65,,20.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.92,35,,11.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.78,90,,28.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.11,35.78,
INSULIN  30 MINUTES,220096,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN  FASTING,220101,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN 120 MINUTES,220098,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN 60 MINUTES,220097,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN 70/30 (HUMULIN 70/30)INJ 10ML,3301290,CDM,259,RC,,,Outpatient,,,230.66,230.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.46,70,,129.17,percent of total billed charges,70% of total billed charges for outpatient setting,195.78,84.88,,156.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.33,50,,92.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173,75,,138.4,percent of total billed charges,75% of total billed charges for outpatient setting,161.46,70,,129.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,12.84,,23.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.53,80,,147.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,12.84,,23.7,percent of total billed charges,12.84% of total billed charges,29.62,12.84,,23.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.93,65,,119.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.73,35,,64.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.59,90,,166.07,percent of total billed charges,90% of total billed charges for outpatient setting,29.62,207.59,
INSULIN 90 MINUTES,220099,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN ANTIBODY,220047,CDM,310,RC,86337,HCPCS,Outpatient,,,96.35,86.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.45,70,,53.96,percent of total billed charges,70% of total billed charges for outpatient setting,81.78,84.88,,65.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,72.26,75,,57.81,percent of total billed charges,75% of total billed charges for outpatient setting,67.45,70,,53.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.08,80,,61.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,100,,,Fee Schedule,100% of Custom Fee Schedule,86.72,90,,69.38,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,86.72,
INSULIN L 100U/ML (HUMULIN L)INJ:10ML,3301288,CDM,259,RC,,,Outpatient,,,89.23,89.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.46,70,,49.97,percent of total billed charges,70% of total billed charges for outpatient setting,75.74,84.88,,60.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.92,75,,53.54,percent of total billed charges,75% of total billed charges for outpatient setting,62.46,70,,49.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.38,80,,57.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58,65,,46.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,35,,24.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.31,90,,64.25,percent of total billed charges,90% of total billed charges for outpatient setting,11.46,80.31,
INSULIN NPH 50/50(HUMULIN REG)INJ:10ML,3301287,CDM,259,RC,,,Outpatient,,,80.4,80.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.28,70,,45.02,percent of total billed charges,70% of total billed charges for outpatient setting,68.24,84.88,,54.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.2,50,,32.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,75,,48.24,percent of total billed charges,75% of total billed charges for outpatient setting,56.28,70,,45.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.32,80,,51.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.26,65,,41.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,35,,22.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.36,90,,57.89,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,72.36,
INSULIN R 100U/ML (NOVOLIN R) INJ: 10ML,3301292,CDM,259,RC,,,Outpatient,,,71.65,71.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,60.82,84.88,,48.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.83,50,,28.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.74,75,,42.99,percent of total billed charges,75% of total billed charges for outpatient setting,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.32,80,,45.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.57,65,,37.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.08,35,,20.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.49,90,,51.59,percent of total billed charges,90% of total billed charges for outpatient setting,9.2,64.49,
INSULIN RANDOM,220090,CDM,301,RC,83525,HCPCS,Outpatient,,,51.44,46.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,43.66,84.88,,34.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.58,75,,30.86,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,70,,28.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.15,80,,32.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.69,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,100,,,Fee Schedule,100% of Custom Fee Schedule,46.3,90,,37.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,46.3,
INSULIN REG 100U/M(NOVOLIN R)INJ 3 ML,3301294,CDM,259,RC,J1815,HCPCS,Outpatient,,,38.66,38.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,70,,21.65,percent of total billed charges,70% of total billed charges for outpatient setting,32.81,84.88,,26.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29,75,,23.2,percent of total billed charges,75% of total billed charges for outpatient setting,27.06,70,,21.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.93,80,,24.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,4.96,12.84,,3.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.13,65,,20.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,100,,,Fee Schedule,100% of Custom Fee Schedule,34.79,90,,27.83,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,34.79,
INSULIN REG 100U/ML(NOVOLIN R)INJ:10ML,3301289,CDM,259,RC,,,Outpatient,,,78.81,78.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.17,70,,44.14,percent of total billed charges,70% of total billed charges for outpatient setting,66.89,84.88,,53.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.41,50,,31.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.11,75,,47.29,percent of total billed charges,75% of total billed charges for outpatient setting,55.17,70,,44.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,12.84,,8.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.05,80,,50.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,10.12,12.84,,8.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.23,65,,40.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.58,35,,22.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.93,90,,56.74,percent of total billed charges,90% of total billed charges for outpatient setting,10.12,70.93,
INSULIN REG. 100U/ML (HUMULIN R)INJ 10ML,3302688,CDM,259,RC,J1815,HCPCS,Outpatient,,,100.78,100.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.55,70,,56.44,percent of total billed charges,70% of total billed charges for outpatient setting,85.54,84.88,,68.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,75.59,75,,60.47,percent of total billed charges,75% of total billed charges for outpatient setting,70.55,70,,56.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,12.84,,10.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.62,80,,64.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,12.84,,10.35,percent of total billed charges,12.84% of total billed charges,12.94,12.84,,10.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.51,65,,52.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,100,,,Fee Schedule,100% of Custom Fee Schedule,90.7,90,,72.56,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,90.7,
INSULIN U 100U/ML (HUMULIN U) INJ:10ML,3301295,CDM,259,RC,,,Outpatient,,,71.65,71.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,60.82,84.88,,48.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.83,50,,28.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.74,75,,42.99,percent of total billed charges,75% of total billed charges for outpatient setting,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.32,80,,45.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.57,65,,37.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.08,35,,20.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.49,90,,51.59,percent of total billed charges,90% of total billed charges for outpatient setting,9.2,64.49,
INSULINL L 100U/ML (HUMULIN L)INJ:10ML,3301293,CDM,259,RC,,,Outpatient,,,71.65,71.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,60.82,84.88,,48.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.83,50,,28.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.74,75,,42.99,percent of total billed charges,75% of total billed charges for outpatient setting,50.16,70,,40.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.32,80,,45.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.57,65,,37.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.08,35,,20.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.49,90,,51.59,percent of total billed charges,90% of total billed charges for outpatient setting,9.2,64.49,
INTACT PTH,200435,CDM,300,RC,83970,HCPCS,Outpatient,,,185.76,167.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.03,70,,104.02,percent of total billed charges,70% of total billed charges for outpatient setting,157.67,84.88,,126.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,139.32,75,,111.46,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,70,,104.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.61,80,,118.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,60.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.27,100,,,Fee Schedule,100% of Custom Fee Schedule,167.18,90,,133.74,percent of total billed charges,90% of total billed charges for outpatient setting,41.28,167.18,
INTEGRILIN 0.75 MG/ML INJ: 100 ML,3302645,CDM,250,RC,,,Outpatient,,,613.41,613.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.39,70,,343.51,percent of total billed charges,70% of total billed charges for outpatient setting,520.66,84.88,,416.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,306.71,50,,245.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,460.06,75,,368.05,percent of total billed charges,75% of total billed charges for outpatient setting,429.39,70,,343.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.76,12.84,,63.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.73,80,,392.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.76,12.84,,63.01,percent of total billed charges,12.84% of total billed charges,78.76,12.84,,63.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,398.72,65,,318.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.69,35,,171.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,552.07,90,,441.66,percent of total billed charges,90% of total billed charges for outpatient setting,78.76,552.07,
INTEGRILIN 2MG/ML INJ: 10 ML,3302646,CDM,250,RC,,,Outpatient,,,196,196,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.2,70,,109.76,percent of total billed charges,70% of total billed charges for outpatient setting,166.36,84.88,,133.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,98,50,,78.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147,75,,117.6,percent of total billed charges,75% of total billed charges for outpatient setting,137.2,70,,109.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.17,12.84,,20.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.8,80,,125.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.17,12.84,,20.14,percent of total billed charges,12.84% of total billed charges,25.17,12.84,,20.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.4,65,,101.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.6,35,,54.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,176.4,90,,141.12,percent of total billed charges,90% of total billed charges for outpatient setting,25.17,176.4,
INTERBODY 10X22X10MM /6101-2102210NC-G2,69169188,CDM,278,RC,C1821,HCPCS,Outpatient,,,9256,9256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5553.6,60,,4442.88,percent of total billed charges,60% of total Billed charges for outpatient setting,7856.49,84.88,,6285.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6942,75,,5553.6,percent of total billed charges,75% of total billed charges for outpatient setting,4628,50,,3702.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.8,80,,5923.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9718.8,105,,7775.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3239.6,35,,2591.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5553.6,60,,4442.88,percent of total billed charges,60% of total billed charges for outpatient setting,1188.47,9718.8,
INTERBODY 10X22X11MM /6101-2102211NC-G2,69169160,CDM,278,RC,C1821,HCPCS,Outpatient,,,9256,9256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5553.6,60,,4442.88,percent of total billed charges,60% of total Billed charges for outpatient setting,7856.49,84.88,,6285.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6942,75,,5553.6,percent of total billed charges,75% of total billed charges for outpatient setting,4628,50,,3702.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.8,80,,5923.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9718.8,105,,7775.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3239.6,35,,2591.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5553.6,60,,4442.88,percent of total billed charges,60% of total billed charges for outpatient setting,1188.47,9718.8,
INTERBODY 10X22X7MM /6101-2102207NC-G2,69169174,CDM,278,RC,C1821,HCPCS,Outpatient,,,9256,9256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5553.6,60,,4442.88,percent of total billed charges,60% of total Billed charges for outpatient setting,7856.49,84.88,,6285.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6942,75,,5553.6,percent of total billed charges,75% of total billed charges for outpatient setting,4628,50,,3702.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.8,80,,5923.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9718.8,105,,7775.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3239.6,35,,2591.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5553.6,60,,4442.88,percent of total billed charges,60% of total billed charges for outpatient setting,1188.47,9718.8,
INTERBODY 10X22X8MM /6101-2102208NC-G2,69169148,CDM,278,RC,C1821,HCPCS,Outpatient,,,9256,9256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5553.6,60,,4442.88,percent of total billed charges,60% of total Billed charges for outpatient setting,7856.49,84.88,,6285.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6942,75,,5553.6,percent of total billed charges,75% of total billed charges for outpatient setting,4628,50,,3702.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.8,80,,5923.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9718.8,105,,7775.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3239.6,35,,2591.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5553.6,60,,4442.88,percent of total billed charges,60% of total billed charges for outpatient setting,1188.47,9718.8,
INTERBODY 10X22X9MM /6101-2102209NC-G2,69169162,CDM,278,RC,C1821,HCPCS,Outpatient,,,9256,9256,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5553.6,60,,4442.88,percent of total billed charges,60% of total Billed charges for outpatient setting,7856.49,84.88,,6285.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6942,75,,5553.6,percent of total billed charges,75% of total billed charges for outpatient setting,4628,50,,3702.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.8,80,,5923.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,1188.47,12.84,,950.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9718.8,105,,7775.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3239.6,35,,2591.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5553.6,60,,4442.88,percent of total billed charges,60% of total billed charges for outpatient setting,1188.47,9718.8,
INTERNAL AUDITORY MEATI COMPLETE,2400045,CDM,320,RC,70134,HCPCS,Outpatient,,,1545.1,1158.83,,692.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,1311.48,84.88,,1049.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1158.83,75,,927.06,percent of total billed charges,75% of total billed charges for outpatient setting,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,736.08,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,198.39,12.84,,158.712,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1236.08,80,,988.86,percent of total billed charges,80% of total billed charges for outpatient setting,606.18,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,1390.59,90,,1112.47,percent of total billed charges,90% of total billed charges for outpatient setting,68.22,1390.59,
INTERPRETATION & REPORT,201513,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
INTERSEED / 4350,6152003,CDM,278,RC,,,Outpatient,,,774.35,774.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.61,60,,371.69,percent of total billed charges,60% of total Billed charges for outpatient setting,657.27,84.88,,525.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,387.18,50,,309.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,580.76,75,,464.61,percent of total billed charges,75% of total billed charges for outpatient setting,387.18,50,,309.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.43,12.84,,79.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.48,80,,495.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.43,12.84,,79.54,percent of total billed charges,12.84% of total billed charges,99.43,12.84,,79.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774.35,65,,619.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.02,35,,216.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,464.61,60,,371.69,percent of total billed charges,60% of total billed charges for outpatient setting,99.43,774.35,
INTERSTIM COMM W/HANDSET KIT/ TH90Q01,69169212,CDM,272,RC,C1787,HCPCS,Outpatient,,,3510,3510,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2457,70,,1965.6,percent of total billed charges,70% of total billed charges for outpatient setting,2979.29,84.88,,2383.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2632.5,75,,2106,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.68,12.84,,360.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2808,80,,2246.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.68,12.84,,360.54,percent of total billed charges,12.84% of total billed charges,450.68,12.84,,360.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2281.5,65,,1825.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.5,35,,982.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3159,90,,2527.2,percent of total billed charges,90% of total billed charges for outpatient setting,450.68,3159,
INTERSTIM II NEUROSTIMULATOR / 97800,69161057,CDM,278,RC,C1767,HCPCS,Outpatient,,,21024,21024,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12614.4,60,,10091.52,percent of total billed charges,60% of total Billed charges for outpatient setting,17845.17,84.88,,14276.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15768,75,,12614.4,percent of total billed charges,75% of total billed charges for outpatient setting,10512,50,,8409.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2699.48,12.84,,2159.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16819.2,80,,13455.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2699.48,12.84,,2159.58,percent of total billed charges,12.84% of total billed charges,2699.48,12.84,,2159.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22075.2,105,,17660.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7358.4,35,,5886.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12614.4,60,,10091.52,percent of total billed charges,60% of total billed charges for outpatient setting,2699.48,22075.2,
INTRALIPID 10%: 500CC,3302815,CDM,250,RC,,,Outpatient,,,210.74,210.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.52,70,,118.02,percent of total billed charges,70% of total billed charges for outpatient setting,178.88,84.88,,143.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.37,50,,84.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.06,75,,126.45,percent of total billed charges,75% of total billed charges for outpatient setting,147.52,70,,118.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,12.84,,21.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.59,80,,134.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,12.84,,21.65,percent of total billed charges,12.84% of total billed charges,27.06,12.84,,21.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.98,65,,109.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.76,35,,59.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.67,90,,151.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.06,189.67,
INTRALIPID 20%  250MLS,3303319,CDM,250,RC,,,Outpatient,,,84.48,84.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.14,70,,47.31,percent of total billed charges,70% of total billed charges for outpatient setting,71.71,84.88,,57.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.24,50,,33.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.36,75,,50.69,percent of total billed charges,75% of total billed charges for outpatient setting,59.14,70,,47.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.58,80,,54.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,10.85,12.84,,8.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,65,,43.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,35,,23.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.03,90,,60.82,percent of total billed charges,90% of total billed charges for outpatient setting,10.85,76.03,
INTRALIPID 20%: 500MLS,3303081,CDM,250,RC,,,Outpatient,,,185.72,185.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130,70,,104,percent of total billed charges,70% of total billed charges for outpatient setting,157.64,84.88,,126.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.86,50,,74.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.29,75,,111.43,percent of total billed charges,75% of total billed charges for outpatient setting,130,70,,104,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,12.84,,19.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.58,80,,118.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,12.84,,19.08,percent of total billed charges,12.84% of total billed charges,23.85,12.84,,19.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.72,65,,96.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65,35,,52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.15,90,,133.72,percent of total billed charges,90% of total billed charges for outpatient setting,23.85,167.15,
INTRALUMINAL DIALTION OF STRICTURES AND/,2400725,CDM,320,RC,74360,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
INTRAOP NEUROPHY MON PED SCREW STIM 11-1,6000659,CDM,920,RC,95912,HCPCS,Outpatient,,,1182.6,1182.6,,699.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,827.82,70,,662.26,percent of total billed charges,70% of total billed charges for outpatient setting,1003.79,84.88,,803.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,618.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,886.95,75,,709.56,percent of total billed charges,75% of total billed charges for outpatient setting,827.82,70,,662.26,percent of total billed charges,70% of total billed charges for outpatient setting,743.61,170,,,Fee Schedule,170% of Medicare OPPS rate,940.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,765.47,175,,,Fee Schedule,175% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,946.08,80,,756.86,percent of total billed charges,80% of total billed charges for outpatient setting,612.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,546.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226,100,,,Case rate,pays based on fixed rate ,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,1064.34,90,,851.47,percent of total billed charges,90% of total billed charges for outpatient setting,151.85,1064.34,
INTRAOP NEUROPHY MON PED SCREW STIM 13+,6000660,CDM,920,RC,95912,HCPCS,Outpatient,,,1182.6,1182.6,,699.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,827.82,70,,662.26,percent of total billed charges,70% of total billed charges for outpatient setting,1003.79,84.88,,803.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,618.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,886.95,75,,709.56,percent of total billed charges,75% of total billed charges for outpatient setting,827.82,70,,662.26,percent of total billed charges,70% of total billed charges for outpatient setting,743.61,170,,,Fee Schedule,170% of Medicare OPPS rate,940.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,765.47,175,,,Fee Schedule,175% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,946.08,80,,756.86,percent of total billed charges,80% of total billed charges for outpatient setting,612.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,546.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,151.85,12.84,,121.48,percent of total billed charges,12.84% of total billed charges,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226,100,,,Case rate,pays based on fixed rate ,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,1064.34,90,,851.47,percent of total billed charges,90% of total billed charges for outpatient setting,151.85,1064.34,
INTRAOP NEUROPHY MON PED SCREW STIM 9-10,6000658,CDM,920,RC,95911,HCPCS,Outpatient,,,124.48,124.48,,699.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,87.14,70,,69.71,percent of total billed charges,70% of total billed charges for outpatient setting,105.66,84.88,,84.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,618.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.36,75,,74.69,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,70,,69.71,percent of total billed charges,70% of total billed charges for outpatient setting,743.61,170,,,Fee Schedule,170% of Medicare OPPS rate,940.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,15.98,12.84,,12.784,percent of total billed charges,12.84% of total billed charges,765.47,175,,,Fee Schedule,175% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.58,80,,79.66,percent of total billed charges,80% of total billed charges for outpatient setting,612.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,546.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,15.98,12.84,,12.78,percent of total billed charges,12.84% of total billed charges,15.98,12.84,,12.78,percent of total billed charges,12.84% of total billed charges,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226,100,,,Case rate,pays based on fixed rate ,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,437.42,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,112.03,90,,89.62,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,940.44,
INTRAOP NEUROPHYS MON PEDICLE SCREW STIM,6000656,CDM,760,RC,95909,HCPCS,Outpatient,,,98.03,98.03,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,83.21,84.88,,66.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.52,75,,58.82,percent of total billed charges,75% of total billed charges for outpatient setting,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.42,80,,62.74,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.72,65,,50.98,percent of total billed charges,65% of total billed charges for outpatient setting,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,88.23,90,,70.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,509.88,
INTRAOP NEUROPHYS MON PEDICLE SCREW STIM,6000657,CDM,740,RC,95910,HCPCS,Outpatient,,,98.03,98.03,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,83.21,84.88,,66.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.52,75,,58.82,percent of total billed charges,75% of total billed charges for outpatient setting,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.42,80,,62.74,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,257.89,100,,,Fee Schedule,100% of Custom Fee Schedule,88.23,90,,70.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,509.88,
INTRAOP NEUROPHYS MON REMOTE PER HR,6000665,CDM,740,RC,95941,HCPCS,Outpatient,,,392.11,392.11,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.48,70,,219.58,percent of total billed charges,70% of total billed charges for outpatient setting,332.82,84.88,,266.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,196.06,50,,156.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.08,75,,235.26,percent of total billed charges,75% of total billed charges for outpatient setting,274.48,70,,219.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.35,12.84,,40.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.69,80,,250.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.35,12.84,,40.28,percent of total billed charges,12.84% of total billed charges,50.35,12.84,,40.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.24,35,,109.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.9,90,,282.32,percent of total billed charges,90% of total billed charges for outpatient setting,50.35,352.9,
INTRAOP NEUROPHYS MONITORING EA 15 MIN,6000652,CDM,740,RC,95940,HCPCS,Outpatient,,,98.03,98.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,83.21,84.88,,66.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,75,,58.82,percent of total billed charges,75% of total billed charges for outpatient setting,68.62,70,,54.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,12.84,,10.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.42,80,,62.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,12.59,12.84,,10.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.23,90,,70.58,percent of total billed charges,90% of total billed charges for outpatient setting,12.59,323,
INTRINSIC FACTOR BLOCKING AB,220841,CDM,302,RC,86340,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,61.07,
INTRODUCER 10.5FR 6210.S1,69162207,CDM,272,RC,C1894,HCPCS,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
INTRODUCER 15FR 70CM BOUGIE / 9-0212-70,625631,CDM,272,RC,,,Outpatient,,,37.31,37.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,31.67,84.88,,25.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.66,50,,14.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.98,75,,22.38,percent of total billed charges,75% of total billed charges for outpatient setting,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,80,,23.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.25,65,,19.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,35,,10.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.58,90,,26.86,percent of total billed charges,90% of total billed charges for outpatient setting,4.79,33.58,
INTRODUCER 7FR SAFESHEATH / SU7,69161675,CDM,272,RC,C1894,HCPCS,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
INTRODUCER 7FRX13CM / 1000093002,70000488,CDM,272,RC,,,Outpatient,,,264.58,264.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,224.58,84.88,,179.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,132.29,50,,105.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.44,75,,158.75,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.66,80,,169.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.98,65,,137.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.6,35,,74.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.12,90,,190.5,percent of total billed charges,90% of total billed charges for outpatient setting,33.97,238.12,
INTRODUCER 9FRX13CM / 1000093004,69162670,CDM,272,RC,,,Outpatient,,,264.58,264.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,224.58,84.88,,179.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,132.29,50,,105.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.44,75,,158.75,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.66,80,,169.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.98,65,,137.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.6,35,,74.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.12,90,,190.5,percent of total billed charges,90% of total billed charges for outpatient setting,33.97,238.12,
INTRODUCER AIRGUARD 8 FR / 5515180,69160963,CDM,272,RC,C1894,HCPCS,Outpatient,,,379.01,379.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.31,70,,212.25,percent of total billed charges,70% of total billed charges for outpatient setting,321.7,84.88,,257.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.26,75,,227.41,percent of total billed charges,75% of total billed charges for outpatient setting,265.31,70,,212.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.66,12.84,,38.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.21,80,,242.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.66,12.84,,38.93,percent of total billed charges,12.84% of total billed charges,48.66,12.84,,38.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,246.36,65,,197.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.65,35,,106.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.11,90,,272.89,percent of total billed charges,90% of total billed charges for outpatient setting,48.66,341.11,
INTRODUCER KIT POWERPORT / 0607780,69160965,CDM,272,RC,,,Outpatient,,,363.38,363.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.37,70,,203.5,percent of total billed charges,70% of total billed charges for outpatient setting,308.44,84.88,,246.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,181.69,50,,145.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.54,75,,218.03,percent of total billed charges,75% of total billed charges for outpatient setting,254.37,70,,203.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.66,12.84,,37.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.7,80,,232.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.66,12.84,,37.33,percent of total billed charges,12.84% of total billed charges,46.66,12.84,,37.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.2,65,,188.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.18,35,,101.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,327.04,90,,261.63,percent of total billed charges,90% of total billed charges for outpatient setting,46.66,327.04,
INTRODUCER/6209SI (MEDTRONIC),6150718,CDM,272,RC,C1894,HCPCS,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
INTRODUCTION OF LONG GASTROINTESTINAL,2400710,CDM,320,RC,74340,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
INTUBATION EMERGENCY,1300090,CDM,360,RC,,,Outpatient,,,1544.95,1544.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.47,70,,865.18,percent of total billed charges,70% of total billed charges for outpatient setting,1311.35,84.88,,1049.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,772.48,50,,617.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1158.71,75,,926.97,percent of total billed charges,75% of total billed charges for outpatient setting,1081.47,70,,865.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.37,12.84,,158.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.96,80,,988.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.37,12.84,,158.7,percent of total billed charges,12.84% of total billed charges,198.37,12.84,,158.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.73,35,,432.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1390.46,90,,1112.37,percent of total billed charges,90% of total billed charges for outpatient setting,198.37,1390.46,
INVANZ 1 G/ NS 50 ML:IVPB,3302728,CDM,250,RC,,,Outpatient,,,101.08,101.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.76,70,,56.61,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,84.88,,68.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.54,50,,40.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.81,75,,60.65,percent of total billed charges,75% of total billed charges for outpatient setting,70.76,70,,56.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.98,12.84,,10.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,80,,64.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.98,12.84,,10.38,percent of total billed charges,12.84% of total billed charges,12.98,12.84,,10.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.7,65,,52.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.38,35,,28.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.97,90,,72.78,percent of total billed charges,90% of total billed charges for outpatient setting,12.98,90.97,
IODINE SERUM OR PLASMA,200893,CDM,302,RC,83789,HCPCS,Outpatient,,,108.5,97.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.95,70,,60.76,percent of total billed charges,70% of total billed charges for outpatient setting,92.09,84.88,,73.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,81.38,75,,65.1,percent of total billed charges,75% of total billed charges for outpatient setting,75.95,70,,60.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.8,80,,69.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,97.65,90,,78.12,percent of total billed charges,90% of total billed charges for outpatient setting,24.11,97.65,
IODINE STRONG (LUGOLS) SOL :,3301296,CDM,259,RC,,,Outpatient,,,145.55,145.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.89,70,,81.51,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,84.88,,98.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.78,50,,58.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.16,75,,87.33,percent of total billed charges,75% of total billed charges for outpatient setting,101.89,70,,81.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.69,12.84,,14.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.44,80,,93.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.69,12.84,,14.95,percent of total billed charges,12.84% of total billed charges,18.69,12.84,,14.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.61,65,,75.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.94,35,,40.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131,90,,104.8,percent of total billed charges,90% of total billed charges for outpatient setting,18.69,131,
IOL CUTTER HANDLE / DFH-1028,69161914,CDM,271,RC,,,Outpatient,,,428.27,428.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.79,70,,239.83,percent of total billed charges,70% of total billed charges for outpatient setting,363.52,84.88,,290.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,214.14,50,,171.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.2,75,,256.96,percent of total billed charges,75% of total billed charges for outpatient setting,299.79,70,,239.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.99,12.84,,43.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.62,80,,274.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.99,12.84,,43.99,percent of total billed charges,12.84% of total billed charges,54.99,12.84,,43.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,278.38,65,,222.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.89,35,,119.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,385.44,90,,308.35,percent of total billed charges,90% of total billed charges for outpatient setting,54.99,385.44,
IOL CUTTER SCISSOR FORCEP / PCK-1001,69161915,CDM,272,RC,,,Outpatient,,,1100,1100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,70,,616,percent of total billed charges,70% of total billed charges for outpatient setting,933.68,84.88,,746.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,550,50,,440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,825,75,,660,percent of total billed charges,75% of total billed charges for outpatient setting,770,70,,616,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.24,12.84,,112.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880,80,,704,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.24,12.84,,112.99,percent of total billed charges,12.84% of total billed charges,141.24,12.84,,112.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,715,65,,572,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385,35,,308,percent of total billed charges,35% of total Billed charges for Outpatient Setting,990,90,,792,percent of total billed charges,90% of total billed charges for outpatient setting,141.24,990,
IONIZED CALCIUM,200430,CDM,300,RC,82330,HCPCS,Outpatient,,,61.56,55.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,70,,34.47,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,84.88,,41.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.17,75,,36.94,percent of total billed charges,75% of total billed charges for outpatient setting,43.09,70,,34.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.25,80,,39.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.95,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,100,,,Fee Schedule,100% of Custom Fee Schedule,55.4,90,,44.32,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,55.4,
IONIZED CALCIUM,220657,CDM,301,RC,82330,HCPCS,Outpatient,,,61.56,55.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,70,,34.47,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,84.88,,41.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.17,75,,36.94,percent of total billed charges,75% of total billed charges for outpatient setting,43.09,70,,34.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.25,80,,39.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.95,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,100,,,Fee Schedule,100% of Custom Fee Schedule,55.4,90,,44.32,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,55.4,
IOVERSOL (OPTIRAY) 320MG/ML 100ML,2350047,CDM,636,RC,Q9967,HCPCS,Outpatient,,,77.27,77.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.09,70,,43.27,percent of total billed charges,70% of total billed charges for outpatient setting,65.59,84.88,,52.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.95,75,,46.36,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,70,,43.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.92,12.84,,7.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.82,80,,49.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.92,12.84,,7.94,percent of total billed charges,12.84% of total billed charges,9.92,12.84,,7.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.23,65,,40.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,69.54,90,,55.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,69.54,
IOVERSOL (OPTIRAY) 350MG/ML 100ML,2350046,CDM,636,RC,Q9967,HCPCS,Outpatient,,,85.4,85.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,72.49,84.88,,57.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,64.05,75,,51.24,percent of total billed charges,75% of total billed charges for outpatient setting,59.78,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,80,,54.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.51,65,,44.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,76.86,90,,61.49,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,76.86,
IPECAC SYRP 30ML :,3301297,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IPECAC SYRP 30ML: UD,3301298,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
IPRATROPIUM (genATROVENT) INH 12.9GM,3301300,CDM,259,RC,,,Outpatient,,,117.59,117.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.31,70,,65.85,percent of total billed charges,70% of total billed charges for outpatient setting,99.81,84.88,,79.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.8,50,,47.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.19,75,,70.55,percent of total billed charges,75% of total billed charges for outpatient setting,82.31,70,,65.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.1,12.84,,12.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.07,80,,75.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.1,12.84,,12.08,percent of total billed charges,12.84% of total billed charges,15.1,12.84,,12.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.43,65,,61.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.16,35,,32.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.83,90,,84.66,percent of total billed charges,90% of total billed charges for outpatient setting,15.1,105.83,
IPRATROPIUM 0.02% NEB 2.5ML ATROVENT GEN,3301299,CDM,250,RC,J7644,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.24,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.22,2.92,
iPRISM / SGL5,69169193,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
IRON,201726,CDM,300,RC,83540,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,26.21,
IRON DEXT (INFED) INJ : 50MG/UNIT,3301301,CDM,636,RC,J1750,HCPCS,Outpatient,,,91.02,91.02,,26.44,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.71,70,,50.97,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,84.88,,61.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.27,75,,54.62,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,70,,50.97,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,170,,,Fee Schedule,170% of Medicare OPPS rate,35.53,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,11.69,12.84,,9.352,percent of total billed charges,12.84% of total billed charges,28.92,175,,,Fee Schedule,175% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.82,80,,58.26,percent of total billed charges,80% of total billed charges for outpatient setting,23.14,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,20.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,11.69,12.84,,9.35,percent of total billed charges,12.84% of total billed charges,11.69,12.84,,9.35,percent of total billed charges,12.84% of total billed charges,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.16,65,,47.33,percent of total billed charges,65% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.32,100,,,Fee Schedule,100% of Custom Fee Schedule,81.92,90,,65.54,percent of total billed charges,90% of total billed charges for outpatient setting,11.69,81.92,
IRON DEXT (INFED): 50MG/UNIT (WASTAGE),3305392,CDM,636,RC,J1750,HCPCS,Outpatient,,,46.9,46.9,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,70,,26.26,percent of total billed charges,70% of total billed charges for outpatient setting,39.81,84.88,,31.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.45,50,,18.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.18,75,,28.14,percent of total billed charges,75% of total billed charges for outpatient setting,32.83,70,,26.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,12.84,,4.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.52,80,,30.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,6.02,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.49,65,,24.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,35,,13.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.21,90,,33.77,percent of total billed charges,90% of total billed charges for outpatient setting,6.02,42.21,
IRON POLYSAC (FERREX) CAP: 150 MG,3301302,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IRON POLYSAC (NIFEREX) CAP : 150MG U/D,3301303,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IRON SUPPLMT (DEXFERRUM)INJ 50MG/ML:1ML,3301304,CDM,636,RC,J1750,HCPCS,Outpatient,,,114.02,114.02,,26.44,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,79.81,70,,63.85,percent of total billed charges,70% of total billed charges for outpatient setting,96.78,84.88,,77.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,85.52,75,,68.42,percent of total billed charges,75% of total billed charges for outpatient setting,79.81,70,,63.85,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,170,,,Fee Schedule,170% of Medicare OPPS rate,35.53,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,14.64,12.84,,11.712,percent of total billed charges,12.84% of total billed charges,28.92,175,,,Fee Schedule,175% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.22,80,,72.98,percent of total billed charges,80% of total billed charges for outpatient setting,23.14,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,20.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,14.64,12.84,,11.71,percent of total billed charges,12.84% of total billed charges,14.64,12.84,,11.71,percent of total billed charges,12.84% of total billed charges,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,74.11,65,,59.29,percent of total billed charges,65% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.32,100,,,Fee Schedule,100% of Custom Fee Schedule,102.62,90,,82.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.32,102.62,
IRON W/TIBC,201727,CDM,300,RC,83550,HCPCS,Outpatient,,,39.33,35.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,84.88,,26.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.5,75,,23.6,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,80,,25.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.58,100,,,Fee Schedule,100% of Custom Fee Schedule,35.4,90,,28.32,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,35.4,
IRRIG CYSTOTOME ANGLED 27G / 8065425820,6150515,CDM,272,RC,,,Outpatient,,,28.64,28.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,70,,16.04,percent of total billed charges,70% of total billed charges for outpatient setting,24.31,84.88,,19.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.32,50,,11.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.48,75,,17.18,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,70,,16.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,12.84,,2.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,80,,18.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,3.68,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.62,65,,14.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,35,,8.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.78,90,,20.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.68,25.78,
IRRIGATOR DEFENDO YOPSY / 100303,359562,CDM,272,RC,,,Outpatient,,,25.92,25.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,22,84.88,,17.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.96,50,,10.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.44,75,,15.55,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.74,80,,16.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.85,65,,13.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,35,,7.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.33,90,,18.66,percent of total billed charges,90% of total billed charges for outpatient setting,3.33,23.33,
ISLET CELL ANTIBODY,201421,CDM,301,RC,86341,HCPCS,Outpatient,,,106.07,95.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,90.03,84.88,,72.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.55,75,,63.64,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,70,,59.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.86,80,,67.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.52,100,,,Fee Schedule,100% of Custom Fee Schedule,95.46,90,,76.37,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,95.46,
ISOENZYMES AMYLASE,220104,CDM,300,RC,82150,HCPCS,Outpatient,,,29.16,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,24.75,84.88,,19.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.87,75,,17.5,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,80,,18.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of Custom Fee Schedule,26.24,90,,20.99,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,26.24,
ISOFLURANE (FORANE) LIQ : 100 ML,3301305,CDM,250,RC,,,Outpatient,,,111.86,111.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.3,70,,62.64,percent of total billed charges,70% of total billed charges for outpatient setting,94.95,84.88,,75.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.93,50,,44.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.9,75,,67.12,percent of total billed charges,75% of total billed charges for outpatient setting,78.3,70,,62.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.36,12.84,,11.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.49,80,,71.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.36,12.84,,11.49,percent of total billed charges,12.84% of total billed charges,14.36,12.84,,11.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.71,65,,58.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,35,,31.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.67,90,,80.54,percent of total billed charges,90% of total billed charges for outpatient setting,14.36,100.67,
ISOFLURANE (FORANE) LIQ : 250 ML,3301306,CDM,250,RC,,,Outpatient,,,111.86,111.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.3,70,,62.64,percent of total billed charges,70% of total billed charges for outpatient setting,94.95,84.88,,75.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.93,50,,44.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.9,75,,67.12,percent of total billed charges,75% of total billed charges for outpatient setting,78.3,70,,62.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.36,12.84,,11.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.49,80,,71.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.36,12.84,,11.49,percent of total billed charges,12.84% of total billed charges,14.36,12.84,,11.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.71,65,,58.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,35,,31.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.67,90,,80.54,percent of total billed charges,90% of total billed charges for outpatient setting,14.36,100.67,
ISOHEMAGGLUTININ TITER,220833,CDM,310,RC,86940,HCPCS,Outpatient,,,39.47,35.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.63,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,33.5,84.88,,26.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.6,75,,23.68,percent of total billed charges,75% of total billed charges for outpatient setting,27.63,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,80,,25.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.55,100,,,Fee Schedule,100% of Custom Fee Schedule,35.52,90,,28.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.77,35.52,
ISONIAZID TAB: 100MG UD,3301307,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ISOPROPYL ALCOHOL 70% SOL : 480ML,3301309,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOPROPYL ALCOHOL SOL 70% : 480ML,3301308,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOPROPYL ALCOHOL SOL 70%:480ML,3301310,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ISOPROTENOL (ISUPRL)1.50M/0.2MG INJ:10ML,3301313,CDM,250,RC,,,Outpatient,,,43.48,43.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,70,,24.35,percent of total billed charges,70% of total billed charges for outpatient setting,36.91,84.88,,29.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.74,50,,17.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.61,75,,26.09,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,70,,24.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,12.84,,4.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.78,80,,27.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,5.58,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.26,65,,22.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,35,,12.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.13,90,,31.3,percent of total billed charges,90% of total billed charges for outpatient setting,5.58,39.13,
ISOPROTERENOL (ISUPREL) 1.5M SYRNGE: 5ML,3301311,CDM,250,RC,,,Outpatient,,,14.83,14.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,12.59,84.88,,10.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.42,50,,5.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.12,75,,8.9,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.86,80,,9.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.64,65,,7.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,35,,4.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.35,90,,10.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.9,13.35,
ISOPROTERENOL (ISUPREL) INJ : 0.2MG,3301312,CDM,250,RC,,,Outpatient,,,61.71,61.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,70,,34.56,percent of total billed charges,70% of total billed charges for outpatient setting,52.38,84.88,,41.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.86,50,,24.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.28,75,,37.02,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,70,,34.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,12.84,,6.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.37,80,,39.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.92,12.84,,6.34,percent of total billed charges,12.84% of total billed charges,7.92,12.84,,6.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.11,65,,32.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,35,,17.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.54,90,,44.43,percent of total billed charges,90% of total billed charges for outpatient setting,7.92,55.54,
ISOPTO TEARS: HYDROXYPROPYLCELLULOSE,3303204,CDM,259,RC,,,Outpatient,,,59.76,59.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,50.72,84.88,,40.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.88,50,,23.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.82,75,,35.86,percent of total billed charges,75% of total billed charges for outpatient setting,41.83,70,,33.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.67,12.84,,6.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.81,80,,38.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.67,12.84,,6.14,percent of total billed charges,12.84% of total billed charges,7.67,12.84,,6.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.84,65,,31.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,35,,16.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.78,90,,43.02,percent of total billed charges,90% of total billed charges for outpatient setting,7.67,53.78,
ISOSORBIDE  TAB : 20 MG,3301324,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
ISOSORBIDE  TAB : 60 MG,3301323,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ISOSORBIDE (ISORDIL) TAB: 10 MG,3301317,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 10 MG,3301319,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301314,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301315,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301316,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301318,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301320,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 20 MG,3301321,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ISOSORBIDE (ISORDIL) TAB: 40 MG,3301322,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
ISOSORBIDE 10 MG: TABS,3302879,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ISOSORBIDE 60MG TAB (IMDUR),3301326,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ISOSORBIDE DINITRATE 30MG TAB,3314241,CDM,259,RC,,,Outpatient,,,3.07,3.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,75,,1.84,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.76,90,,2.21,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.76,
ISOSORBIDE MONO 30MG TAB(IMDUR),3303014,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ISOSORBIDE TAB : 20 MG,3301325,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
ISOVUE 300 (IOPAMIDOL) 100ML BOTTLE,69160799,CDM,255,RC,Q9967,HCPCS,Outpatient,,,79.38,79.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.57,70,,44.46,percent of total billed charges,70% of total billed charges for outpatient setting,67.38,84.88,,53.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,59.54,75,,47.63,percent of total billed charges,75% of total billed charges for outpatient setting,55.57,70,,44.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,80,,50.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.6,65,,41.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,71.44,90,,57.15,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,71.44,
ISOVUE 370 150ML BOTTLE / 131637,70000214,CDM,255,RC,Q9967,HCPCS,Outpatient,,,91.91,91.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.34,70,,51.47,percent of total billed charges,70% of total billed charges for outpatient setting,78.01,84.88,,62.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,68.93,75,,55.14,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,70,,51.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.53,80,,58.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.74,65,,47.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,82.72,90,,66.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,82.72,
ISOVUE-M 200 (IOPAMIDOL) 10MLS,3314316,CDM,255,RC,Q9967,HCPCS,Outpatient,,,71.33,71.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.93,70,,39.94,percent of total billed charges,70% of total billed charges for outpatient setting,60.54,84.88,,48.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.5,75,,42.8,percent of total billed charges,75% of total billed charges for outpatient setting,49.93,70,,39.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.16,12.84,,7.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.06,80,,45.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.16,12.84,,7.33,percent of total billed charges,12.84% of total billed charges,9.16,12.84,,7.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.36,65,,37.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,64.2,90,,51.36,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,64.2,
ISOVUE-M 300 (IOPAMIDOL) 15MLS,3314280,CDM,255,RC,Q9967,HCPCS,Outpatient,,,94.85,94.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.4,70,,53.12,percent of total billed charges,70% of total billed charges for outpatient setting,80.51,84.88,,64.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.14,75,,56.91,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,70,,53.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.18,12.84,,9.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.88,80,,60.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.18,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,12.18,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.65,65,,49.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,85.37,90,,68.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,85.37,
iSTENT INJECT / G2W-US,69169191,CDM,278,RC,C1783,HCPCS,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
ISUPREL 1/5000 (0.2MG/ML) AMP: 5 ML,3302602,CDM,250,RC,,,Outpatient,,,616.73,616.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.71,70,,345.37,percent of total billed charges,70% of total billed charges for outpatient setting,523.48,84.88,,418.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,308.37,50,,246.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.55,75,,370.04,percent of total billed charges,75% of total billed charges for outpatient setting,431.71,70,,345.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.19,12.84,,63.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.38,80,,394.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.19,12.84,,63.35,percent of total billed charges,12.84% of total billed charges,79.19,12.84,,63.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400.87,65,,320.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.86,35,,172.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,555.06,90,,444.05,percent of total billed charges,90% of total billed charges for outpatient setting,79.19,555.06,
IV 1/2 NACL 1000CC / 2B1314X,5150167,CDM,258,RC,J7030,HCPCS,Outpatient,,,16.29,16.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,13.83,84.88,,11.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.22,75,,9.78,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,80,,10.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.59,65,,8.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,100,,,Fee Schedule,100% of Custom Fee Schedule,14.66,90,,11.73,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.66,
IV ADMINISTRATION DEVICE,3302225,CDM,272,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IV CATHETER JELCO,7650551,CDM,272,RC,,,Outpatient,,,30.24,30.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,25.67,84.88,,20.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.12,50,,12.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.68,75,,18.14,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,80,,19.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.66,65,,15.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,35,,8.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.22,90,,21.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.88,27.22,
IV D5 1/2 NACL 1000ML / 2B1074X,5050024,CDM,258,RC,,,Outpatient,,,15.93,15.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,84.88,,10.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.97,50,,6.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.95,75,,9.56,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,80,,10.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.35,65,,8.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.34,90,,11.47,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.34,
IV D5 1/4 NACL 1000CC / 2B1094X,5150168,CDM,258,RC,,,Outpatient,,,15.84,15.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.09,70,,8.87,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,84.88,,10.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.92,50,,6.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.88,75,,9.5,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,70,,8.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,12.84,,1.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.67,80,,10.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.03,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.3,65,,8.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.54,35,,4.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.26,90,,11.41,percent of total billed charges,90% of total billed charges for outpatient setting,2.03,14.26,
IV D5 I/2 NACL 500CC / 2B1073Q,5150157,CDM,258,RC,,,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.38,50,,68.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
IV D5 NACL 1000CC / 2B1064X,5150169,CDM,258,RC,,,Outpatient,,,15.75,15.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,13.37,84.88,,10.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.88,50,,6.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.81,75,,9.45,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,80,,10.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.24,65,,8.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,35,,4.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.18,90,,11.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.18,
IV D5LR 1000CC / 2B2074X,5150180,CDM,258,RC,,,Outpatient,,,13.53,13.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,70,,7.58,percent of total billed charges,70% of total billed charges for outpatient setting,11.48,84.88,,9.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.77,50,,5.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.15,75,,8.12,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,70,,7.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.82,80,,8.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.79,65,,7.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,35,,3.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.18,90,,9.74,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.18,
IV D5W  500CC / 2B0063Q,5150194,CDM,258,RC,,,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.38,50,,68.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
IV D5W 1000CC / 2B0064X,6150069,CDM,258,RC,,,Outpatient,,,15.59,15.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.91,70,,8.73,percent of total billed charges,70% of total billed charges for outpatient setting,13.23,84.88,,10.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.8,50,,6.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.69,75,,9.35,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,70,,8.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,80,,9.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,2,12.84,,1.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.13,65,,8.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,35,,4.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.03,90,,11.22,percent of total billed charges,90% of total billed charges for outpatient setting,2,14.03,
IV HYDRATION EACH ADDL HR >30min,5100182,CDM,260,RC,96361,HCPCS,Outpatient,,,303.84,303.84,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,212.69,70,,170.15,percent of total billed charges,70% of total billed charges for outpatient setting,257.9,84.88,,206.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.88,75,,182.3,percent of total billed charges,75% of total billed charges for outpatient setting,212.69,70,,170.15,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,39.01,12.84,,31.208,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,243.07,80,,194.46,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,39.01,12.84,,31.21,percent of total billed charges,12.84% of total billed charges,39.01,12.84,,31.21,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,273.46,90,,218.77,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,273.46,
IV HYDRATIONANTIBIOTIC UP TO 1 HR,5100180,CDM,260,RC,96360,HCPCS,Outpatient,,,303.84,303.84,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,212.69,70,,170.15,percent of total billed charges,70% of total billed charges for outpatient setting,257.9,84.88,,206.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.88,75,,182.3,percent of total billed charges,75% of total billed charges for outpatient setting,212.69,70,,170.15,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,39.01,12.84,,31.208,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,243.07,80,,194.46,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,39.01,12.84,,31.21,percent of total billed charges,12.84% of total billed charges,39.01,12.84,,31.21,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,273.46,90,,218.77,percent of total billed charges,90% of total billed charges for outpatient setting,39.01,394.12,
IV INFUSION  THERAPY PROPHY  UP TO 1HR,5000005,CDM,260,RC,96365,HCPCS,Outpatient,,,489.98,489.98,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,415.9,84.88,,332.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.49,75,,293.99,percent of total billed charges,75% of total billed charges for outpatient setting,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,62.91,12.84,,50.328,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,391.98,80,,313.58,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,440.98,90,,352.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.91,440.98,
IV INFUSION > 8HRS USING PUMP,5100013,CDM,260,RC,C8957,HCPCS,Outpatient,,,539.93,539.93,,457.15,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,377.95,70,,302.36,percent of total billed charges,70% of total billed charges for outpatient setting,458.29,84.88,,366.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,413.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,404.95,75,,323.96,percent of total billed charges,75% of total billed charges for outpatient setting,377.95,70,,302.36,percent of total billed charges,70% of total billed charges for outpatient setting,485.72,170,,,Fee Schedule,170% of Medicare OPPS rate,614.29,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,69.33,12.84,,55.464,percent of total billed charges,12.84% of total billed charges,500.01,175,,,Fee Schedule,175% of Medicare OPPS rate,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,431.94,80,,345.55,percent of total billed charges,80% of total billed charges for outpatient setting,400,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,357.15,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,69.33,12.84,,55.46,percent of total billed charges,12.84% of total billed charges,69.33,12.84,,55.46,percent of total billed charges,12.84% of total billed charges,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,285.72,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,356.32,100,,,Fee Schedule,100% of Custom Fee Schedule,485.94,90,,388.75,percent of total billed charges,90% of total billed charges for outpatient setting,69.33,614.29,
IV INFUSION; HYDRATION EA ADDL HR,5100022,CDM,260,RC,96361,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV INFUSION; HYDRATION INITIAL UP TO 1HR,5100014,CDM,260,RC,96360,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
IV LACTATED RINGERS 500CC / 2B2323Q,6150074,CDM,258,RC,,,Outpatient,,,16.56,16.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.06,84.88,,11.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.42,75,,9.94,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,80,,10.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,35,,4.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
IV NACL 0.9 1000ML / 2B1324X,6150073,CDM,258,RC,J7030,HCPCS,Outpatient,,,15.03,15.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,70,,8.42,percent of total billed charges,70% of total billed charges for outpatient setting,12.76,84.88,,10.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,11.27,75,,9.02,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,70,,8.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,12.84,,1.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,80,,9.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,1.93,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.77,65,,7.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,100,,,Fee Schedule,100% of Custom Fee Schedule,13.53,90,,10.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.93,13.53,
IV NACL 0.9 500ML / 2B1323Q,6150072,CDM,258,RC,,,Outpatient,,,15.03,15.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,70,,8.42,percent of total billed charges,70% of total billed charges for outpatient setting,12.76,84.88,,10.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.52,50,,6.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.27,75,,9.02,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,70,,8.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,12.84,,1.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,80,,9.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,1.93,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.77,65,,7.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,35,,4.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.53,90,,10.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.93,13.53,
IV NACL 0.9% 250CC / 2B1322Q,2450016,CDM,258,RC,,,Outpatient,,,11.58,11.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.11,70,,6.49,percent of total billed charges,70% of total billed charges for outpatient setting,9.83,84.88,,7.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.79,50,,4.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.69,75,,6.95,percent of total billed charges,75% of total billed charges for outpatient setting,8.11,70,,6.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.26,80,,7.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.53,65,,6.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,35,,3.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.42,90,,8.34,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.42,
IV SET BUTRETOL 60GTTS TUBING 2C7562,69162103,CDM,272,RC,,,Outpatient,,,39.89,39.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.92,70,,22.34,percent of total billed charges,70% of total billed charges for outpatient setting,33.86,84.88,,27.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.95,50,,15.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.92,75,,23.94,percent of total billed charges,75% of total billed charges for outpatient setting,27.92,70,,22.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.91,80,,25.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,5.12,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.93,65,,20.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,35,,11.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.9,90,,28.72,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,35.9,
IV START KIT / 01-9001C,5150149,CDM,272,RC,,,Outpatient,,,6.84,6.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,70,,3.83,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,84.88,,4.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.42,50,,2.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.13,75,,4.1,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,70,,3.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,80,,4.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.45,65,,3.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,35,,1.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.16,90,,4.93,percent of total billed charges,90% of total billed charges for outpatient setting,0.88,6.16,
IV START KIT STD TRAY W/CHLORAPREP,69169030,CDM,272,RC,,,Outpatient,,,9.35,9.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.55,70,,5.24,percent of total billed charges,70% of total billed charges for outpatient setting,7.94,84.88,,6.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.68,50,,3.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.01,75,,5.61,percent of total billed charges,75% of total billed charges for outpatient setting,6.55,70,,5.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,80,,5.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.08,65,,4.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,35,,2.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.42,90,,6.74,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,8.42,
IV THERAPY,5100005,CDM,510,RC,96365,HCPCS,Outpatient,,,458.99,458.99,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,321.29,70,,257.03,percent of total billed charges,70% of total billed charges for outpatient setting,389.59,84.88,,311.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,344.24,75,,275.39,percent of total billed charges,75% of total billed charges for outpatient setting,321.29,70,,257.03,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,58.93,12.84,,47.144,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.19,80,,293.75,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,58.93,12.84,,47.14,percent of total billed charges,12.84% of total billed charges,58.93,12.84,,47.14,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.34,65,,238.67,percent of total billed charges,65% of total billed charges for outpatient setting,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,413.09,90,,330.47,percent of total billed charges,90% of total billed charges for outpatient setting,58.93,413.09,
IV THERAPY,6000020,CDM,262,RC,96360,HCPCS,Outpatient,,,458.99,458.99,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,321.29,70,,257.03,percent of total billed charges,70% of total billed charges for outpatient setting,389.59,84.88,,311.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,344.24,75,,275.39,percent of total billed charges,75% of total billed charges for outpatient setting,321.29,70,,257.03,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,58.93,12.84,,47.144,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.19,80,,293.75,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,58.93,12.84,,47.14,percent of total billed charges,12.84% of total billed charges,58.93,12.84,,47.14,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.34,65,,238.67,percent of total billed charges,65% of total billed charges for outpatient setting,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.98,100,,,Fee Schedule,100% of Custom Fee Schedule,413.09,90,,330.47,percent of total billed charges,90% of total billed charges for outpatient setting,58.93,413.09,
IV THERAPY  CONCURRENT INFUSION,5100003,CDM,260,RC,96368,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY  EA ADDL HR,5100007,CDM,260,RC,96366,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY  EA ADDL SEQ INFUS UP TO 1HR,5100002,CDM,260,RC,96367,HCPCS,Outpatient,,,180,180,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,77.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; EA ADDL HR,5000007,CDM,260,RC,96366,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; EA ADDL HR,6000007,CDM,260,RC,96366,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; EA ADDL HR,6110007,CDM,260,RC,96366,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; SUBCUT ADDTL PUMP/NEW SITE,5100009,CDM,260,RC,96371,HCPCS,Outpatient,,,180,180,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,77.78,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,64.51,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; SUBCUT INFUSION EA ADDTL HR,5100012,CDM,260,RC,96370,HCPCS,Outpatient,,,180,180,,57.37,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,152.78,84.88,,122.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135,75,,108,percent of total billed charges,75% of total billed charges for outpatient setting,126,70,,100.8,percent of total billed charges,70% of total billed charges for outpatient setting,60.95,170,,,Fee Schedule,170% of Medicare OPPS rate,77.09,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.11,12.84,,18.488,percent of total billed charges,12.84% of total billed charges,62.75,175,,,Fee Schedule,175% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144,80,,115.2,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,44.82,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,23.11,12.84,,18.49,percent of total billed charges,12.84% of total billed charges,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,162,90,,129.6,percent of total billed charges,90% of total billed charges for outpatient setting,23.11,162,
IV THERAPY; SUBCUT INFUSION UP TO 1HR,5100004,CDM,260,RC,96369,HCPCS,Outpatient,,,473.19,473.19,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,401.64,84.88,,321.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354.89,75,,283.91,percent of total billed charges,75% of total billed charges for outpatient setting,331.23,70,,264.98,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.76,12.84,,48.608,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.55,80,,302.84,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,60.76,12.84,,48.61,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,425.87,90,,340.7,percent of total billed charges,90% of total billed charges for outpatient setting,60.76,425.87,
IV THERAPY; UP TO 1 HOUR,5100006,CDM,260,RC,96367,HCPCS,Outpatient,,,480.39,480.39,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,336.27,70,,269.02,percent of total billed charges,70% of total billed charges for outpatient setting,407.76,84.88,,326.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,360.29,75,,288.23,percent of total billed charges,75% of total billed charges for outpatient setting,336.27,70,,269.02,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,61.68,12.84,,49.344,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,384.31,80,,307.45,percent of total billed charges,80% of total billed charges for outpatient setting,77.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,61.68,12.84,,49.34,percent of total billed charges,12.84% of total billed charges,61.68,12.84,,49.34,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,432.35,90,,345.88,percent of total billed charges,90% of total billed charges for outpatient setting,52.08,432.35,
IV THERAPY; UP TO 1 HOUR,5000006,CDM,260,RC,96365,HCPCS,Outpatient,,,489.98,489.98,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,415.9,84.88,,332.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.49,75,,293.99,percent of total billed charges,75% of total billed charges for outpatient setting,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,62.91,12.84,,50.328,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,391.98,80,,313.58,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,440.98,90,,352.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.91,440.98,
IV THERAPY; UP TO 1 HOUR,6000006,CDM,260,RC,96365,HCPCS,Outpatient,,,489.98,489.98,,293.3,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,415.9,84.88,,332.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.49,75,,293.99,percent of total billed charges,75% of total billed charges for outpatient setting,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,311.64,170,,,Fee Schedule,170% of Medicare OPPS rate,394.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,62.91,12.84,,50.328,percent of total billed charges,12.84% of total billed charges,320.8,175,,,Fee Schedule,175% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,391.98,80,,313.58,percent of total billed charges,80% of total billed charges for outpatient setting,256.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,229.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,183.32,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.82,100,,,Fee Schedule,100% of Custom Fee Schedule,440.98,90,,352.78,percent of total billed charges,90% of total billed charges for outpatient setting,62.91,440.98,
IV THERAPY; UP TO 1 HOUR,6110006,CDM,260,RC,96367,HCPCS,Outpatient,,,489.98,489.98,,88.89,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,415.9,84.88,,332.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,367.49,75,,293.99,percent of total billed charges,75% of total billed charges for outpatient setting,342.99,70,,274.39,percent of total billed charges,70% of total billed charges for outpatient setting,94.44,170,,,Fee Schedule,170% of Medicare OPPS rate,119.44,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,62.91,12.84,,50.328,percent of total billed charges,12.84% of total billed charges,97.22,175,,,Fee Schedule,175% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,391.98,80,,313.58,percent of total billed charges,80% of total billed charges for outpatient setting,77.77,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,69.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,62.91,12.84,,50.33,percent of total billed charges,12.84% of total billed charges,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.55,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,52.08,100,,,Fee Schedule,100% of Custom Fee Schedule,440.98,90,,352.78,percent of total billed charges,90% of total billed charges for outpatient setting,52.08,440.98,
IVA SEAL: RED,3301327,CDM,270,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IVA SEAL: RED,3301328,CDM,270,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
IVIG PREADMINISTRATION FEE,3303135,CDM,640,RC,,,Outpatient,,,278.49,278.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.94,70,,155.95,percent of total billed charges,70% of total billed charges for outpatient setting,236.38,84.88,,189.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,139.25,50,,111.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.87,75,,167.1,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,70,,155.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.76,12.84,,28.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,80,,178.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.76,12.84,,28.61,percent of total billed charges,12.84% of total billed charges,35.76,12.84,,28.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,35,,77.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,250.64,90,,200.51,percent of total billed charges,90% of total billed charges for outpatient setting,35.76,250.64,
IVP W/O TOMO,2400735,CDM,320,RC,74400,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
JAK2 GENE V617F MUTATION QUALITATIVE,201337,CDM,300,RC,81270,HCPCS,Outpatient,,,412.47,371.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.73,70,,230.98,percent of total billed charges,70% of total billed charges for outpatient setting,350.1,84.88,,280.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,157.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,309.35,75,,247.48,percent of total billed charges,75% of total billed charges for outpatient setting,288.73,70,,230.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.96,12.84,,42.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.98,80,,263.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.96,12.84,,42.37,percent of total billed charges,12.84% of total billed charges,52.96,12.84,,42.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,125.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.83,100,,,Fee Schedule,100% of Custom Fee Schedule,371.22,90,,296.98,percent of total billed charges,90% of total billed charges for outpatient setting,52.96,371.22,
JANUVIA (SITAGLILPTIN) 50MG  TAB,3313987,CDM,259,RC,,,Outpatient,,,103.18,103.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.23,70,,57.78,percent of total billed charges,70% of total billed charges for outpatient setting,87.58,84.88,,70.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.59,50,,41.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.39,75,,61.91,percent of total billed charges,75% of total billed charges for outpatient setting,72.23,70,,57.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.54,80,,66.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.07,65,,53.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.11,35,,28.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.86,90,,74.29,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,92.86,
JANUVIA 100 MG : TAB,3303205,CDM,259,RC,,,Outpatient,,,22.21,22.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.55,70,,12.44,percent of total billed charges,70% of total billed charges for outpatient setting,18.85,84.88,,15.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.11,50,,8.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.66,75,,13.33,percent of total billed charges,75% of total billed charges for outpatient setting,15.55,70,,12.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.77,80,,14.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.44,65,,11.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,35,,6.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.99,90,,15.99,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.99,
JELCO IV CATH 14G 1.25IN / 4048,6152893,CDM,272,RC,,,Outpatient,,,18.24,18.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,70,,10.22,percent of total billed charges,70% of total billed charges for outpatient setting,15.48,84.88,,12.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.12,50,,7.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.68,75,,10.94,percent of total billed charges,75% of total billed charges for outpatient setting,12.77,70,,10.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,12.84,,1.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.59,80,,11.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,12.84,,1.87,percent of total billed charges,12.84% of total billed charges,2.34,12.84,,1.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.86,65,,9.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.38,35,,5.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.42,90,,13.14,percent of total billed charges,90% of total billed charges for outpatient setting,2.34,16.42,
JELCO IV CATH 16g X 1.25  JJ4042,6152613,CDM,272,RC,,,Outpatient,,,22.92,22.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,70,,12.83,percent of total billed charges,70% of total billed charges for outpatient setting,19.45,84.88,,15.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.46,50,,9.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.19,75,,13.75,percent of total billed charges,75% of total billed charges for outpatient setting,16.04,70,,12.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.34,80,,14.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.9,65,,11.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,35,,6.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.63,90,,16.5,percent of total billed charges,90% of total billed charges for outpatient setting,2.94,20.63,
JELCO IV CATH 18GX1.25 / 4055,6152892,CDM,272,RC,,,Outpatient,,,20.7,20.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,17.57,84.88,,14.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.35,50,,8.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,75,,12.42,percent of total billed charges,75% of total billed charges for outpatient setting,14.49,70,,11.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,12.84,,2.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.56,80,,13.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,12.84,,2.13,percent of total billed charges,12.84% of total billed charges,2.66,12.84,,2.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.46,65,,10.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,35,,5.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.63,90,,14.9,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,18.63,
JELCO IV CATH 20g X 1.25  /JJ4056,6152891,CDM,272,RC,,,Outpatient,,,23.73,23.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,70,,13.29,percent of total billed charges,70% of total billed charges for outpatient setting,20.14,84.88,,16.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.87,50,,9.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.8,75,,14.24,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,70,,13.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,80,,15.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,65,,12.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,35,,6.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.36,90,,17.09,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,21.36,
JELCO IV CATH 22G X 1IN / 405011,761680,CDM,272,RC,,,Outpatient,,,18.72,18.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,70,,10.48,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,84.88,,12.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.36,50,,7.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.04,75,,11.23,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,70,,10.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.4,12.84,,1.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,80,,11.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.4,12.84,,1.92,percent of total billed charges,12.84% of total billed charges,2.4,12.84,,1.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.17,65,,9.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.55,35,,5.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.85,90,,13.48,percent of total billed charges,90% of total billed charges for outpatient setting,2.4,16.85,
JELCO IV CATH 24G 0.75IN / 405311,761685,CDM,272,RC,,,Outpatient,,,18.14,18.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,70,,10.16,percent of total billed charges,70% of total billed charges for outpatient setting,15.4,84.88,,12.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.07,50,,7.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.61,75,,10.89,percent of total billed charges,75% of total billed charges for outpatient setting,12.7,70,,10.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,80,,11.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.79,65,,9.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.35,35,,5.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.33,90,,13.06,percent of total billed charges,90% of total billed charges for outpatient setting,2.33,16.33,
JELLY LUBRICATING SYRINGE / DYNJLUBESYR,69169265,CDM,272,RC,,,Outpatient,,,8.73,8.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,70,,4.89,percent of total billed charges,70% of total billed charges for outpatient setting,7.41,84.88,,5.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.37,50,,3.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.55,75,,5.24,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,70,,4.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,80,,5.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,65,,4.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,35,,2.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.86,90,,6.29,percent of total billed charges,90% of total billed charges for outpatient setting,1.12,7.86,
JEVITY NUTRITION 1.5 CAL,3314041,CDM,259,RC,,,Outpatient,,,55.96,55.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.17,70,,31.34,percent of total billed charges,70% of total billed charges for outpatient setting,47.5,84.88,,38,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.98,50,,22.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.97,75,,33.58,percent of total billed charges,75% of total billed charges for outpatient setting,39.17,70,,31.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.19,12.84,,5.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.77,80,,35.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.19,12.84,,5.75,percent of total billed charges,12.84% of total billed charges,7.19,12.84,,5.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.37,65,,29.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,35,,15.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.36,90,,40.29,percent of total billed charges,90% of total billed charges for outpatient setting,7.19,50.36,
JP DRAIN EVACUATOR 100ML / SU130-1305,6150224,CDM,272,RC,,,Outpatient,,,32.8,32.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.96,70,,18.37,percent of total billed charges,70% of total billed charges for outpatient setting,27.84,84.88,,22.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.4,50,,13.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.6,75,,19.68,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,70,,18.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.24,80,,20.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.32,65,,17.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,35,,9.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.52,90,,23.62,percent of total billed charges,90% of total billed charges for outpatient setting,4.21,29.52,
JUGGERKNOT 1.4MM SHRT W/NEEDLES 912068,69161978,CDM,278,RC,,,Outpatient,,,1834.22,1834.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.53,60,,880.42,percent of total billed charges,60% of total Billed charges for outpatient setting,1556.89,84.88,,1245.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,917.11,50,,733.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1375.67,75,,1100.54,percent of total billed charges,75% of total billed charges for outpatient setting,917.11,50,,733.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.51,12.84,,188.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1467.38,80,,1173.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.51,12.84,,188.41,percent of total billed charges,12.84% of total billed charges,235.51,12.84,,188.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1834.22,65,,1467.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.98,35,,513.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1100.53,60,,880.42,percent of total billed charges,60% of total billed charges for outpatient setting,235.51,1834.22,
JUGGERKNOT 2.9MM #2 BLUE2  912029,69161492,CDM,278,RC,,,Outpatient,,,2033.22,2033.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.93,60,,975.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1725.8,84.88,,1380.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1524.92,75,,1219.94,percent of total billed charges,75% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.58,80,,1301.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2033.22,65,,1626.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.63,35,,569.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1219.93,60,,975.94,percent of total billed charges,60% of total billed charges for outpatient setting,261.07,2033.22,
JUGGERKNOT 2.9MM 2  #2 WHITE  912050,69161493,CDM,278,RC,,,Outpatient,,,2033.22,2033.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.93,60,,975.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1725.8,84.88,,1380.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1524.92,75,,1219.94,percent of total billed charges,75% of total billed charges for outpatient setting,1016.61,50,,813.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.58,80,,1301.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,261.07,12.84,,208.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2033.22,65,,1626.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.63,35,,569.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1219.93,60,,975.94,percent of total billed charges,60% of total billed charges for outpatient setting,261.07,2033.22,
JUGGERKNOT 2.9MM DISPOSABLE KIT  912057,69161494,CDM,272,RC,,,Outpatient,,,1890.46,1890.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323.32,70,,1058.66,percent of total billed charges,70% of total billed charges for outpatient setting,1604.62,84.88,,1283.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,945.23,50,,756.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1417.85,75,,1134.28,percent of total billed charges,75% of total billed charges for outpatient setting,1323.32,70,,1058.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.74,12.84,,194.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512.37,80,,1209.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.74,12.84,,194.19,percent of total billed charges,12.84% of total billed charges,242.74,12.84,,194.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1228.8,65,,983.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.66,35,,529.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701.41,90,,1361.13,percent of total billed charges,90% of total billed charges for outpatient setting,242.74,1701.41,
JURGAN PIN BALL BLUE 2MM / W564-BL,6152247,CDM,270,RC,,,Outpatient,,,47.78,47.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,70,,26.76,percent of total billed charges,70% of total billed charges for outpatient setting,40.56,84.88,,32.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.89,50,,19.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.84,75,,28.67,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,70,,26.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.22,80,,30.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.06,65,,24.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.72,35,,13.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43,90,,34.4,percent of total billed charges,90% of total billed charges for outpatient setting,6.13,43,
JURGAN PIN BALLS GREEN / W062-GN,612162,CDM,270,RC,,,Outpatient,,,49,49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,41.59,84.88,,33.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,75,,29.4,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,80,,31.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.85,65,,25.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.1,90,,35.28,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.1,
JURGAN PIN BALLS YELLOW 1.1MM / WO45-YL,6152161,CDM,270,RC,,,Outpatient,,,47.78,47.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,70,,26.76,percent of total billed charges,70% of total billed charges for outpatient setting,40.56,84.88,,32.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.89,50,,19.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.84,75,,28.67,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,70,,26.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.22,80,,30.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,6.13,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.06,65,,24.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.72,35,,13.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43,90,,34.4,percent of total billed charges,90% of total billed charges for outpatient setting,6.13,43,
JURGAN PINBALL 7/64-1/8 13MM / X003,6152245,CDM,270,RC,,,Outpatient,,,41.64,41.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,70,,23.32,percent of total billed charges,70% of total billed charges for outpatient setting,35.34,84.88,,28.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.82,50,,16.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.23,75,,24.98,percent of total billed charges,75% of total billed charges for outpatient setting,29.15,70,,23.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.31,80,,26.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.07,65,,21.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,35,,11.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.48,90,,29.98,percent of total billed charges,90% of total billed charges for outpatient setting,5.35,37.48,
JURGAN PINBALL 9/64-5/32 4MM / X004,6152246,CDM,270,RC,,,Outpatient,,,41.64,41.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,70,,23.32,percent of total billed charges,70% of total billed charges for outpatient setting,35.34,84.88,,28.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.82,50,,16.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.23,75,,24.98,percent of total billed charges,75% of total billed charges for outpatient setting,29.15,70,,23.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.31,80,,26.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,5.35,12.84,,4.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.07,65,,21.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,35,,11.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.48,90,,29.98,percent of total billed charges,90% of total billed charges for outpatient setting,5.35,37.48,
JURGAN PINBALL CREAM 2.5MM / W332-CR,6152248,CDM,270,RC,,,Outpatient,,,45.42,45.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,38.55,84.88,,30.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.71,50,,18.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.07,75,,27.26,percent of total billed charges,75% of total billed charges for outpatient setting,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,80,,29.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.52,65,,23.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.9,35,,12.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.88,90,,32.7,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.88,
JUST LIKE (TOP):,3302648,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
JUVEN POWDER 27.5GM PKT,3313649,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
K,200595,CDM,300,RC,84132,HCPCS,Outpatient,,,21.42,19.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,18.18,84.88,,14.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,19.28,90,,15.42,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,19.28,
K WIRE 0.9X80MM  451-1136,69162732,CDM,278,RC,,,Outpatient,,,94.82,94.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.89,60,,45.51,percent of total billed charges,60% of total Billed charges for outpatient setting,80.48,84.88,,64.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.41,50,,37.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.12,75,,56.9,percent of total billed charges,75% of total billed charges for outpatient setting,47.41,50,,37.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.17,12.84,,9.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.86,80,,60.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.17,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,12.17,12.84,,9.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.82,65,,75.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.19,35,,26.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.89,60,,45.51,percent of total billed charges,60% of total billed charges for outpatient setting,12.17,94.82,
K WIRE 1.0MM      AGK10070,69161632,CDM,278,RC,L8699,HCPCS,Outpatient,,,218.34,218.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,60,,104.8,percent of total billed charges,60% of total Billed charges for outpatient setting,185.33,84.88,,148.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.17,50,,87.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.76,75,,131.01,percent of total billed charges,75% of total billed charges for outpatient setting,109.17,50,,87.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.03,12.84,,22.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.67,80,,139.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.03,12.84,,22.42,percent of total billed charges,12.84% of total billed charges,28.03,12.84,,22.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,218.34,65,,174.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.42,35,,61.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131,60,,104.8,percent of total billed charges,60% of total billed charges for outpatient setting,28.03,218.34,
K WIRE 1.0MM TROCAR PT / 292.10,69162490,CDM,278,RC,C1713,HCPCS,Outpatient,,,425.88,425.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.53,60,,204.42,percent of total billed charges,60% of total Billed charges for outpatient setting,361.49,84.88,,289.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.41,75,,255.53,percent of total billed charges,75% of total billed charges for outpatient setting,212.94,50,,170.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.68,12.84,,43.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.7,80,,272.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.68,12.84,,43.74,percent of total billed charges,12.84% of total billed charges,54.68,12.84,,43.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,425.88,65,,340.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.06,35,,119.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,255.53,60,,204.42,percent of total billed charges,60% of total billed charges for outpatient setting,54.68,425.88,
K WIRE 1.0MM TROCAR PT BTH ENDS / 292.50,6150649,CDM,278,RC,,,Outpatient,,,87.76,87.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.66,60,,42.13,percent of total billed charges,60% of total Billed charges for outpatient setting,74.49,84.88,,59.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.88,50,,35.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.82,75,,52.66,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,50,,35.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,12.84,,9.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.21,80,,56.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,12.84,,9.02,percent of total billed charges,12.84% of total billed charges,11.27,12.84,,9.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.76,65,,70.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,35,,24.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.66,60,,42.13,percent of total billed charges,60% of total billed charges for outpatient setting,11.27,87.76,
K WIRE 1.25MM TROCAR PT / 292.12,69162494,CDM,278,RC,L8699,HCPCS,Outpatient,,,70.98,70.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.59,60,,34.07,percent of total billed charges,60% of total Billed charges for outpatient setting,60.25,84.88,,48.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.49,50,,28.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.24,75,,42.59,percent of total billed charges,75% of total billed charges for outpatient setting,35.49,50,,28.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,80,,45.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.98,65,,56.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,35,,19.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.59,60,,34.07,percent of total billed charges,60% of total billed charges for outpatient setting,9.11,70.98,
K WIRE 1.25MM TROCAR PT BOTH END /292.52,6150650,CDM,278,RC,C1713,HCPCS,Outpatient,,,87.76,87.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.66,60,,42.13,percent of total billed charges,60% of total Billed charges for outpatient setting,74.49,84.88,,59.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.82,75,,52.66,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,50,,35.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,12.84,,9.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.21,80,,56.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,12.84,,9.02,percent of total billed charges,12.84% of total billed charges,11.27,12.84,,9.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.76,65,,70.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,35,,24.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.66,60,,42.13,percent of total billed charges,60% of total billed charges for outpatient setting,11.27,87.76,
K WIRE 1.25X150MM STRYKER / 390157,69162681,CDM,278,RC,C1713,HCPCS,Outpatient,,,45.22,45.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.13,60,,21.7,percent of total billed charges,60% of total Billed charges for outpatient setting,38.38,84.88,,30.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.92,75,,27.14,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,50,,18.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.81,12.84,,4.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,80,,28.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.81,12.84,,4.65,percent of total billed charges,12.84% of total billed charges,5.81,12.84,,4.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.22,65,,36.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,35,,12.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.13,60,,21.7,percent of total billed charges,60% of total billed charges for outpatient setting,5.81,45.22,
K WIRE 1.6MM Biomet  8290-16-006,69161591,CDM,278,RC,,,Outpatient,,,206.08,206.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.65,60,,98.92,percent of total billed charges,60% of total Billed charges for outpatient setting,174.92,84.88,,139.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.04,50,,82.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.56,75,,123.65,percent of total billed charges,75% of total billed charges for outpatient setting,103.04,50,,82.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,12.84,,21.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.86,80,,131.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,12.84,,21.17,percent of total billed charges,12.84% of total billed charges,26.46,12.84,,21.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,206.08,65,,164.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.13,35,,57.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.65,60,,98.92,percent of total billed charges,60% of total billed charges for outpatient setting,26.46,206.08,
K WIRE 1.6MM TROCAR PT / 292.16,69162491,CDM,278,RC,C1713,HCPCS,Outpatient,,,80.22,80.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.13,60,,38.5,percent of total billed charges,60% of total Billed charges for outpatient setting,68.09,84.88,,54.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.17,75,,48.14,percent of total billed charges,75% of total billed charges for outpatient setting,40.11,50,,32.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.18,80,,51.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.22,65,,64.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.08,35,,22.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.13,60,,38.5,percent of total billed charges,60% of total billed charges for outpatient setting,10.3,80.22,
K WIRE 1.6MM TROCAR PT BTH ENDS / 292.56,6150651,CDM,278,RC,,,Outpatient,,,103.87,103.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.32,60,,49.86,percent of total billed charges,60% of total Billed charges for outpatient setting,88.16,84.88,,70.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.94,50,,41.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,75,,62.32,percent of total billed charges,75% of total billed charges for outpatient setting,51.94,50,,41.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,12.84,,10.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,80,,66.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,12.84,,10.67,percent of total billed charges,12.84% of total billed charges,13.34,12.84,,10.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,103.87,65,,83.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,35,,29.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.32,60,,49.86,percent of total billed charges,60% of total billed charges for outpatient setting,13.34,103.87,
K WIRE 1.6MMX285MM TROCAR PT / 292.18,69162493,CDM,278,RC,,,Outpatient,,,82.29,82.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.37,60,,39.5,percent of total billed charges,60% of total Billed charges for outpatient setting,69.85,84.88,,55.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.15,50,,32.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.72,75,,49.38,percent of total billed charges,75% of total billed charges for outpatient setting,41.15,50,,32.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.57,12.84,,8.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.83,80,,52.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.57,12.84,,8.46,percent of total billed charges,12.84% of total billed charges,10.57,12.84,,8.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.29,65,,65.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,35,,23.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.37,60,,39.5,percent of total billed charges,60% of total billed charges for outpatient setting,10.57,82.29,
K WIRE 1.6X127MM / KW062SS,69169571,CDM,278,RC,,,Outpatient,,,138.6,138.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,60,,66.53,percent of total billed charges,60% of total Billed charges for outpatient setting,117.64,84.88,,94.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.3,50,,55.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.95,75,,83.16,percent of total billed charges,75% of total billed charges for outpatient setting,69.3,50,,55.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,80,,88.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,138.6,65,,110.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.51,35,,38.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.16,60,,66.53,percent of total billed charges,60% of total billed charges for outpatient setting,17.8,138.6,
K WIRE 1.6X150MM / 390164,69161954,CDM,278,RC,C1713,HCPCS,Outpatient,,,45.22,45.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.13,60,,21.7,percent of total billed charges,60% of total Billed charges for outpatient setting,38.38,84.88,,30.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.92,75,,27.14,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,50,,18.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.81,12.84,,4.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,80,,28.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.81,12.84,,4.65,percent of total billed charges,12.84% of total billed charges,5.81,12.84,,4.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.22,65,,36.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,35,,12.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.13,60,,21.7,percent of total billed charges,60% of total billed charges for outpatient setting,5.81,45.22,
K WIRE 1.6X150MM TI / 492.16,69162575,CDM,278,RC,C1769,HCPCS,Outpatient,,,80.09,80.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.05,60,,38.44,percent of total billed charges,60% of total Billed charges for outpatient setting,67.98,84.88,,54.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.07,75,,48.06,percent of total billed charges,75% of total billed charges for outpatient setting,40.05,50,,32.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,12.84,,8.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.07,80,,51.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,12.84,,8.22,percent of total billed charges,12.84% of total billed charges,10.28,12.84,,8.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.09,65,,64.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.03,35,,22.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.05,60,,38.44,percent of total billed charges,60% of total billed charges for outpatient setting,10.28,80.09,
K WIRE 1.8X310MM CONDYLE / 0152-0218S,70000686,CDM,278,RC,,,Outpatient,,,250.48,250.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.29,60,,120.23,percent of total billed charges,60% of total Billed charges for outpatient setting,212.61,84.88,,170.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.24,50,,100.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.86,75,,150.29,percent of total billed charges,75% of total billed charges for outpatient setting,125.24,50,,100.19,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,12.84,,25.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.38,80,,160.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,12.84,,25.73,percent of total billed charges,12.84% of total billed charges,32.16,12.84,,25.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,250.48,65,,200.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.67,35,,70.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.29,60,,120.23,percent of total billed charges,60% of total billed charges for outpatient setting,32.16,250.48,
K WIRE 2.0MM / 390192,69161549,CDM,278,RC,,,Outpatient,,,115.2,115.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.12,60,,55.3,percent of total billed charges,60% of total Billed charges for outpatient setting,97.78,84.88,,78.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.6,50,,46.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.4,75,,69.12,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,50,,46.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,12.84,,11.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,80,,73.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,12.84,,11.83,percent of total billed charges,12.84% of total billed charges,14.79,12.84,,11.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.2,65,,92.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,35,,32.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.12,60,,55.3,percent of total billed charges,60% of total billed charges for outpatient setting,14.79,115.2,
K WIRE 2.0MM / 702460S,69162537,CDM,278,RC,C1713,HCPCS,Outpatient,,,389.34,389.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.6,60,,186.88,percent of total billed charges,60% of total Billed charges for outpatient setting,330.47,84.88,,264.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.01,75,,233.61,percent of total billed charges,75% of total billed charges for outpatient setting,194.67,50,,155.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,80,,249.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,389.34,65,,311.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,35,,109.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.6,60,,186.88,percent of total billed charges,60% of total billed charges for outpatient setting,49.99,389.34,
K WIRE 2.0MM TROCAR PT / 292.20,69162492,CDM,278,RC,C1713,HCPCS,Outpatient,,,80.22,80.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.13,60,,38.5,percent of total billed charges,60% of total Billed charges for outpatient setting,68.09,84.88,,54.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.17,75,,48.14,percent of total billed charges,75% of total billed charges for outpatient setting,40.11,50,,32.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.18,80,,51.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,10.3,12.84,,8.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.22,65,,64.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.08,35,,22.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.13,60,,38.5,percent of total billed charges,60% of total billed charges for outpatient setting,10.3,80.22,
K WIRE 2.0MM TROCAR PT BOTH ENDS/ 292.58,6150652,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.83,77.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.7,60,,37.36,percent of total billed charges,60% of total Billed charges for outpatient setting,66.06,84.88,,52.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.37,75,,46.7,percent of total billed charges,75% of total billed charges for outpatient setting,38.92,50,,31.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,12.84,,7.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.26,80,,49.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,12.84,,7.99,percent of total billed charges,12.84% of total billed charges,9.99,12.84,,7.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.83,65,,62.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,35,,21.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.7,60,,37.36,percent of total billed charges,60% of total billed charges for outpatient setting,9.99,77.83,
K WIRE 2.5MM TROCAR POINT / 292.25,6150653,CDM,278,RC,C1713,HCPCS,Outpatient,,,70.98,70.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.59,60,,34.07,percent of total billed charges,60% of total Billed charges for outpatient setting,60.25,84.88,,48.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.24,75,,42.59,percent of total billed charges,75% of total billed charges for outpatient setting,35.49,50,,28.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,80,,45.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.98,65,,56.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,35,,19.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.59,60,,34.07,percent of total billed charges,60% of total billed charges for outpatient setting,9.11,70.98,
K WIRE 3.0MMX150MM W/TROCAR PT/ 292.30,6150656,CDM,278,RC,,,Outpatient,,,74.53,74.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.72,60,,35.78,percent of total billed charges,60% of total Billed charges for outpatient setting,63.26,84.88,,50.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.27,50,,29.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.9,75,,44.72,percent of total billed charges,75% of total billed charges for outpatient setting,37.27,50,,29.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.62,80,,47.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,9.57,12.84,,7.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.53,65,,59.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.09,35,,20.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.72,60,,35.78,percent of total billed charges,60% of total billed charges for outpatient setting,9.57,74.53,
K WIRE TROCAR POINT / 390162,70000164,CDM,278,RC,,,Outpatient,,,79.5,79.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,60,,38.16,percent of total billed charges,60% of total Billed charges for outpatient setting,67.48,84.88,,53.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.75,50,,31.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,75,,47.7,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,50,,31.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,12.84,,8.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,80,,50.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,12.84,,8.17,percent of total billed charges,12.84% of total billed charges,10.21,12.84,,8.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.5,65,,63.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.83,35,,22.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.7,60,,38.16,percent of total billed charges,60% of total billed charges for outpatient setting,10.21,79.5,
K WIRE W/ LENGTH MARKINGS / 07-40281,70000116,CDM,278,RC,C1769,HCPCS,Outpatient,,,154.12,154.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.47,60,,73.98,percent of total billed charges,60% of total Billed charges for outpatient setting,130.82,84.88,,104.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.59,75,,92.47,percent of total billed charges,75% of total billed charges for outpatient setting,77.06,50,,61.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.79,12.84,,15.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,80,,98.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.79,12.84,,15.83,percent of total billed charges,12.84% of total billed charges,19.79,12.84,,15.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.12,65,,123.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.94,35,,43.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.47,60,,73.98,percent of total billed charges,60% of total billed charges for outpatient setting,19.79,154.12,
K WIRE W/ OLIVE STOP / 56-40281,70000055,CDM,278,RC,C1769,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.2,60,,58.56,percent of total billed charges,60% of total Billed charges for outpatient setting,103.55,84.88,,82.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.5,75,,73.2,percent of total billed charges,75% of total billed charges for outpatient setting,61,50,,48.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.66,12.84,,12.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.6,80,,78.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.66,12.84,,12.53,percent of total billed charges,12.84% of total billed charges,15.66,12.84,,12.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122,65,,97.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,35,,34.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.2,60,,58.56,percent of total billed charges,60% of total billed charges for outpatient setting,15.66,122,
K WIRE W/ STOP / 703818,69162682,CDM,278,RC,,,Outpatient,,,275.2,275.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.12,60,,132.1,percent of total billed charges,60% of total Billed charges for outpatient setting,233.59,84.88,,186.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,137.6,50,,110.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.4,75,,165.12,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,50,,110.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.34,12.84,,28.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.16,80,,176.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.34,12.84,,28.27,percent of total billed charges,12.84% of total billed charges,35.34,12.84,,28.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.2,65,,220.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.32,35,,77.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,165.12,60,,132.1,percent of total billed charges,60% of total billed charges for outpatient setting,35.34,275.2,
"K WIRE, W/PT 1.8x150MM / 02.110.300",69161299,CDM,278,RC,,,Outpatient,,,386.7,386.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.02,60,,185.62,percent of total billed charges,60% of total Billed charges for outpatient setting,328.23,84.88,,262.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,193.35,50,,154.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.03,75,,232.02,percent of total billed charges,75% of total billed charges for outpatient setting,193.35,50,,154.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.65,12.84,,39.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.36,80,,247.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.65,12.84,,39.72,percent of total billed charges,12.84% of total billed charges,49.65,12.84,,39.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,386.7,65,,309.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.35,35,,108.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.02,60,,185.62,percent of total billed charges,60% of total billed charges for outpatient setting,49.65,386.7,
K WIRE1.1MM  451-0016,69169124,CDM,278,RC,,,Outpatient,,,90.85,90.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,60,,43.61,percent of total billed charges,60% of total Billed charges for outpatient setting,77.11,84.88,,61.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.43,50,,36.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.14,75,,54.51,percent of total billed charges,75% of total billed charges for outpatient setting,45.43,50,,36.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,80,,58.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.67,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.85,65,,72.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.8,35,,25.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.51,60,,43.61,percent of total billed charges,60% of total billed charges for outpatient setting,11.67,90.85,
K WIRES   675.399S,69162034,CDM,272,RC,,,Outpatient,,,856.55,856.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.59,70,,479.67,percent of total billed charges,70% of total billed charges for outpatient setting,727.04,84.88,,581.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,428.28,50,,342.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,642.41,75,,513.93,percent of total billed charges,75% of total billed charges for outpatient setting,599.59,70,,479.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.98,12.84,,87.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.24,80,,548.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.98,12.84,,87.98,percent of total billed charges,12.84% of total billed charges,109.98,12.84,,87.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,556.76,65,,445.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.79,35,,239.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,770.9,90,,616.72,percent of total billed charges,90% of total billed charges for outpatient setting,109.98,770.9,
KAMVAC SUCTION TIP / 5300-20500,6152162,CDM,270,RC,,,Outpatient,,,296,296,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.2,70,,165.76,percent of total billed charges,70% of total billed charges for outpatient setting,251.24,84.88,,200.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,148,50,,118.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222,75,,177.6,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,70,,165.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.01,12.84,,30.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.8,80,,189.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.01,12.84,,30.41,percent of total billed charges,12.84% of total billed charges,38.01,12.84,,30.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,192.4,65,,153.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.6,35,,82.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,266.4,90,,213.12,percent of total billed charges,90% of total billed charges for outpatient setting,38.01,266.4,
KANAMYCIN (KANTREX) INJ: 500MG,3301329,CDM,636,RC,J1840,HCPCS,Outpatient,,,30.68,30.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,26.04,84.88,,20.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.01,75,,18.41,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.54,80,,19.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.94,65,,15.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.61,90,,22.09,percent of total billed charges,90% of total billed charges for outpatient setting,3.94,27.61,
KANAMYCIN (KANTREX) INJ:1 GM,3301330,CDM,250,RC,,,Outpatient,,,74.14,74.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,62.93,84.88,,50.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.07,50,,29.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.61,75,,44.49,percent of total billed charges,75% of total billed charges for outpatient setting,51.9,70,,41.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.31,80,,47.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,9.52,12.84,,7.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.19,65,,38.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,35,,20.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.73,90,,53.38,percent of total billed charges,90% of total billed charges for outpatient setting,9.52,66.73,
KEITH NEEDLE 2IN / 213406,6152642,CDM,270,RC,,,Outpatient,,,10.48,10.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.34,70,,5.87,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,84.88,,7.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.24,50,,4.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.86,75,,6.29,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,70,,5.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,80,,6.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.81,65,,5.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,35,,2.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.43,90,,7.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.35,9.43,
KELMAN 45 DG 0.9 TURBOSONIC / 8065750853,69161452,CDM,271,RC,,,Outpatient,,,237.93,237.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,201.95,84.88,,161.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.97,50,,95.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.45,75,,142.76,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.34,80,,152.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.65,65,,123.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.28,35,,66.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.14,90,,171.31,percent of total billed charges,90% of total billed charges for outpatient setting,30.55,214.14,
KENALOG (TRIAMCINOLONE ACT)40MG/ML 5ML,3314053,CDM,250,RC,,,Outpatient,,,224.35,224.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.05,70,,125.64,percent of total billed charges,70% of total billed charges for outpatient setting,190.43,84.88,,152.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.18,50,,89.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.26,75,,134.61,percent of total billed charges,75% of total billed charges for outpatient setting,157.05,70,,125.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.48,80,,143.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.83,65,,116.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.52,35,,62.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,201.92,90,,161.54,percent of total billed charges,90% of total billed charges for outpatient setting,28.81,201.92,
KENALOG 40MG INJ: 1ML,3302568,CDM,250,RC,J3301,HCPCS,Outpatient,,,66.93,66.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.85,70,,37.48,percent of total billed charges,70% of total billed charges for outpatient setting,56.81,84.88,,45.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.2,75,,40.16,percent of total billed charges,75% of total billed charges for outpatient setting,46.85,70,,37.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.59,12.84,,6.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,80,,42.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.59,12.84,,6.87,percent of total billed charges,12.84% of total billed charges,8.59,12.84,,6.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.5,65,,34.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,100,,,Fee Schedule,100% of Custom Fee Schedule,60.24,90,,48.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.23,60.24,
KENALOG 40MG INJ: 5ML,3302567,CDM,250,RC,,,Outpatient,,,95.28,95.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.7,70,,53.36,percent of total billed charges,70% of total billed charges for outpatient setting,80.87,84.88,,64.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.64,50,,38.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.46,75,,57.17,percent of total billed charges,75% of total billed charges for outpatient setting,66.7,70,,53.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.23,12.84,,9.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.22,80,,60.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.23,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,12.23,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.93,65,,49.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.35,35,,26.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.75,90,,68.6,percent of total billed charges,90% of total billed charges for outpatient setting,12.23,85.75,
KERI LOTION:60ML,3302599,CDM,259,RC,,,Outpatient,,,11.88,11.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.91,75,,7.13,percent of total billed charges,75% of total billed charges for outpatient setting,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,35,,3.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.69,90,,8.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.53,10.69,
KERLEX ROLL 4IN / 6715,6150469,CDM,272,RC,,,Outpatient,,,7.74,7.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.42,70,,4.34,percent of total billed charges,70% of total billed charges for outpatient setting,6.57,84.88,,5.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.87,50,,3.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.81,75,,4.65,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,70,,4.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,80,,4.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.03,65,,4.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.71,35,,2.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.97,90,,5.58,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.97,
KETAMINE (KETALAR) 100mg/ml: 5ml vial,3301333,CDM,250,RC,,,Outpatient,,,42.79,42.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.95,70,,23.96,percent of total billed charges,70% of total billed charges for outpatient setting,36.32,84.88,,29.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.4,50,,17.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.09,75,,25.67,percent of total billed charges,75% of total billed charges for outpatient setting,29.95,70,,23.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.23,80,,27.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,5.49,12.84,,4.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.81,65,,22.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,35,,11.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.51,90,,30.81,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,38.51,
KETAMINE (KETALAR) 50mg/ml  10ml vial,3309432,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
KETAMINE (KETALAR) INJ 50MG/ML :10ML,3301331,CDM,250,RC,,,Outpatient,,,22.02,22.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,70,,12.33,percent of total billed charges,70% of total billed charges for outpatient setting,18.69,84.88,,14.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.01,50,,8.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,75,,13.22,percent of total billed charges,75% of total billed charges for outpatient setting,15.41,70,,12.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,80,,14.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.31,65,,11.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,35,,6.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.82,90,,15.86,percent of total billed charges,90% of total billed charges for outpatient setting,2.83,19.82,
KETAMINE (KETGALAR) INJ 50MG/ML: 10ML,3301332,CDM,250,RC,,,Outpatient,,,42.05,42.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.44,70,,23.55,percent of total billed charges,70% of total billed charges for outpatient setting,35.69,84.88,,28.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.03,50,,16.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,75,,25.23,percent of total billed charges,75% of total billed charges for outpatient setting,29.44,70,,23.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.64,80,,26.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.33,65,,21.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.72,35,,11.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.85,90,,30.28,percent of total billed charges,90% of total billed charges for outpatient setting,5.4,37.85,
KETAMINE 50mg/5ml SYRINGE (FAGRON),3314054,CDM,250,RC,,,Outpatient,,,38.5,38.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,32.68,84.88,,26.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.25,50,,15.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,75,,23.1,percent of total billed charges,75% of total billed charges for outpatient setting,26.95,70,,21.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,80,,24.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.03,65,,20.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,35,,10.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.65,
KETAMINE 50mg/ml 1ml SYRINGE (FAGRON),3313742,CDM,250,RC,,,Outpatient,,,35.7,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,84.88,,24.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.85,50,,14.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,75,,21.42,percent of total billed charges,75% of total billed charges for outpatient setting,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,80,,22.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.21,65,,18.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,35,,10,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.13,90,,25.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,32.13,
KETAMINE 50mg/ml 1ml UD charge,3307417,CDM,250,RC,,,Outpatient,,,35.7,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,84.88,,24.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.85,50,,14.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,75,,21.42,percent of total billed charges,75% of total billed charges for outpatient setting,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,80,,22.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.21,65,,18.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,35,,10,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.13,90,,25.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,32.13,
KETOCONAZOLE (NIZORAL) CRM : 15 GM,3301334,CDM,259,RC,,,Outpatient,,,42.32,42.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,70,,23.7,percent of total billed charges,70% of total billed charges for outpatient setting,35.92,84.88,,28.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.16,50,,16.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.74,75,,25.39,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,70,,23.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,12.84,,4.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.86,80,,27.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,12.84,,4.34,percent of total billed charges,12.84% of total billed charges,5.43,12.84,,4.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.51,65,,22.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,35,,11.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.09,90,,30.47,percent of total billed charges,90% of total billed charges for outpatient setting,5.43,38.09,
KETOCONAZOLE (NIZORAL) CRM : 15 GM,3301336,CDM,259,RC,,,Outpatient,,,58.07,58.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.65,70,,32.52,percent of total billed charges,70% of total billed charges for outpatient setting,49.29,84.88,,39.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.04,50,,23.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.55,75,,34.84,percent of total billed charges,75% of total billed charges for outpatient setting,40.65,70,,32.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,12.84,,5.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.46,80,,37.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,12.84,,5.97,percent of total billed charges,12.84% of total billed charges,7.46,12.84,,5.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.75,65,,30.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,35,,16.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.26,90,,41.81,percent of total billed charges,90% of total billed charges for outpatient setting,7.46,52.26,
KETOCONAZOLE (NIZORAL) TAB : 100 MG,3303094,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
KETOCONAZOLE (NIZORAL) TAB : 200 MG,3301335,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
KETOROLAC (ACULAR) OPTH SOL 0.5% : 3ML,3301337,CDM,259,RC,,,Outpatient,,,80.41,80.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.29,70,,45.03,percent of total billed charges,70% of total billed charges for outpatient setting,68.25,84.88,,54.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.21,50,,32.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.31,75,,48.25,percent of total billed charges,75% of total billed charges for outpatient setting,56.29,70,,45.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,80,,51.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.27,65,,41.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,35,,22.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.37,90,,57.9,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,72.37,
KETOROLAC (ACULAR) OPTH SOL 0.5% : 5ML,3301339,CDM,259,RC,,,Outpatient,,,135.06,135.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.54,70,,75.63,percent of total billed charges,70% of total billed charges for outpatient setting,114.64,84.88,,91.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.53,50,,54.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.3,75,,81.04,percent of total billed charges,75% of total billed charges for outpatient setting,94.54,70,,75.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.34,12.84,,13.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.05,80,,86.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.34,12.84,,13.87,percent of total billed charges,12.84% of total billed charges,17.34,12.84,,13.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.79,65,,70.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.27,35,,37.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.55,90,,97.24,percent of total billed charges,90% of total billed charges for outpatient setting,17.34,121.55,
KETOROLAC (genericTORADOL) TAB 10 MG,3301340,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
KETOROLAC (TORADOL) 15MG/ML INJ:1ML,3305256,CDM,636,RC,J1885,HCPCS,Outpatient,,,34.59,34.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,29.36,84.88,,23.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.94,75,,20.75,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.67,80,,22.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.48,65,,17.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,100,,,Fee Schedule,100% of Custom Fee Schedule,31.13,90,,24.9,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,31.13,
KETOROLAC (TORADOL) 60MG INJ: 2ML,3301342,CDM,250,RC,,,Outpatient,,,14.15,14.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,84.88,,9.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.08,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.61,75,,8.49,percent of total billed charges,75% of total billed charges for outpatient setting,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,80,,9.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.2,65,,7.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,35,,3.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.74,90,,10.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.74,
KETOROLAC (TORADOL) INJ : 60 MG,3301338,CDM,250,RC,,,Outpatient,,,11.66,11.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,70,,6.53,percent of total billed charges,70% of total billed charges for outpatient setting,9.9,84.88,,7.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.83,50,,4.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.75,75,,7,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,70,,6.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.33,80,,7.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.58,65,,6.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.49,90,,8.39,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.49,
KETOROLAC genericTORADOL 30MG/ML 1ML,3301341,CDM,636,RC,J1885,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
KETOROLAC TROMETHAMINE 0.5% OPHTH  5ML,3308061,CDM,259,RC,,,Outpatient,,,61.88,61.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.32,70,,34.66,percent of total billed charges,70% of total billed charges for outpatient setting,52.52,84.88,,42.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.94,50,,24.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.41,75,,37.13,percent of total billed charges,75% of total billed charges for outpatient setting,43.32,70,,34.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.95,12.84,,6.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.5,80,,39.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.95,12.84,,6.36,percent of total billed charges,12.84% of total billed charges,7.95,12.84,,6.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.22,65,,32.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.66,35,,17.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.69,90,,44.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.95,55.69,
KETOTIFEN FUMARATE (ZADITOR): 5MLS,3303327,CDM,259,RC,,,Outpatient,,,47.28,47.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,70,,26.48,percent of total billed charges,70% of total billed charges for outpatient setting,40.13,84.88,,32.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.64,50,,18.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.46,75,,28.37,percent of total billed charges,75% of total billed charges for outpatient setting,33.1,70,,26.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,12.84,,4.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.82,80,,30.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.73,65,,24.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.55,35,,13.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.55,90,,34.04,percent of total billed charges,90% of total billed charges for outpatient setting,6.07,42.55,
KINEX  BIO PLUS  PUTTY 10CC 8115.5310S,69162268,CDM,278,RC,C9359,HCPCS,Outpatient,,,4500,4500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,60,,2160,percent of total billed charges,60% of total Billed charges for outpatient setting,3819.6,84.88,,3055.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3375,75,,2700,percent of total billed charges,75% of total billed charges for outpatient setting,2250,50,,1800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,80,,2880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4725,105,,3780,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,35,,1260,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,60,,2160,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,4725,
KINEX  BIOACTIVE  STRIP 10CC  8115.0010S,69162081,CDM,278,RC,C9362,HCPCS,Outpatient,,,4500,4500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,60,,2160,percent of total billed charges,60% of total Billed charges for outpatient setting,3819.6,84.88,,3055.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3375,75,,2700,percent of total billed charges,75% of total billed charges for outpatient setting,2250,50,,1800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,80,,2880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4725,105,,3780,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,35,,1260,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,60,,2160,percent of total billed charges,60% of total billed charges for outpatient setting,110.85,4725,
KINEX  BIOACTIVE  STRIP 10CC  8115.0110S,69162167,CDM,278,RC,C9362,HCPCS,Outpatient,,,4500,4500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,60,,2160,percent of total billed charges,60% of total Billed charges for outpatient setting,3819.6,84.88,,3055.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3375,75,,2700,percent of total billed charges,75% of total billed charges for outpatient setting,2250,50,,1800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,80,,2880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4725,105,,3780,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,35,,1260,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,60,,2160,percent of total billed charges,60% of total billed charges for outpatient setting,110.85,4725,
KINEX  BIOACTIVE  STRIP 20CC  8115.0120S,69162077,CDM,278,RC,C9362,HCPCS,Outpatient,,,7008,7008,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4204.8,60,,3363.84,percent of total billed charges,60% of total Billed charges for outpatient setting,5948.39,84.88,,4758.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,5256,75,,4204.8,percent of total billed charges,75% of total billed charges for outpatient setting,3504,50,,2803.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.83,12.84,,719.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5606.4,80,,4485.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.83,12.84,,719.86,percent of total billed charges,12.84% of total billed charges,899.83,12.84,,719.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7358.4,105,,5886.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2452.8,35,,1962.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4204.8,60,,3363.84,percent of total billed charges,60% of total billed charges for outpatient setting,110.85,7358.4,
KINEX  BIOACTIVE GEL 10CC  8115.0210S,69162191,CDM,278,RC,C9359,HCPCS,Outpatient,,,4500,4500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,60,,2160,percent of total billed charges,60% of total Billed charges for outpatient setting,3819.6,84.88,,3055.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3375,75,,2700,percent of total billed charges,75% of total billed charges for outpatient setting,2250,50,,1800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,80,,2880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4725,105,,3780,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,35,,1260,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,60,,2160,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,4725,
KINEX  BIOACTIVE GEL 2CC  8115.0202S,69162015,CDM,278,RC,C9359,HCPCS,Outpatient,,,2649.68,2649.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,60,,1271.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2249.05,84.88,,1799.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1987.26,75,,1589.81,percent of total billed charges,75% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,80,,1695.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2782.16,105,,2225.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.39,35,,741.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1589.81,60,,1271.85,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2782.16,
KINEX  BIOACTIVE GEL 5CC  8115.0205S,69161945,CDM,278,RC,,,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
KINEX  BIOACTIVE PUTTY 10CC  8115.0310S,69162148,CDM,278,RC,C9359,HCPCS,Outpatient,,,4500,4500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,60,,2160,percent of total billed charges,60% of total Billed charges for outpatient setting,3819.6,84.88,,3055.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3375,75,,2700,percent of total billed charges,75% of total billed charges for outpatient setting,2250,50,,1800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,80,,2880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,577.8,12.84,,462.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4725,105,,3780,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,35,,1260,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,60,,2160,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,4725,
KINEX  BIOACTIVE STRIP  5CC  8115.0005S,69162063,CDM,278,RC,C9362,HCPCS,Outpatient,,,2604,2604,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.4,60,,1249.92,percent of total billed charges,60% of total Billed charges for outpatient setting,2210.28,84.88,,1768.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1953,75,,1562.4,percent of total billed charges,75% of total billed charges for outpatient setting,1302,50,,1041.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2083.2,80,,1666.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2734.2,105,,2187.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.4,35,,729.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1562.4,60,,1249.92,percent of total billed charges,60% of total billed charges for outpatient setting,110.85,2734.2,
KINEX  PLUS BIO PUTTY 5CC 8115.5305S,69162305,CDM,278,RC,C9359,HCPCS,Outpatient,,,2604,2604,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.4,60,,1249.92,percent of total billed charges,60% of total Billed charges for outpatient setting,2210.28,84.88,,1768.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1953,75,,1562.4,percent of total billed charges,75% of total billed charges for outpatient setting,1302,50,,1041.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2083.2,80,,1666.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2734.2,105,,2187.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.4,35,,729.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1562.4,60,,1249.92,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2734.2,
KINEX PLUS BIOACTIVE GEL 2CC  8115.5202S,69169528,CDM,278,RC,C9359,HCPCS,Outpatient,,,2649.68,2649.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,60,,1271.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2249.05,84.88,,1799.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1987.26,75,,1589.81,percent of total billed charges,75% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,80,,1695.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2782.16,105,,2225.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.39,35,,741.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1589.81,60,,1271.85,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2782.16,
KINEX PUTTY  2CC / 8115.0302S,69161942,CDM,278,RC,C9359,HCPCS,Outpatient,,,2649.68,2649.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,60,,1271.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2249.05,84.88,,1799.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1987.26,75,,1589.81,percent of total billed charges,75% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,80,,1695.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2782.16,105,,2225.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.39,35,,741.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1589.81,60,,1271.85,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2782.16,
KINEX PUTTY  5CC  8115.0305S,69162169,CDM,278,RC,C9359,HCPCS,Outpatient,,,2604,2604,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.4,60,,1249.92,percent of total billed charges,60% of total Billed charges for outpatient setting,2210.28,84.88,,1768.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1953,75,,1562.4,percent of total billed charges,75% of total billed charges for outpatient setting,1302,50,,1041.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2083.2,80,,1666.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,334.35,12.84,,267.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2734.2,105,,2187.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.4,35,,729.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1562.4,60,,1249.92,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2734.2,
KIT 1.6 HAMMERTOE LG / 46.239.002,7297179,CDM,272,RC,,,Outpatient,,,4881.6,4881.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3417.12,70,,2733.7,percent of total billed charges,70% of total billed charges for outpatient setting,4143.5,84.88,,3314.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,2440.8,50,,1952.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3661.2,75,,2928.96,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.8,12.84,,501.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3905.28,80,,3124.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.8,12.84,,501.44,percent of total billed charges,12.84% of total billed charges,626.8,12.84,,501.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3173.04,65,,2538.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1708.56,35,,1366.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4393.44,90,,3514.75,percent of total billed charges,90% of total billed charges for outpatient setting,626.8,4393.44,
KIT 1.8MM FIBERTAK / AR-3610PK-3,71000595,CDM,272,RC,,,Outpatient,,,945,945,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,70,,529.2,percent of total billed charges,70% of total billed charges for outpatient setting,802.12,84.88,,641.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,472.5,50,,378,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,708.75,75,,567,percent of total billed charges,75% of total billed charges for outpatient setting,661.5,70,,529.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.34,12.84,,97.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,80,,604.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.34,12.84,,97.07,percent of total billed charges,12.84% of total billed charges,121.34,12.84,,97.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,614.25,65,,491.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.75,35,,264.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,850.5,90,,680.4,percent of total billed charges,90% of total billed charges for outpatient setting,121.34,850.5,
KIT 1.8MM INSERT FIBERTAK / AR-1610PK-3,71000537,CDM,278,RC,C1713,HCPCS,Outpatient,,,945,945,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567,60,,453.6,percent of total billed charges,60% of total Billed charges for outpatient setting,802.12,84.88,,641.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.75,75,,567,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,50,,378,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.34,12.84,,97.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,80,,604.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.34,12.84,,97.07,percent of total billed charges,12.84% of total billed charges,121.34,12.84,,97.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,945,65,,756,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.75,35,,264.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,567,60,,453.6,percent of total billed charges,60% of total billed charges for outpatient setting,121.34,945,
KIT 10ML GENEX ANTBTC BEAD / 910-010Z,71000349,CDM,278,RC,C1713,HCPCS,Outpatient,,,6600,6600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3960,60,,3168,percent of total billed charges,60% of total Billed charges for outpatient setting,5602.08,84.88,,4481.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4950,75,,3960,percent of total billed charges,75% of total billed charges for outpatient setting,3300,50,,2640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.44,12.84,,677.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5280,80,,4224,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.44,12.84,,677.95,percent of total billed charges,12.84% of total billed charges,847.44,12.84,,677.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6930,105,,5544,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2310,35,,1848,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3960,60,,3168,percent of total billed charges,60% of total billed charges for outpatient setting,847.44,6930,
KIT 10ML ORISE PREDYE / M00519221,7220910,CDM,272,RC,,,Outpatient,,,422.44,422.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,70,,236.57,percent of total billed charges,70% of total billed charges for outpatient setting,358.57,84.88,,286.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,211.22,50,,168.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.83,75,,253.46,percent of total billed charges,75% of total billed charges for outpatient setting,295.71,70,,236.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,12.84,,43.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.95,80,,270.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,12.84,,43.39,percent of total billed charges,12.84% of total billed charges,54.24,12.84,,43.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,274.59,65,,219.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.85,35,,118.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,380.2,90,,304.16,percent of total billed charges,90% of total billed charges for outpatient setting,54.24,380.2,
KIT 2.9MM SHORT P-LOK / AR-2923DS,69162852,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
KIT 20FR 16IN TROCAR / 8888561043,71000607,CDM,272,RC,,,Outpatient,,,170.05,170.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,70,,95.23,percent of total billed charges,70% of total billed charges for outpatient setting,144.34,84.88,,115.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.03,50,,68.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.54,75,,102.03,percent of total billed charges,75% of total billed charges for outpatient setting,119.04,70,,95.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,12.84,,17.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.04,80,,108.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,12.84,,17.46,percent of total billed charges,12.84% of total billed charges,21.83,12.84,,17.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.53,65,,88.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,35,,47.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.05,90,,122.44,percent of total billed charges,90% of total billed charges for outpatient setting,21.83,153.05,
KIT 3.5X8.5MM SWIVELOCK / AR-8978DS-01,71000502,CDM,278,RC,C1713,HCPCS,Outpatient,,,1155,1155,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693,60,,554.4,percent of total billed charges,60% of total Billed charges for outpatient setting,980.36,84.88,,784.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,866.25,75,,693,percent of total billed charges,75% of total billed charges for outpatient setting,577.5,50,,462,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924,80,,739.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1155,65,,924,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.25,35,,323.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,693,60,,554.4,percent of total billed charges,60% of total billed charges for outpatient setting,148.3,1155,
KIT 3MM INSERT PERC KNTLSS / AR-1938PK,71000530,CDM,272,RC,,,Outpatient,,,1491,1491,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1043.7,70,,834.96,percent of total billed charges,70% of total billed charges for outpatient setting,1265.56,84.88,,1012.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,745.5,50,,596.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1118.25,75,,894.6,percent of total billed charges,75% of total billed charges for outpatient setting,1043.7,70,,834.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.44,12.84,,153.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.8,80,,954.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.44,12.84,,153.15,percent of total billed charges,12.84% of total billed charges,191.44,12.84,,153.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,969.15,65,,775.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.85,35,,417.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1341.9,90,,1073.52,percent of total billed charges,90% of total billed charges for outpatient setting,191.44,1341.9,
KIT 5ML GENEX ANTIBIOTIC BEAD / 910-005Z,71000348,CDM,278,RC,C1713,HCPCS,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
KIT 7X23 BICEP BIOCOMP / AR-1662BCS-723S,71000310,CDM,272,RC,,,Outpatient,,,2516.5,2516.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1761.55,70,,1409.24,percent of total billed charges,70% of total billed charges for outpatient setting,2136.01,84.88,,1708.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,1258.25,50,,1006.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1887.38,75,,1509.9,percent of total billed charges,75% of total billed charges for outpatient setting,1761.55,70,,1409.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.12,12.84,,258.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2013.2,80,,1610.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.12,12.84,,258.5,percent of total billed charges,12.84% of total billed charges,323.12,12.84,,258.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1635.73,65,,1308.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.78,35,,704.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2264.85,90,,1811.88,percent of total billed charges,90% of total billed charges for outpatient setting,323.12,2264.85,
KIT AFFIRM VCF ULTRA 10U  658.923S,69162362,CDM,272,RC,,,Outpatient,,,13816.16,13816.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9671.31,70,,7737.05,percent of total billed charges,70% of total billed charges for outpatient setting,11727.16,84.88,,9381.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,6908.08,50,,5526.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10362.12,75,,8289.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1773.99,12.84,,1419.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11052.93,80,,8842.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1773.99,12.84,,1419.19,percent of total billed charges,12.84% of total billed charges,1773.99,12.84,,1419.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8980.5,65,,7184.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4835.66,35,,3868.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12434.54,90,,9947.63,percent of total billed charges,90% of total billed charges for outpatient setting,1773.99,12434.54,
KIT AFFIRM VCF ULTRA 15U / 658.924S,69162199,CDM,272,RC,,,Outpatient,,,7300,7300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5110,70,,4088,percent of total billed charges,70% of total billed charges for outpatient setting,6196.24,84.88,,4956.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,3650,50,,2920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5475,75,,4380,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.32,12.84,,749.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5840,80,,4672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.32,12.84,,749.86,percent of total billed charges,12.84% of total billed charges,937.32,12.84,,749.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4745,65,,3796,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2555,35,,2044,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6570,90,,5256,percent of total billed charges,90% of total billed charges for outpatient setting,937.32,6570,
KIT ASPIRATION 3 HOLE 6IN NDL,70000449,CDM,272,RC,,,Outpatient,,,982.65,982.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,687.86,70,,550.29,percent of total billed charges,70% of total billed charges for outpatient setting,834.07,84.88,,667.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,491.33,50,,393.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,736.99,75,,589.59,percent of total billed charges,75% of total billed charges for outpatient setting,687.86,70,,550.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.17,12.84,,100.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.12,80,,628.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.17,12.84,,100.94,percent of total billed charges,12.84% of total billed charges,126.17,12.84,,100.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,638.72,65,,510.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.93,35,,275.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,884.39,90,,707.51,percent of total billed charges,90% of total billed charges for outpatient setting,126.17,884.39,
KIT ASSEMBLY TITAN / 919480SC,826018,CDM,272,RC,,,Outpatient,,,1892,1892,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.4,70,,1059.52,percent of total billed charges,70% of total billed charges for outpatient setting,1605.93,84.88,,1284.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,946,50,,756.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1419,75,,1135.2,percent of total billed charges,75% of total billed charges for outpatient setting,1324.4,70,,1059.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.93,12.84,,194.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.6,80,,1210.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.93,12.84,,194.34,percent of total billed charges,12.84% of total billed charges,242.93,12.84,,194.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1229.8,65,,983.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.2,35,,529.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1702.8,90,,1362.24,percent of total billed charges,90% of total billed charges for outpatient setting,242.93,1702.8,
KIT BIOPREP BONE PREP / 0206-710-000,417649,CDM,270,RC,,,Outpatient,,,2216.06,2216.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1551.24,70,,1240.99,percent of total billed charges,70% of total billed charges for outpatient setting,1880.99,84.88,,1504.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,1108.03,50,,886.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1662.05,75,,1329.64,percent of total billed charges,75% of total billed charges for outpatient setting,1551.24,70,,1240.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.54,12.84,,227.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1772.85,80,,1418.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.54,12.84,,227.63,percent of total billed charges,12.84% of total billed charges,284.54,12.84,,227.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1440.44,65,,1152.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.62,35,,620.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1994.45,90,,1595.56,percent of total billed charges,90% of total billed charges for outpatient setting,284.54,1994.45,
KIT BLUE INTUBATION / 7700BIN,71000643,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT CATH CENTRAL LINE PEDI /AK16553,6150963,CDM,272,RC,,,Outpatient,,,298.15,298.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.71,70,,166.97,percent of total billed charges,70% of total billed charges for outpatient setting,253.07,84.88,,202.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,149.08,50,,119.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.61,75,,178.89,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,70,,166.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,12.84,,30.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.52,80,,190.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,12.84,,30.62,percent of total billed charges,12.84% of total billed charges,38.28,12.84,,30.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,193.8,65,,155.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.35,35,,83.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,268.34,90,,214.67,percent of total billed charges,90% of total billed charges for outpatient setting,38.28,268.34,
KIT CHARGING SYSTEM PREC / SC-6412-3,70000137,CDM,273,RC,C1820,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,70,,1680,percent of total billed charges,70% of total billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2700,90,,2160,percent of total billed charges,90% of total billed charges for outpatient setting,385.2,2700,
KIT CO2 TUBING OLYMPUS / 20325-239,71000082,CDM,272,RC,,,Outpatient,,,134.75,134.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.33,70,,75.46,percent of total billed charges,70% of total billed charges for outpatient setting,114.38,84.88,,91.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.38,50,,53.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.06,75,,80.85,percent of total billed charges,75% of total billed charges for outpatient setting,94.33,70,,75.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.3,12.84,,13.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.8,80,,86.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.3,12.84,,13.84,percent of total billed charges,12.84% of total billed charges,17.3,12.84,,13.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.59,65,,70.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.16,35,,37.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.28,90,,97.02,percent of total billed charges,90% of total billed charges for outpatient setting,17.3,121.28,
KIT COLON ENDOVIVE / CEK-725-20,2386001,CDM,272,RC,,,Outpatient,,,76.65,76.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,65.06,84.88,,52.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.33,50,,30.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.49,75,,45.99,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.32,80,,49.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.82,65,,39.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.83,35,,21.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.99,90,,55.19,percent of total billed charges,90% of total billed charges for outpatient setting,9.84,68.99,
KIT DEFOG / NONFB100,6150868,CDM,270,RC,,,Outpatient,,,7.87,7.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,70,,4.41,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,84.88,,5.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.94,50,,3.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.9,75,,4.72,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,70,,4.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,80,,5.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.12,65,,4.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,35,,2.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.08,90,,5.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.01,7.08,
KIT ENEMA 1500ML BAG / DYND70102H,5150225,CDM,270,RC,,,Outpatient,,,19.8,19.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,16.81,84.88,,13.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.9,50,,7.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,75,,11.88,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,70,,11.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,80,,12.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,2.54,12.84,,2.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.87,65,,10.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.93,35,,5.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.82,90,,14.26,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,17.82,
KIT EXTENSION 1X8 / 37081-60,70000050,CDM,278,RC,C1778,HCPCS,Outpatient,,,2252.23,2252.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.34,60,,1081.07,percent of total billed charges,60% of total Billed charges for outpatient setting,1911.69,84.88,,1529.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1689.17,75,,1351.34,percent of total billed charges,75% of total billed charges for outpatient setting,1126.12,50,,900.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.19,12.84,,231.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1801.78,80,,1441.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.19,12.84,,231.35,percent of total billed charges,12.84% of total billed charges,289.19,12.84,,231.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2364.84,105,,1891.87,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.28,35,,630.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1351.34,60,,1081.07,percent of total billed charges,60% of total billed charges for outpatient setting,289.19,2364.84,
KIT FIBERTAK DISP / AR-8990DS,71000024,CDM,272,RC,,,Outpatient,,,1100,1100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,70,,616,percent of total billed charges,70% of total billed charges for outpatient setting,933.68,84.88,,746.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,550,50,,440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,825,75,,660,percent of total billed charges,75% of total billed charges for outpatient setting,770,70,,616,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.24,12.84,,112.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880,80,,704,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.24,12.84,,112.99,percent of total billed charges,12.84% of total billed charges,141.24,12.84,,112.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,715,65,,572,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385,35,,308,percent of total billed charges,35% of total Billed charges for Outpatient Setting,990,90,,792,percent of total billed charges,90% of total billed charges for outpatient setting,141.24,990,
KIT FIBERTAK KNOTLESS / AR-8991DS,71000263,CDM,272,RC,,,Outpatient,,,1010.62,1010.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.43,70,,565.94,percent of total billed charges,70% of total billed charges for outpatient setting,857.81,84.88,,686.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,505.31,50,,404.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,757.97,75,,606.38,percent of total billed charges,75% of total billed charges for outpatient setting,707.43,70,,565.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.76,12.84,,103.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.5,80,,646.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.76,12.84,,103.81,percent of total billed charges,12.84% of total billed charges,129.76,12.84,,103.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,656.9,65,,525.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.72,35,,282.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,909.56,90,,727.65,percent of total billed charges,90% of total billed charges for outpatient setting,129.76,909.56,
KIT FIBERTAK KNOTLESS DX / AR-8991CP,71000803,CDM,272,RC,,,Outpatient,,,3500,3500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,70,,1960,percent of total billed charges,70% of total billed charges for outpatient setting,2970.8,84.88,,2376.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,1750,50,,1400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2625,75,,2100,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,80,,2240,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,449.4,12.84,,359.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2275,65,,1820,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225,35,,980,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3150,90,,2520,percent of total billed charges,90% of total billed charges for outpatient setting,449.4,3150,
KIT FIBULOCK SYSTEM / AR-8973DS,71000506,CDM,278,RC,C1713,HCPCS,Outpatient,,,2572.5,2572.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1543.5,60,,1234.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2183.54,84.88,,1746.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,75,,1543.5,percent of total billed charges,75% of total billed charges for outpatient setting,1286.25,50,,1029,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.31,12.84,,264.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2058,80,,1646.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.31,12.84,,264.25,percent of total billed charges,12.84% of total billed charges,330.31,12.84,,264.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2701.13,105,,2160.9,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.38,35,,720.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1543.5,60,,1234.8,percent of total billed charges,60% of total billed charges for outpatient setting,330.31,2701.13,
KIT FOLEY CATHETER 16F/KC6155,5050199,CDM,272,RC,,,Outpatient,,,155.35,155.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.75,70,,87,percent of total billed charges,70% of total billed charges for outpatient setting,131.86,84.88,,105.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.68,50,,62.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.51,75,,93.21,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,70,,87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,12.84,,15.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.28,80,,99.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,12.84,,15.96,percent of total billed charges,12.84% of total billed charges,19.95,12.84,,15.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.98,65,,80.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.37,35,,43.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.82,90,,111.86,percent of total billed charges,90% of total billed charges for outpatient setting,19.95,139.82,
KIT FOOT ANKLE SCP  / 514.315,69162832,CDM,278,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
KIT GREEN INTUBATION / 7700GIN,71000652,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT HAMERTOE SYNTHES STD / 46.239.001,7297131,CDM,272,RC,,,Outpatient,,,4050,4050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2835,70,,2268,percent of total billed charges,70% of total billed charges for outpatient setting,3437.64,84.88,,2750.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,2025,50,,1620,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3037.5,75,,2430,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.02,12.84,,416.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,80,,2592,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.02,12.84,,416.02,percent of total billed charges,12.84% of total billed charges,520.02,12.84,,416.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2632.5,65,,2106,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,35,,1134,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3645,90,,2916,percent of total billed charges,90% of total billed charges for outpatient setting,520.02,3645,
KIT HANA PROFX W BOOT LINER / 6851,2003842,CDM,272,RC,,,Outpatient,,,231.32,231.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.92,70,,129.54,percent of total billed charges,70% of total billed charges for outpatient setting,196.34,84.88,,157.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.66,50,,92.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.49,75,,138.79,percent of total billed charges,75% of total billed charges for outpatient setting,161.92,70,,129.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.06,80,,148.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,29.7,12.84,,23.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.36,65,,120.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.96,35,,64.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,208.19,90,,166.55,percent of total billed charges,90% of total billed charges for outpatient setting,29.7,208.19,
KIT HOOK TRIANGLE BLADE / 3056-6,2312832,CDM,272,RC,,,Outpatient,,,502.4,502.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,426.44,84.88,,341.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.2,50,,200.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.8,75,,301.44,percent of total billed charges,75% of total billed charges for outpatient setting,351.68,70,,281.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.92,80,,321.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,64.51,12.84,,51.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,326.56,65,,261.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.84,35,,140.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.16,90,,361.73,percent of total billed charges,90% of total billed charges for outpatient setting,64.51,452.16,
KIT IB JUMPSTART / AR-1788J-CP,71000261,CDM,272,RC,,,Outpatient,,,3139.5,3139.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.65,70,,1758.12,percent of total billed charges,70% of total billed charges for outpatient setting,2664.81,84.88,,2131.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,1569.75,50,,1255.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2354.63,75,,1883.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.6,80,,2009.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2040.68,65,,1632.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.83,35,,879.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2825.55,90,,2260.44,percent of total billed charges,90% of total billed charges for outpatient setting,403.11,2825.55,
KIT INFLATE BONE TAMP 15U / 658.352S,70000563,CDM,272,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,70,,2016,percent of total billed charges,70% of total billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2340,65,,1872,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,90,,2592,percent of total billed charges,90% of total billed charges for outpatient setting,462.24,3240,
KIT JUMPSTART IB BC / AR-1789J-CP,71000393,CDM,272,RC,,,Outpatient,,,3139.5,3139.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.65,70,,1758.12,percent of total billed charges,70% of total billed charges for outpatient setting,2664.81,84.88,,2131.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,1569.75,50,,1255.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2354.63,75,,1883.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.6,80,,2009.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2040.68,65,,1632.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.83,35,,879.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2825.55,90,,2260.44,percent of total billed charges,90% of total billed charges for outpatient setting,403.11,2825.55,
KIT LEAD COVEREDGE 32 / SC-8336-50,70000134,CDM,272,RC,C1778,HCPCS,Outpatient,,,8100,8100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,70,,4536,percent of total billed charges,70% of total billed charges for outpatient setting,6875.28,84.88,,5500.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6075,75,,4860,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.04,12.84,,832.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6480,80,,5184,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.04,12.84,,832.03,percent of total billed charges,12.84% of total billed charges,1040.04,12.84,,832.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5265,65,,4212,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2835,35,,2268,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7290,90,,5832,percent of total billed charges,90% of total billed charges for outpatient setting,1040.04,7290,
KIT LIGAMENT REPAIR RECON / AR-1677BC-CP,71000099,CDM,278,RC,C1713,HCPCS,Outpatient,,,2554.12,2554.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.47,60,,1225.98,percent of total billed charges,60% of total Billed charges for outpatient setting,2167.94,84.88,,1734.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.59,75,,1532.47,percent of total billed charges,75% of total billed charges for outpatient setting,1277.06,50,,1021.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2043.3,80,,1634.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2681.83,105,,2145.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.94,35,,715.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1532.47,60,,1225.98,percent of total billed charges,60% of total billed charges for outpatient setting,327.95,2681.83,
KIT LIPOGRAFTER / 913000,7236308,CDM,272,RC,,,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,845,65,,676,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1170,90,,936,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1170,
KIT LTA ADULT/469801,6150999,CDM,272,RC,,,Outpatient,,,42.61,42.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,36.17,84.88,,28.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.31,50,,17.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.96,75,,25.57,percent of total billed charges,75% of total billed charges for outpatient setting,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,80,,27.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.7,65,,22.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,35,,11.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.35,90,,30.68,percent of total billed charges,90% of total billed charges for outpatient setting,5.47,38.35,
KIT MENISCAL ROOT REPAIR BC / AR-4550BC,71000828,CDM,278,RC,C1713,HCPCS,Outpatient,,,3570,3570,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2142,60,,1713.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3030.22,84.88,,2424.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2677.5,75,,2142,percent of total billed charges,75% of total billed charges for outpatient setting,1785,50,,1428,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.39,12.84,,366.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2856,80,,2284.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.39,12.84,,366.71,percent of total billed charges,12.84% of total billed charges,458.39,12.84,,366.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3748.5,105,,2998.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.5,35,,999.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2142,60,,1713.6,percent of total billed charges,60% of total billed charges for outpatient setting,458.39,3748.5,
KIT MENISCAL ROOT REPAIR PEEK / AR-4550P,71000432,CDM,272,RC,,,Outpatient,,,2929.5,2929.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2050.65,70,,1640.52,percent of total billed charges,70% of total billed charges for outpatient setting,2486.56,84.88,,1989.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,1464.75,50,,1171.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2197.13,75,,1757.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.6,80,,1874.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1904.18,65,,1523.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025.33,35,,820.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2636.55,90,,2109.24,percent of total billed charges,90% of total billed charges for outpatient setting,376.15,2636.55,
KIT MENISCAL ROOT REPAIR STRLC / AR-4551,71000588,CDM,272,RC,,,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,70,,2240,percent of total billed charges,70% of total billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2600,65,,2080,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,90,,2880,percent of total billed charges,90% of total billed charges for outpatient setting,513.6,3600,
KIT NAVITRACKER KNEE / 20-8000-000-07,71000342,CDM,278,RC,C1713,HCPCS,Outpatient,,,1840,1840,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104,60,,883.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1561.79,84.88,,1249.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,75,,1104,percent of total billed charges,75% of total billed charges for outpatient setting,920,50,,736,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.26,12.84,,189.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1472,80,,1177.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.26,12.84,,189.01,percent of total billed charges,12.84% of total billed charges,236.26,12.84,,189.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1840,65,,1472,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644,35,,515.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1104,60,,883.2,percent of total billed charges,60% of total billed charges for outpatient setting,236.26,1840,
KIT NEBULIZER PREFILLED / 041-35,6152582,CDM,272,RC,,,Outpatient,,,39.28,39.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,33.34,84.88,,26.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.64,50,,15.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.46,75,,23.57,percent of total billed charges,75% of total billed charges for outpatient setting,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,80,,25.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.53,65,,20.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,35,,11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.35,90,,28.28,percent of total billed charges,90% of total billed charges for outpatient setting,5.04,35.35,
KIT NEPTUNE MANIFOLD SPEC / 0750-200-000,7786733,CDM,272,RC,,,Outpatient,,,119.4,119.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.58,70,,66.86,percent of total billed charges,70% of total billed charges for outpatient setting,101.35,84.88,,81.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.7,50,,47.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.55,75,,71.64,percent of total billed charges,75% of total billed charges for outpatient setting,83.58,70,,66.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.33,12.84,,12.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.52,80,,76.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.33,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,15.33,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.61,65,,62.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.79,35,,33.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,107.46,90,,85.97,percent of total billed charges,90% of total billed charges for outpatient setting,15.33,107.46,
KIT ORANGE INTUBATION / 7700OIN,71000644,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT PEDICLE ACCESS  624.027S,69162372,CDM,272,RC,,,Outpatient,,,2186,2186,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.2,70,,1224.16,percent of total billed charges,70% of total billed charges for outpatient setting,1855.48,84.88,,1484.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1093,50,,874.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1639.5,75,,1311.6,percent of total billed charges,75% of total billed charges for outpatient setting,1530.2,70,,1224.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.68,12.84,,224.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1748.8,80,,1399.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.68,12.84,,224.54,percent of total billed charges,12.84% of total billed charges,280.68,12.84,,224.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1420.9,65,,1136.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.1,35,,612.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1967.4,90,,1573.92,percent of total billed charges,90% of total billed charges for outpatient setting,280.68,1967.4,
KIT PEG PULL TUBE 24FR KIT / 6820,69169060,CDM,272,RC,,,Outpatient,,,298.68,298.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.08,70,,167.26,percent of total billed charges,70% of total billed charges for outpatient setting,253.52,84.88,,202.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,149.34,50,,119.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.01,75,,179.21,percent of total billed charges,75% of total billed charges for outpatient setting,209.08,70,,167.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.35,12.84,,30.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.94,80,,191.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.35,12.84,,30.68,percent of total billed charges,12.84% of total billed charges,38.35,12.84,,30.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,194.14,65,,155.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.54,35,,83.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,268.81,90,,215.05,percent of total billed charges,90% of total billed charges for outpatient setting,38.35,268.81,
KIT PERC INSERT 2.9MM P-LOK / AR-1923PK,69162396,CDM,272,RC,,,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600.6,65,,480.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,90,,665.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.64,831.6,
KIT PERC INSERT 3.0MM  S-T/ AR-1934PI-30,69162785,CDM,272,RC,C1713,HCPCS,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
KIT PICC DRESSING CHANGE / 77-2100K01,69169078,CDM,270,RC,,,Outpatient,,,87.71,87.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.4,70,,49.12,percent of total billed charges,70% of total billed charges for outpatient setting,74.45,84.88,,59.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.86,50,,35.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.78,75,,52.62,percent of total billed charges,75% of total billed charges for outpatient setting,61.4,70,,49.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,12.84,,9.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.17,80,,56.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,12.84,,9.01,percent of total billed charges,12.84% of total billed charges,11.26,12.84,,9.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.01,65,,45.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.7,35,,24.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.94,90,,63.15,percent of total billed charges,90% of total billed charges for outpatient setting,11.26,78.94,
KIT PICC W/ BIOPATCH / 03-2200,1366036,CDM,272,RC,,,Outpatient,,,60.76,60.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.53,70,,34.02,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,84.88,,41.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.38,50,,24.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.57,75,,36.46,percent of total billed charges,75% of total billed charges for outpatient setting,42.53,70,,34.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,12.84,,6.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.61,80,,38.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,12.84,,6.24,percent of total billed charges,12.84% of total billed charges,7.8,12.84,,6.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.49,65,,31.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,35,,17.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.68,90,,43.74,percent of total billed charges,90% of total billed charges for outpatient setting,7.8,54.68,
KIT PLATELET RICH PLASMA / AMS310,71000111,CDM,278,RC,G0460,HCPCS,Outpatient,,,1750,1750,,2455.73,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1050,60,,840,percent of total billed charges,60% of total Billed charges for outpatient setting,1485.4,84.88,,1188.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,2181.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1312.5,75,,1050,percent of total billed charges,75% of total billed charges for outpatient setting,875,50,,700,percent of total billed charges,50% of total billed charges for Outpatient setting,2609.21,170,,,Fee Schedule,170% of Medicare OPPS rate,3299.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,2685.95,175,,,Fee Schedule,175% of Medicare OPPS rate,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1400,80,,1120,percent of total billed charges,80% of total billed charges for outpatient setting,2148.76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1918.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1750,65,,1400,percent of total billed charges,65% of total billed charges for outpatient setting,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1534.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,487.03,100,,,Fee Schedule,100% of Custom Fee Schedule,1050,60,,840,percent of total billed charges,60% of total billed charges for outpatient setting,224.7,3299.88,
KIT PLI SAFESHEATH 7FR / SS7,70000097,CDM,272,RC,C1894,HCPCS,Outpatient,,,264.58,264.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,224.58,84.88,,179.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.44,75,,158.75,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.66,80,,169.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.98,65,,137.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.6,35,,74.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.12,90,,190.5,percent of total billed charges,90% of total billed charges for outpatient setting,33.97,238.12,
KIT PLI SAFESHEATH 9FR / SS9,70000096,CDM,272,RC,C1894,HCPCS,Outpatient,,,264.58,264.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,224.58,84.88,,179.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.44,75,,158.75,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,70,,148.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.66,80,,169.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,33.97,12.84,,27.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.98,65,,137.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.6,35,,74.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.12,90,,190.5,percent of total billed charges,90% of total billed charges for outpatient setting,33.97,238.12,
KIT PREVENA NPWT / PRE1101US,71000362,CDM,272,RC,,,Outpatient,,,1667.92,1667.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.54,70,,934.03,percent of total billed charges,70% of total billed charges for outpatient setting,1415.73,84.88,,1132.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,833.96,50,,667.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1250.94,75,,1000.75,percent of total billed charges,75% of total billed charges for outpatient setting,1167.54,70,,934.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.16,12.84,,171.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1334.34,80,,1067.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.16,12.84,,171.33,percent of total billed charges,12.84% of total billed charges,214.16,12.84,,171.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1084.15,65,,867.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583.77,35,,467.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1501.13,90,,1200.9,percent of total billed charges,90% of total billed charges for outpatient setting,214.16,1501.13,
KIT PROCEDURE OLYMPUS / 345CKETA,7361432,CDM,272,RC,,,Outpatient,,,96.25,96.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.38,70,,53.9,percent of total billed charges,70% of total billed charges for outpatient setting,81.7,84.88,,65.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.13,50,,38.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.19,75,,57.75,percent of total billed charges,75% of total billed charges for outpatient setting,67.38,70,,53.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.36,12.84,,9.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,80,,61.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.36,12.84,,9.89,percent of total billed charges,12.84% of total billed charges,12.36,12.84,,9.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.56,65,,50.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.69,35,,26.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,86.63,
KIT PRONE JACKSON TABLE / SPK10293,69162889,CDM,271,RC,,,Outpatient,,,248.05,248.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.64,70,,138.91,percent of total billed charges,70% of total billed charges for outpatient setting,210.54,84.88,,168.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.03,50,,99.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.04,75,,148.83,percent of total billed charges,75% of total billed charges for outpatient setting,173.64,70,,138.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.44,80,,158.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.23,65,,128.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.82,35,,69.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.25,90,,178.6,percent of total billed charges,90% of total billed charges for outpatient setting,31.85,223.25,
KIT PULSE GENERATOR SPECTRA / SC-1132,70000141,CDM,278,RC,C1820,HCPCS,Outpatient,,,33200,33200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19920,60,,15936,percent of total billed charges,60% of total Billed charges for outpatient setting,28180.16,84.88,,22544.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24900,75,,19920,percent of total billed charges,75% of total billed charges for outpatient setting,16600,50,,13280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4262.88,12.84,,3410.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26560,80,,21248,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4262.88,12.84,,3410.3,percent of total billed charges,12.84% of total billed charges,4262.88,12.84,,3410.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34860,105,,27888,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11620,35,,9296,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19920,60,,15936,percent of total billed charges,60% of total billed charges for outpatient setting,4262.88,34860,
KIT PURPLE INTUBATION / 7700PIN,71000634,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT RED INTUBATION / 7700RIN,71000632,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT REMOTE CONTROL FREELINK / SC-5552-1,70000136,CDM,273,RC,,,Outpatient,,,3217.46,3217.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2252.22,70,,1801.78,percent of total billed charges,70% of total billed charges for outpatient setting,2730.98,84.88,,2184.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1608.73,50,,1286.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2413.1,75,,1930.48,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.12,12.84,,330.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2573.97,80,,2059.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.12,12.84,,330.5,percent of total billed charges,12.84% of total billed charges,413.12,12.84,,330.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.11,35,,900.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2895.71,90,,2316.57,percent of total billed charges,90% of total billed charges for outpatient setting,413.12,2895.71,
KIT REMOTE CONTROL FREELINK / SC-5572-1,71000612,CDM,278,RC,C1787,HCPCS,Outpatient,,,3150,3150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,60,,1512,percent of total billed charges,60% of total Billed charges for outpatient setting,2673.72,84.88,,2138.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2362.5,75,,1890,percent of total billed charges,75% of total billed charges for outpatient setting,1575,50,,1260,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,80,,2016,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3307.5,105,,2646,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,35,,882,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1890,60,,1512,percent of total billed charges,60% of total billed charges for outpatient setting,404.46,3307.5,
KIT REPAIR ACUTE AC / AR-2271,71000098,CDM,272,RC,,,Outpatient,,,2250,2250,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,70,,1260,percent of total billed charges,70% of total billed charges for outpatient setting,1909.8,84.88,,1527.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1125,50,,900,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1687.5,75,,1350,percent of total billed charges,75% of total billed charges for outpatient setting,1575,70,,1260,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,80,,1440,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,288.9,12.84,,231.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1462.5,65,,1170,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.5,35,,630,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2025,90,,1620,percent of total billed charges,90% of total billed charges for outpatient setting,288.9,2025,
KIT REPAIR FIBULINK SYND / FGS-1000,7236651,CDM,272,RC,,,Outpatient,,,30809.28,30809.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21566.5,70,,17253.2,percent of total billed charges,70% of total billed charges for outpatient setting,26150.92,84.88,,20920.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,15404.64,50,,12323.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23106.96,75,,18485.57,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3955.91,12.84,,3164.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24647.42,80,,19717.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3955.91,12.84,,3164.73,percent of total billed charges,12.84% of total billed charges,3955.91,12.84,,3164.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20026.03,65,,16020.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10783.25,35,,8626.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27728.35,90,,22182.68,percent of total billed charges,90% of total billed charges for outpatient setting,2000,27728.35,
KIT SCHLEIN SHLDR / BC1000X,6152657,CDM,270,RC,,,Outpatient,,,95.82,95.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.07,70,,53.66,percent of total billed charges,70% of total billed charges for outpatient setting,81.33,84.88,,65.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.91,50,,38.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.87,75,,57.5,percent of total billed charges,75% of total billed charges for outpatient setting,67.07,70,,53.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.66,80,,61.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,12.3,12.84,,9.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.28,65,,49.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.54,35,,26.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.24,90,,68.99,percent of total billed charges,90% of total billed charges for outpatient setting,12.3,86.24,
KIT SECONDARY FIX ACL/PCL / AR-1593,69162753,CDM,278,RC,,,Outpatient,,,2271.15,2271.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.69,60,,1090.15,percent of total billed charges,60% of total Billed charges for outpatient setting,1927.75,84.88,,1542.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1135.58,50,,908.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1703.36,75,,1362.69,percent of total billed charges,75% of total billed charges for outpatient setting,1135.58,50,,908.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,80,,1453.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2384.71,105,,1907.77,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.9,35,,635.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1362.69,60,,1090.15,percent of total billed charges,60% of total billed charges for outpatient setting,291.62,2384.71,
KIT SECONDARY FIX W/BIOCOMP / AR-1593-BC,69169849,CDM,278,RC,,,Outpatient,,,2664.37,2664.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.62,60,,1278.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2261.52,84.88,,1809.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,1332.19,50,,1065.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1998.28,75,,1598.62,percent of total billed charges,75% of total billed charges for outpatient setting,1332.19,50,,1065.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2131.5,80,,1705.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2797.59,105,,2238.07,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.53,35,,746.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1598.62,60,,1278.9,percent of total billed charges,60% of total billed charges for outpatient setting,342.11,2797.59,
KIT STYLET ACCESS / 6082-52,70000489,CDM,275,RC,C1779,HCPCS,Outpatient,,,203.54,203.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.48,70,,113.98,percent of total billed charges,70% of total billed charges for outpatient setting,172.76,84.88,,138.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.66,75,,122.13,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,50,,81.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.13,12.84,,20.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.83,80,,130.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.13,12.84,,20.9,percent of total billed charges,12.84% of total billed charges,26.13,12.84,,20.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.54,65,,162.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.24,35,,56.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,183.19,90,,146.55,percent of total billed charges,90% of total billed charges for outpatient setting,26.13,203.54,
KIT SUTURE FIBERWIRE / AR-7214,70000254,CDM,278,RC,,,Outpatient,,,428.27,428.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.96,60,,205.57,percent of total billed charges,60% of total Billed charges for outpatient setting,363.52,84.88,,290.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,214.14,50,,171.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.2,75,,256.96,percent of total billed charges,75% of total billed charges for outpatient setting,214.14,50,,171.31,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.99,12.84,,43.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.62,80,,274.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.99,12.84,,43.99,percent of total billed charges,12.84% of total billed charges,54.99,12.84,,43.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,428.27,65,,342.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.89,35,,119.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,256.96,60,,205.57,percent of total billed charges,60% of total billed charges for outpatient setting,54.99,428.27,
KIT SYMPHION ACCESSORY / FG-0201,71000192,CDM,272,RC,,,Outpatient,,,3496.5,3496.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2447.55,70,,1958.04,percent of total billed charges,70% of total billed charges for outpatient setting,2967.83,84.88,,2374.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1748.25,50,,1398.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2622.38,75,,2097.9,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.95,12.84,,359.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2797.2,80,,2237.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.95,12.84,,359.16,percent of total billed charges,12.84% of total billed charges,448.95,12.84,,359.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2272.73,65,,1818.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1223.78,35,,979.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3146.85,90,,2517.48,percent of total billed charges,90% of total billed charges for outpatient setting,448.95,3146.85,
KIT SZ 8 TIBIAL PREP / 5555-2328,71000671,CDM,278,RC,C1713,HCPCS,Outpatient,,,593.92,593.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.35,60,,285.08,percent of total billed charges,60% of total Billed charges for outpatient setting,504.12,84.88,,403.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.44,75,,356.35,percent of total billed charges,75% of total billed charges for outpatient setting,296.96,50,,237.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.26,12.84,,61.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.14,80,,380.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.26,12.84,,61.01,percent of total billed charges,12.84% of total billed charges,76.26,12.84,,61.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,593.92,65,,475.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.87,35,,166.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.35,60,,285.08,percent of total billed charges,60% of total billed charges for outpatient setting,76.26,593.92,
KIT THORACOSTOMY PROC / 88-565036A,6151003,CDM,270,RC,,,Outpatient,,,151.1,151.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.77,70,,84.62,percent of total billed charges,70% of total billed charges for outpatient setting,128.25,84.88,,102.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.55,50,,60.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.33,75,,90.66,percent of total billed charges,75% of total billed charges for outpatient setting,105.77,70,,84.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.88,80,,96.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.22,65,,78.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.89,35,,42.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.99,90,,108.79,percent of total billed charges,90% of total billed charges for outpatient setting,19.4,135.99,
KIT TOTAL HIP IMPLANTS / 98-B-001-025-10,71000895,CDM,278,RC,C1776,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
KIT TRANSTIBIAL ACL / AR-1898S,69161807,CDM,272,RC,,,Outpatient,,,609,609,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.3,70,,341.04,percent of total billed charges,70% of total billed charges for outpatient setting,516.92,84.88,,413.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,304.5,50,,243.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456.75,75,,365.4,percent of total billed charges,75% of total billed charges for outpatient setting,426.3,70,,341.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.2,12.84,,62.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.2,80,,389.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.2,12.84,,62.56,percent of total billed charges,12.84% of total billed charges,78.2,12.84,,62.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,395.85,65,,316.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.15,35,,170.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,548.1,90,,438.48,percent of total billed charges,90% of total billed charges for outpatient setting,78.2,548.1,
KIT WHITE INTUBATION / 7700WIN,71000637,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT WILSON FRAME XODUS / SPK10309,69162888,CDM,271,RC,,,Outpatient,,,248.05,248.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.64,70,,138.91,percent of total billed charges,70% of total billed charges for outpatient setting,210.54,84.88,,168.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.03,50,,99.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.04,75,,148.83,percent of total billed charges,75% of total billed charges for outpatient setting,173.64,70,,138.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.44,80,,158.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,31.85,12.84,,25.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.23,65,,128.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.82,35,,69.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.25,90,,178.6,percent of total billed charges,90% of total billed charges for outpatient setting,31.85,223.25,
KIT WRENCH TORQUE / 5873W,70000236,CDM,272,RC,,,Outpatient,,,228.95,228.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.27,70,,128.22,percent of total billed charges,70% of total billed charges for outpatient setting,194.33,84.88,,155.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.48,50,,91.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.71,75,,137.37,percent of total billed charges,75% of total billed charges for outpatient setting,160.27,70,,128.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,12.84,,23.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.16,80,,146.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,12.84,,23.52,percent of total billed charges,12.84% of total billed charges,29.4,12.84,,23.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.82,65,,119.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.13,35,,64.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.06,90,,164.85,percent of total billed charges,90% of total billed charges for outpatient setting,29.4,206.06,
KIT YELLOW INTUBATION / 7700YIN,71000625,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
KIT-WILSON PLUS PT CARE / 5322PV,69162298,CDM,271,RC,,,Outpatient,,,215.7,215.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.99,70,,120.79,percent of total billed charges,70% of total billed charges for outpatient setting,183.09,84.88,,146.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.85,50,,86.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.78,75,,129.42,percent of total billed charges,75% of total billed charges for outpatient setting,150.99,70,,120.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.56,80,,138.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.21,65,,112.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,35,,60.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.13,90,,155.3,percent of total billed charges,90% of total billed charges for outpatient setting,27.7,194.13,
KLING 2IN / 2231,6150317,CDM,270,RC,,,Outpatient,,,2.52,2.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,70,,1.41,percent of total billed charges,70% of total billed charges for outpatient setting,2.14,84.88,,1.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.26,50,,1.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.89,75,,1.51,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,70,,1.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,80,,1.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.64,65,,1.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,35,,0.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.27,90,,1.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.32,2.27,
KLING 3IN / 2232,6152027,CDM,272,RC,,,Outpatient,,,3.26,3.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,84.88,,2.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.63,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.45,75,,1.96,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,80,,2.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.12,65,,1.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,35,,0.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.93,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.93,
KLING 4IN / 2236,6150319,CDM,272,RC,,,Outpatient,,,2.53,2.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,70,,1.42,percent of total billed charges,70% of total billed charges for outpatient setting,2.15,84.88,,1.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.27,50,,1.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.9,75,,1.52,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,70,,1.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,80,,1.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.64,65,,1.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,35,,0.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.28,90,,1.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.32,2.28,
KLING 6IN / 2238,6150885,CDM,272,RC,,,Outpatient,,,5.83,5.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,70,,3.26,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,84.88,,3.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.92,50,,2.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.37,75,,3.5,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,70,,3.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,80,,3.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.79,65,,3.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,35,,1.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.25,90,,4.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.75,5.25,
KLONOPIN CLONAZEPAM,220531,CDM,310,RC,80346,HCPCS,Outpatient,,,179.46,161.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.62,70,,100.5,percent of total billed charges,70% of total billed charges for outpatient setting,152.33,84.88,,121.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,134.6,75,,107.68,percent of total billed charges,75% of total billed charges for outpatient setting,125.62,70,,100.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,12.84,,18.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.57,80,,114.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,12.84,,18.43,percent of total billed charges,12.84% of total billed charges,23.04,12.84,,18.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.51,90,,129.21,percent of total billed charges,90% of total billed charges for outpatient setting,23.04,161.51,
KNEE 1 OR 2 VWS BILATERAL,2400347,CDM,320,RC,73560,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
KNEE 1 OR 2 VWS LEFT,2400346,CDM,320,RC,73560,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
KNEE 1 OR 2 VWS RIGHT,2400345,CDM,320,RC,73560,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
KNEE 3 VWS BILATERAL,2400352,CDM,320,RC,73562,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
KNEE 3 VWS LEFT,2400351,CDM,320,RC,73562,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
KNEE 3 VWS RIGHT,2400350,CDM,320,RC,73562,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
KNEE ARTHROGRAPHY RADIOLOGICAL SUPERVISI,2400405,CDM,322,RC,73580,HCPCS,Outpatient,,,1141.31,855.98,,527.98,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,560.98,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,577.48,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,461.98,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,403.66,100,,,Fee Schedule,100% of Custom Fee Schedule,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
KNEE COMPLETE FOUR OR MORE VIEWS LEFT,2400356,CDM,320,RC,73564,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
KNEE COMPLETE FOUR OR MORE VIEWS RIGHT,2400355,CDM,320,RC,73564,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
KNEE COMPLETE FOUR/+ VIEWS BILATERAL,2400357,CDM,320,RC,73564,HCPCS,Outpatient,,,492.35,369.26,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.65,70,,275.72,percent of total billed charges,70% of total billed charges for outpatient setting,417.91,84.88,,334.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,246.18,50,,196.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.26,75,,295.41,percent of total billed charges,75% of total billed charges for outpatient setting,344.65,70,,275.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.22,12.84,,50.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.88,80,,315.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.22,12.84,,50.58,percent of total billed charges,12.84% of total billed charges,63.22,12.84,,50.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.32,35,,137.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,443.12,90,,354.5,percent of total billed charges,90% of total billed charges for outpatient setting,63.22,443.12,
KNEE IMMBOLIZER  20,6152573,CDM,271,RC,,,Outpatient,,,139.01,139.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.31,70,,77.85,percent of total billed charges,70% of total billed charges for outpatient setting,117.99,84.88,,94.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.51,50,,55.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.26,75,,83.41,percent of total billed charges,75% of total billed charges for outpatient setting,97.31,70,,77.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.85,12.84,,14.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.21,80,,88.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.85,12.84,,14.28,percent of total billed charges,12.84% of total billed charges,17.85,12.84,,14.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.36,65,,72.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.65,35,,38.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.11,90,,100.09,percent of total billed charges,90% of total billed charges for outpatient setting,17.85,125.11,
KNEE STANDING AP,2400400,CDM,320,RC,73565,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
KNIFE 1.0MM SLIT ANGLED OPTH / MSL10,69162296,CDM,272,RC,,,Outpatient,,,65.31,65.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,84.88,,44.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.66,50,,26.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.98,75,,39.18,percent of total billed charges,75% of total billed charges for outpatient setting,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,80,,41.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.45,65,,33.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,35,,18.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.78,90,,47.02,percent of total billed charges,90% of total billed charges for outpatient setting,8.39,58.78,
KNIFE 15 DEGREE OPHTHALMIC / MST15,6150503,CDM,272,RC,,,Outpatient,,,40.81,40.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,34.64,84.88,,27.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.41,50,,16.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.61,75,,24.49,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.65,80,,26.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.53,65,,21.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.28,35,,11.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.73,90,,29.38,percent of total billed charges,90% of total billed charges for outpatient setting,5.24,36.73,
KNIFE 19G V-LANCE/8065911901,69159578,CDM,272,RC,,,Outpatient,,,168.4,168.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.88,70,,94.3,percent of total billed charges,70% of total billed charges for outpatient setting,142.94,84.88,,114.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.2,50,,67.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.3,75,,101.04,percent of total billed charges,75% of total billed charges for outpatient setting,117.88,70,,94.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.62,12.84,,17.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.72,80,,107.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.62,12.84,,17.3,percent of total billed charges,12.84% of total billed charges,21.62,12.84,,17.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.46,65,,87.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,35,,47.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.56,90,,121.25,percent of total billed charges,90% of total billed charges for outpatient setting,21.62,151.56,
KNIFE 2.0MM CRESCENT ANGLED / MCU20,69169900,CDM,272,RC,,,Outpatient,,,65.31,65.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,84.88,,44.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.66,50,,26.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.98,75,,39.18,percent of total billed charges,75% of total billed charges for outpatient setting,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,80,,41.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.45,65,,33.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,35,,18.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.78,90,,47.02,percent of total billed charges,90% of total billed charges for outpatient setting,8.39,58.78,
KNIFE 2.4MM SLIT ANGLED OPHT / MSL24,69160691,CDM,272,RC,,,Outpatient,,,65.31,65.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,84.88,,44.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.66,50,,26.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.98,75,,39.18,percent of total billed charges,75% of total billed charges for outpatient setting,45.72,70,,36.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,80,,41.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,8.39,12.84,,6.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.45,65,,33.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,35,,18.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.78,90,,47.02,percent of total billed charges,90% of total billed charges for outpatient setting,8.39,58.78,
KNIFE ANNULOTOMY BAYONETTE / 675.405S,69161935,CDM,272,RC,,,Outpatient,,,2593.5,2593.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1815.45,70,,1452.36,percent of total billed charges,70% of total billed charges for outpatient setting,2201.36,84.88,,1761.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1296.75,50,,1037.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1945.13,75,,1556.1,percent of total billed charges,75% of total billed charges for outpatient setting,1815.45,70,,1452.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.01,12.84,,266.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2074.8,80,,1659.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.01,12.84,,266.41,percent of total billed charges,12.84% of total billed charges,333.01,12.84,,266.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1685.78,65,,1348.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.73,35,,726.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2334.15,90,,1867.32,percent of total billed charges,90% of total billed charges for outpatient setting,333.01,2334.15,
KNIFE ELECTRODE / KE-26,6150621,CDM,272,RC,,,Outpatient,,,406.34,406.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.44,70,,227.55,percent of total billed charges,70% of total billed charges for outpatient setting,344.9,84.88,,275.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.17,50,,162.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.76,75,,243.81,percent of total billed charges,75% of total billed charges for outpatient setting,284.44,70,,227.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.17,12.84,,41.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.07,80,,260.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.17,12.84,,41.74,percent of total billed charges,12.84% of total billed charges,52.17,12.84,,41.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.12,65,,211.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.22,35,,113.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.71,90,,292.57,percent of total billed charges,90% of total billed charges for outpatient setting,52.17,365.71,
KNIFE IACCESS  TRABECULAR TREPHINE / AX1,69169863,CDM,272,RC,,,Outpatient,,,1600,1600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,70,,896,percent of total billed charges,70% of total billed charges for outpatient setting,1358.08,84.88,,1086.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,800,50,,640,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1200,75,,960,percent of total billed charges,75% of total billed charges for outpatient setting,1120,70,,896,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.44,12.84,,164.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280,80,,1024,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.44,12.84,,164.35,percent of total billed charges,12.84% of total billed charges,205.44,12.84,,164.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1040,65,,832,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560,35,,448,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1440,90,,1152,percent of total billed charges,90% of total billed charges for outpatient setting,205.44,1440,
KNIFE KDB GLIDE / KDBGLIDE,71000140,CDM,272,RC,,,Outpatient,,,1980,1980,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,70,,1108.8,percent of total billed charges,70% of total billed charges for outpatient setting,1680.62,84.88,,1344.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,990,50,,792,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1485,75,,1188,percent of total billed charges,75% of total billed charges for outpatient setting,1386,70,,1108.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.23,12.84,,203.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1584,80,,1267.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.23,12.84,,203.38,percent of total billed charges,12.84% of total billed charges,254.23,12.84,,203.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1287,65,,1029.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693,35,,554.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1782,90,,1425.6,percent of total billed charges,90% of total billed charges for outpatient setting,254.23,1782,
KNIFE LIGAMENT RETROGRADE / 200-1003,1692841,CDM,272,RC,,,Outpatient,,,1180,1180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826,70,,660.8,percent of total billed charges,70% of total billed charges for outpatient setting,1001.58,84.88,,801.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,590,50,,472,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,885,75,,708,percent of total billed charges,75% of total billed charges for outpatient setting,826,70,,660.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944,80,,755.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,767,65,,613.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,35,,330.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1062,90,,849.6,percent of total billed charges,90% of total billed charges for outpatient setting,151.51,1062,
KNIFE LRI 600 MICRON / K20-2560,69169525,CDM,272,RC,,,Outpatient,,,107.1,107.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.97,70,,59.98,percent of total billed charges,70% of total billed charges for outpatient setting,90.91,84.88,,72.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.55,50,,42.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,75,,64.26,percent of total billed charges,75% of total billed charges for outpatient setting,74.97,70,,59.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.68,80,,68.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.62,65,,55.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,35,,29.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.39,90,,77.11,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,96.39,
KNIFE MVR-LANCE 20 GAUGE /MVR20,6150504,CDM,272,RC,,,Outpatient,,,60.56,60.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,51.4,84.88,,41.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.28,50,,24.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.42,75,,36.34,percent of total billed charges,75% of total billed charges for outpatient setting,42.39,70,,33.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.45,80,,38.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,7.78,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.36,65,,31.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.2,35,,16.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.5,90,,43.6,percent of total billed charges,90% of total billed charges for outpatient setting,7.78,54.5,
KNOT PUSHER SUTURE CUTTER / AR-4515,69160910,CDM,272,RC,,,Outpatient,,,568.11,568.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.68,70,,318.14,percent of total billed charges,70% of total billed charges for outpatient setting,482.21,84.88,,385.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.06,50,,227.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.08,75,,340.86,percent of total billed charges,75% of total billed charges for outpatient setting,397.68,70,,318.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.49,80,,363.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,72.95,12.84,,58.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.27,65,,295.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.84,35,,159.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,511.3,90,,409.04,percent of total billed charges,90% of total billed charges for outpatient setting,72.95,511.3,
KOH PREP,201540,CDM,300,RC,87220,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
KONDREMUL PLAIN: 16 0Z,3302770,CDM,259,RC,,,Outpatient,,,37.92,37.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.54,70,,21.23,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,84.88,,25.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.96,50,,15.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.44,75,,22.75,percent of total billed charges,75% of total billed charges for outpatient setting,26.54,70,,21.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.34,80,,24.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,4.87,12.84,,3.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.65,65,,19.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.27,35,,10.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.13,90,,27.3,percent of total billed charges,90% of total billed charges for outpatient setting,4.87,34.13,
K-PHOS NEUTRAL 250MG TAB,3303183,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
K-WIRE 0.9X2.50MM STRYKER / KN1115,1425314,CDM,278,RC,C1713,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,60,,88.8,percent of total billed charges,60% of total Billed charges for outpatient setting,157.03,84.88,,125.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.75,75,,111,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,50,,74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148,80,,118.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,185,65,,148,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.75,35,,51.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111,60,,88.8,percent of total billed charges,60% of total billed charges for outpatient setting,23.75,185,
K-WIRE 1.10MM TEMPORARY / DC4212,201839,CDM,272,RC,C1713,HCPCS,Outpatient,,,272,272,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.4,70,,152.32,percent of total billed charges,70% of total billed charges for outpatient setting,230.87,84.88,,184.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204,75,,163.2,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,70,,152.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,12.84,,27.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,80,,174.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.92,12.84,,27.94,percent of total billed charges,12.84% of total billed charges,34.92,12.84,,27.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,176.8,65,,141.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.2,35,,76.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,244.8,90,,195.84,percent of total billed charges,90% of total billed charges for outpatient setting,34.92,244.8,
K-WIRE 1.10X150MM BLUNT / DSDS1011,884843,CDM,272,RC,C1713,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,70,percent of total billed charges,70% of total billed charges for outpatient setting,106.1,84.88,,84.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.75,75,,75,percent of total billed charges,75% of total billed charges for outpatient setting,87.5,70,,70,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100,80,,80,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.25,65,,65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.75,35,,35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.5,90,,90,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.5,
K-WIRE 1.15X3MM STRYKER / KN1116,1459970,CDM,278,RC,C1713,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,60,,88.8,percent of total billed charges,60% of total Billed charges for outpatient setting,157.03,84.88,,125.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.75,75,,111,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,50,,74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148,80,,118.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,185,65,,148,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.75,35,,51.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111,60,,88.8,percent of total billed charges,60% of total billed charges for outpatient setting,23.75,185,
K-WIRE 1.2MM X 70MM  AGK0212070,69161247,CDM,278,RC,,,Outpatient,,,255.65,255.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.39,60,,122.71,percent of total billed charges,60% of total Billed charges for outpatient setting,217,84.88,,173.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.83,50,,102.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.74,75,,153.39,percent of total billed charges,75% of total billed charges for outpatient setting,127.83,50,,102.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.52,80,,163.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,255.65,65,,204.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.48,35,,71.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.39,60,,122.71,percent of total billed charges,60% of total billed charges for outpatient setting,32.83,255.65,
K-WIRE 1.60X150MM CHARLOTTE / 44112008,694043,CDM,278,RC,C1713,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,60,,62.4,percent of total billed charges,60% of total Billed charges for outpatient setting,110.34,84.88,,88.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.5,75,,78,percent of total billed charges,75% of total billed charges for outpatient setting,65,50,,52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,12.84,,13.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104,80,,83.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,12.84,,13.35,percent of total billed charges,12.84% of total billed charges,16.69,12.84,,13.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130,65,,104,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,35,,36.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78,60,,62.4,percent of total billed charges,60% of total billed charges for outpatient setting,16.69,130,
K-WIRE 1.6MM WITH BALL / AR-14016B,70000239,CDM,272,RC,C1713,HCPCS,Outpatient,,,389.34,389.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,330.47,84.88,,264.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.01,75,,233.61,percent of total billed charges,75% of total billed charges for outpatient setting,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,80,,249.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,35,,109.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.41,90,,280.33,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,350.41,
K-WIRE 1.8MM / 04.110.300,69160743,CDM,278,RC,,,Outpatient,,,457.78,457.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.67,60,,219.74,percent of total billed charges,60% of total Billed charges for outpatient setting,388.56,84.88,,310.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,228.89,50,,183.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.34,75,,274.67,percent of total billed charges,75% of total billed charges for outpatient setting,228.89,50,,183.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.78,12.84,,47.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.22,80,,292.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.78,12.84,,47.02,percent of total billed charges,12.84% of total billed charges,58.78,12.84,,47.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,457.78,65,,366.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.22,35,,128.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,274.67,60,,219.74,percent of total billed charges,60% of total billed charges for outpatient setting,58.78,457.78,
K-WIRE 2.0 STRYKER / 702460,69162173,CDM,278,RC,,,Outpatient,,,519.12,519.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,60,,249.18,percent of total billed charges,60% of total Billed charges for outpatient setting,440.63,84.88,,352.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.56,50,,207.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.34,75,,311.47,percent of total billed charges,75% of total billed charges for outpatient setting,259.56,50,,207.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,12.84,,53.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.3,80,,332.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,12.84,,53.33,percent of total billed charges,12.84% of total billed charges,66.66,12.84,,53.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.12,65,,415.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.69,35,,145.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.47,60,,249.18,percent of total billed charges,60% of total billed charges for outpatient setting,66.66,519.12,
K-WIRE 2.0X200MM / AR-5050K-2,70000516,CDM,278,RC,C1713,HCPCS,Outpatient,,,204.75,204.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,60,,98.28,percent of total billed charges,60% of total Billed charges for outpatient setting,173.79,84.88,,139.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.56,75,,122.85,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,50,,81.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,12.84,,21.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,80,,131.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,12.84,,21.03,percent of total billed charges,12.84% of total billed charges,26.29,12.84,,21.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,204.75,65,,163.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,35,,57.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.85,60,,98.28,percent of total billed charges,60% of total billed charges for outpatient setting,26.29,204.75,
K-WIRE 2.4X450MM / 639.002,69162451,CDM,278,RC,,,Outpatient,,,562.38,562.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.43,60,,269.94,percent of total billed charges,60% of total Billed charges for outpatient setting,477.35,84.88,,381.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.19,50,,224.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.79,75,,337.43,percent of total billed charges,75% of total billed charges for outpatient setting,281.19,50,,224.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.9,80,,359.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,35,,157.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.43,60,,269.94,percent of total billed charges,60% of total billed charges for outpatient setting,72.21,562.38,
K-WIRE 2.5X285MM / 292.26,70000405,CDM,278,RC,C1713,HCPCS,Outpatient,,,505.28,505.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.17,60,,242.54,percent of total billed charges,60% of total Billed charges for outpatient setting,428.88,84.88,,343.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.96,75,,303.17,percent of total billed charges,75% of total billed charges for outpatient setting,252.64,50,,202.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.88,12.84,,51.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.22,80,,323.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.88,12.84,,51.9,percent of total billed charges,12.84% of total billed charges,64.88,12.84,,51.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.28,65,,404.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.85,35,,141.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.17,60,,242.54,percent of total billed charges,60% of total billed charges for outpatient setting,64.88,505.28,
K-WIRE 2X200MM UNTHREADED / 705355,70000674,CDM,278,RC,C1713,HCPCS,Outpatient,,,344,344,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.4,60,,165.12,percent of total billed charges,60% of total Billed charges for outpatient setting,291.99,84.88,,233.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,75,,206.4,percent of total billed charges,75% of total billed charges for outpatient setting,172,50,,137.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.17,12.84,,35.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.2,80,,220.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.17,12.84,,35.34,percent of total billed charges,12.84% of total billed charges,44.17,12.84,,35.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344,65,,275.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.4,35,,96.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.4,60,,165.12,percent of total billed charges,60% of total billed charges for outpatient setting,44.17,344,
K-WIRE 2X285MM FIX / 703583,1310,CDM,278,RC,C1713,HCPCS,Outpatient,,,299.44,299.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.66,60,,143.73,percent of total billed charges,60% of total Billed charges for outpatient setting,254.16,84.88,,203.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.58,75,,179.66,percent of total billed charges,75% of total billed charges for outpatient setting,149.72,50,,119.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.45,12.84,,30.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.55,80,,191.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.45,12.84,,30.76,percent of total billed charges,12.84% of total billed charges,38.45,12.84,,30.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,299.44,65,,239.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.8,35,,83.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.66,60,,143.73,percent of total billed charges,60% of total billed charges for outpatient setting,38.45,299.44,
K-WIRE 3.2X300 THREADED / 702460,70000433,CDM,278,RC,C1713,HCPCS,Outpatient,,,661.88,661.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,60,,317.7,percent of total billed charges,60% of total Billed charges for outpatient setting,561.8,84.88,,449.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.41,75,,397.13,percent of total billed charges,75% of total billed charges for outpatient setting,330.94,50,,264.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.99,12.84,,67.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.5,80,,423.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.99,12.84,,67.99,percent of total billed charges,12.84% of total billed charges,84.99,12.84,,67.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,661.88,65,,529.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.66,35,,185.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.13,60,,317.7,percent of total billed charges,60% of total billed charges for outpatient setting,84.99,661.88,
K-WIRE 3X285MM FX / 1806-0050S,31172,CDM,278,RC,C1713,HCPCS,Outpatient,,,368,368,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.8,60,,176.64,percent of total billed charges,60% of total Billed charges for outpatient setting,312.36,84.88,,249.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276,75,,220.8,percent of total billed charges,75% of total billed charges for outpatient setting,184,50,,147.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.4,80,,235.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,368,65,,294.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.8,35,,103.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,220.8,60,,176.64,percent of total billed charges,60% of total billed charges for outpatient setting,47.25,368,
K-WIRE COMPRESSION SCREW-STRYKER,69161441,CDM,278,RC,C1769,HCPCS,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.78,60,,103.82,percent of total billed charges,60% of total Billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,216.3,65,,173.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.78,60,,103.82,percent of total billed charges,60% of total billed charges for outpatient setting,27.77,216.3,
K-WIRE FX NS / 675.399S,69162314,CDM,278,RC,,,Outpatient,,,1116,1116,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.6,60,,535.68,percent of total billed charges,60% of total Billed charges for outpatient setting,947.26,84.88,,757.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,558,50,,446.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,837,75,,669.6,percent of total billed charges,75% of total billed charges for outpatient setting,558,50,,446.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.29,12.84,,114.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.8,80,,714.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.29,12.84,,114.63,percent of total billed charges,12.84% of total billed charges,143.29,12.84,,114.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1116,65,,892.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.6,35,,312.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,669.6,60,,535.68,percent of total billed charges,60% of total billed charges for outpatient setting,143.29,1116,
K-WIRE W/ DRILL TIP / 705002,69162875,CDM,278,RC,C1713,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,60,,103.68,percent of total billed charges,60% of total Billed charges for outpatient setting,183.34,84.88,,146.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,75,,129.6,percent of total billed charges,75% of total billed charges for outpatient setting,108,50,,86.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.73,12.84,,22.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,80,,138.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.73,12.84,,22.18,percent of total billed charges,12.84% of total billed charges,27.73,12.84,,22.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,216,65,,172.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,35,,60.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.6,60,,103.68,percent of total billed charges,60% of total billed charges for outpatient setting,27.73,216,
KYTRIL 0.1MG: IV,3302843,CDM,250,RC,,,Outpatient,,,60.65,60.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.46,70,,33.97,percent of total billed charges,70% of total billed charges for outpatient setting,51.48,84.88,,41.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.33,50,,24.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.49,75,,36.39,percent of total billed charges,75% of total billed charges for outpatient setting,42.46,70,,33.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,12.84,,6.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.52,80,,38.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,12.84,,6.23,percent of total billed charges,12.84% of total billed charges,7.79,12.84,,6.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.42,65,,31.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,35,,16.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.59,90,,43.67,percent of total billed charges,90% of total billed charges for outpatient setting,7.79,54.59,
LABEL OPHTHALMIC STERILE / CC18628,69159894,CDM,272,RC,,,Outpatient,,,13.95,13.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,11.84,84.88,,9.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.98,50,,5.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.46,75,,8.37,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,80,,8.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.07,65,,7.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,35,,3.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.56,90,,10.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.79,12.56,
LABEL TRACRIUM/AT67,69159628,CDM,272,RC,,,Outpatient,,,43.9,43.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.73,70,,24.58,percent of total billed charges,70% of total billed charges for outpatient setting,37.26,84.88,,29.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.95,50,,17.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.93,75,,26.34,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,70,,24.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,80,,28.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.54,65,,22.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.37,35,,12.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.51,90,,31.61,percent of total billed charges,90% of total billed charges for outpatient setting,5.64,39.51,
LABELS MEDICATION STERILE / 161804,69159890,CDM,272,RC,,,Outpatient,,,23.2,23.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.24,70,,12.99,percent of total billed charges,70% of total billed charges for outpatient setting,19.69,84.88,,15.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.6,50,,9.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.4,75,,13.92,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,70,,12.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.56,80,,14.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.08,65,,12.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.12,35,,6.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.88,90,,16.7,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,20.88,
LABETALOL (TRANDATE) 5MG/ML INJ: 20ML,3301344,CDM,250,RC,,,Outpatient,,,30.47,30.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.33,70,,17.06,percent of total billed charges,70% of total billed charges for outpatient setting,25.86,84.88,,20.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.24,50,,12.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.85,75,,18.28,percent of total billed charges,75% of total billed charges for outpatient setting,21.33,70,,17.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.38,80,,19.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,3.91,12.84,,3.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.81,65,,15.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,35,,8.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.42,90,,21.94,percent of total billed charges,90% of total billed charges for outpatient setting,3.91,27.42,
LABETALOL (TRANDATE) 5MG/ML INJ: 20ML,3301349,CDM,250,RC,,,Outpatient,,,94.35,94.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,84.88,,64.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.18,50,,37.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.76,75,,56.61,percent of total billed charges,75% of total billed charges for outpatient setting,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,80,,60.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.33,65,,49.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,35,,26.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.92,90,,67.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,84.92,
LABETALOL (TRANDATE) TAB  100 MG,3301345,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LABETALOL (TRANDATE) TAB : 200 MG,3301347,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LABETALOL (TRANDATE) TAB :200MG  UD,3301348,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LABETALOL (TRANDATE) TAB:100MG  UD,3301346,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LABETALOL 20MG/4ML CARPUJECT,3310223,CDM,250,RC,J3490,HCPCS,Outpatient,,,47.55,47.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.29,70,,26.63,percent of total billed charges,70% of total billed charges for outpatient setting,40.36,84.88,,32.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.66,75,,28.53,percent of total billed charges,75% of total billed charges for outpatient setting,33.29,70,,26.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,12.84,,4.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.04,80,,30.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,12.84,,4.89,percent of total billed charges,12.84% of total billed charges,6.11,12.84,,4.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.91,65,,24.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.64,35,,13.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.8,90,,34.24,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,42.8,
LABETALOL 5MG/ML 20ML MDV/GEN TRANDATE,3301343,CDM,250,RC,J3490,HCPCS,Outpatient,,,32.48,32.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,70,,18.19,percent of total billed charges,70% of total billed charges for outpatient setting,27.57,84.88,,22.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.36,75,,19.49,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,70,,18.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,80,,20.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.11,65,,16.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,35,,9.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.23,90,,23.38,percent of total billed charges,90% of total billed charges for outpatient setting,4.17,29.23,
LABRAL TAPE WHITE 1.5MM / AR-7276,70000079,CDM,272,RC,,,Outpatient,,,302.82,302.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,70,,169.58,percent of total billed charges,70% of total billed charges for outpatient setting,257.03,84.88,,205.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.41,50,,121.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.12,75,,181.7,percent of total billed charges,75% of total billed charges for outpatient setting,211.97,70,,169.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,12.84,,31.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.26,80,,193.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.88,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,196.83,65,,157.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.99,35,,84.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,272.54,90,,218.03,percent of total billed charges,90% of total billed charges for outpatient setting,38.88,272.54,
LACOSAMIDE,220197,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
LACRI-LUBE NP O.7 G PETROLATUM,3302697,CDM,259,RC,,,Outpatient,,,10.4,10.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,70,,5.82,percent of total billed charges,70% of total billed charges for outpatient setting,8.83,84.88,,7.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.2,50,,4.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.8,75,,6.24,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,70,,5.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,80,,6.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.76,65,,5.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,35,,2.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.36,90,,7.49,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.36,
LACRIMAL INTUBATION SET 28-0184,6150749,CDM,272,RC,,,Outpatient,,,340.87,340.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.61,70,,190.89,percent of total billed charges,70% of total billed charges for outpatient setting,289.33,84.88,,231.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.44,50,,136.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.65,75,,204.52,percent of total billed charges,75% of total billed charges for outpatient setting,238.61,70,,190.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.7,80,,218.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,221.57,65,,177.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.3,35,,95.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,306.78,90,,245.42,percent of total billed charges,90% of total billed charges for outpatient setting,43.77,306.78,
LACTAID ULTRA: TAB,3302805,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LACTASE (LACTAID) CHEW: 9 MU,3301350,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LACTATED RINGERS (HOSPIRA) 1000ML,70000443,CDM,271,RC,,,Outpatient,,,37.85,37.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,32.13,84.88,,25.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.93,50,,15.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.39,75,,22.71,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,80,,24.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,4.86,12.84,,3.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.6,65,,19.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,35,,10.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.07,90,,27.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,34.07,
LACTATED RINGERS INJ 1LITER / 2B2324X,6150075,CDM,258,RC,,,Outpatient,,,17.1,17.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,14.51,84.88,,11.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.55,50,,6.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.83,75,,10.26,percent of total billed charges,75% of total billed charges for outpatient setting,11.97,70,,9.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,80,,10.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,2.2,12.84,,1.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,65,,8.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,35,,4.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.39,90,,12.31,percent of total billed charges,90% of total billed charges for outpatient setting,2.2,15.39,
LACTATED RINGERS SOLN 1000ML,3302492,CDM,258,RC,J7120,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LACTIC ACID,220103,CDM,301,RC,83605,HCPCS,Outpatient,,,52.07,46.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,70,,29.16,percent of total billed charges,70% of total billed charges for outpatient setting,44.2,84.88,,35.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.05,75,,31.24,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,70,,29.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,80,,33.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.59,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,100,,,Fee Schedule,100% of Custom Fee Schedule,46.86,90,,37.49,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,46.86,
LACTINEX POWDER:1GM,3302768,CDM,259,RC,,,Outpatient,,,55.62,55.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.93,70,,31.14,percent of total billed charges,70% of total billed charges for outpatient setting,47.21,84.88,,37.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.81,50,,22.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.72,75,,33.38,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,70,,31.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,12.84,,5.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.5,80,,35.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,12.84,,5.71,percent of total billed charges,12.84% of total billed charges,7.14,12.84,,5.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.15,65,,28.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.47,35,,15.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.06,90,,40.05,percent of total billed charges,90% of total billed charges for outpatient setting,7.14,50.06,
LACTOBACILLUS (FLORANEX) 0.2MG TAB,3303160,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LACTOFERRIN STOOL,220904,CDM,300,RC,83631,HCPCS,Outpatient,,,88.34,79.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,74.98,84.88,,59.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.26,75,,53.01,percent of total billed charges,75% of total billed charges for outpatient setting,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,12.84,,9.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.67,80,,56.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,12.84,,9.07,percent of total billed charges,12.84% of total billed charges,11.34,12.84,,9.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,100,,,Fee Schedule,100% of Custom Fee Schedule,79.51,90,,63.61,percent of total billed charges,90% of total billed charges for outpatient setting,11.34,79.51,
LACTOSE FREE (TWOCAL): VANILLA 8OZ,3301351,CDM,259,RC,,,Outpatient,,,5.66,5.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,84.88,,3.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.83,50,,2.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.25,75,,3.4,percent of total billed charges,75% of total billed charges for outpatient setting,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,80,,3.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.68,65,,2.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,35,,1.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.09,90,,4.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,5.09,
LACTULOSE (CEPHULAC) SYRUP : 10 GM,3301352,CDM,259,RC,,,Outpatient,,,52.94,52.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.06,70,,29.65,percent of total billed charges,70% of total billed charges for outpatient setting,44.94,84.88,,35.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.47,50,,21.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.71,75,,31.77,percent of total billed charges,75% of total billed charges for outpatient setting,37.06,70,,29.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.35,80,,33.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.41,65,,27.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.53,35,,14.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.65,90,,38.12,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.65,
LACTULOSE (CHRONULAC) SYRUP : 20 GM,3301354,CDM,259,RC,,,Outpatient,,,8.09,8.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,84.88,,5.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.05,50,,3.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.07,75,,4.86,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,80,,5.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.26,65,,4.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,35,,2.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.28,90,,5.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.28,
LACTULOSE 20GM/30ML SOLUTION,3301353,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LAG SCREW  5.0X40mm (POLYAX)  118-50140,69161498,CDM,278,RC,,,Outpatient,,,2534.23,2534.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1520.54,60,,1216.43,percent of total billed charges,60% of total Billed charges for outpatient setting,2151.05,84.88,,1720.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1267.12,50,,1013.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1900.67,75,,1520.54,percent of total billed charges,75% of total billed charges for outpatient setting,1267.12,50,,1013.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.4,12.84,,260.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2027.38,80,,1621.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.4,12.84,,260.32,percent of total billed charges,12.84% of total billed charges,325.4,12.84,,260.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2660.94,105,,2128.75,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.98,35,,709.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1520.54,60,,1216.43,percent of total billed charges,60% of total billed charges for outpatient setting,325.4,2660.94,
LAM TUBING (Lipo),69161922,CDM,272,RC,,,Outpatient,,,45.42,45.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,38.55,84.88,,30.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.71,50,,18.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.07,75,,27.26,percent of total billed charges,75% of total billed charges for outpatient setting,31.79,70,,25.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,80,,29.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.52,65,,23.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.9,35,,12.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.88,90,,32.7,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.88,
LAMICTAL LAMOTRIGINE,200797,CDM,301,RC,80175,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.09,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
LAMIVUDINE (EPIVIR) TAB: 150 MG,3301355,CDM,259,RC,,,Outpatient,,,12.26,12.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.41,84.88,,8.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.13,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.2,75,,7.36,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,80,,7.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,65,,6.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,35,,3.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.03,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.03,
LAMIVUDINE/ZIDOVUDINE (COMBIVIR) 150/300,3303273,CDM,259,RC,,,Outpatient,,,56.5,56.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.55,70,,31.64,percent of total billed charges,70% of total billed charges for outpatient setting,47.96,84.88,,38.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.25,50,,22.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.38,75,,33.9,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,70,,31.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,80,,36.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.73,65,,29.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.78,35,,15.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.85,90,,40.68,percent of total billed charges,90% of total billed charges for outpatient setting,7.25,50.85,
LAMOTRIGINE (genericLAMICTAL) 25 MG TAB,3301356,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LAMOTRIGINE (LAMICTAL) TAB: 200 MG,3303113,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LAMOTRIGINE ORAL TABLET 100MG,3313816,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
LANOLIN MINERAL (ALPHA KERI) LOTION:60ML,3301358,CDM,259,RC,,,Outpatient,,,11.88,11.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.91,75,,7.13,percent of total billed charges,75% of total billed charges for outpatient setting,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,35,,3.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.69,90,,8.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.53,10.69,
LANOLIN MINERAL (ALPHA KERI) OIL :59ML,3301359,CDM,259,RC,,,Outpatient,,,19.57,19.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.7,70,,10.96,percent of total billed charges,70% of total billed charges for outpatient setting,16.61,84.88,,13.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.79,50,,7.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.68,75,,11.74,percent of total billed charges,75% of total billed charges for outpatient setting,13.7,70,,10.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.66,80,,12.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,2.51,12.84,,2.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.72,65,,10.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.85,35,,5.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.61,90,,14.09,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,17.61,
LANOLIN MINERAL (THERA DERM)LOTION:240ML,3301357,CDM,259,RC,,,Outpatient,,,8.09,8.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,84.88,,5.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.05,50,,3.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.07,75,,4.86,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,70,,4.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,80,,5.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.26,65,,4.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,35,,2.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.28,90,,5.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.28,
LANSOPRAZOLE (PREVACID) CAP: 15 MG,3301360,CDM,259,RC,,,Outpatient,,,13.15,13.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.21,70,,7.37,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,84.88,,8.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.58,50,,5.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.86,75,,7.89,percent of total billed charges,75% of total billed charges for outpatient setting,9.21,70,,7.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,12.84,,1.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,80,,8.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,12.84,,1.35,percent of total billed charges,12.84% of total billed charges,1.69,12.84,,1.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.55,65,,6.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.6,35,,3.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.84,90,,9.47,percent of total billed charges,90% of total billed charges for outpatient setting,1.69,11.84,
LANSOPRAZOLE (PREVACID) CAP: 30 MG,3301361,CDM,259,RC,,,Outpatient,,,13.39,13.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.7,50,,5.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.04,75,,8.03,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,80,,8.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.7,65,,6.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.05,90,,9.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.05,
LANTUS INSULIN 10ML 100u/ml,3302858,CDM,259,RC,J1815,HCPCS,Outpatient,,,288.36,288.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.85,70,,161.48,percent of total billed charges,70% of total billed charges for outpatient setting,244.76,84.88,,195.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,216.27,75,,173.02,percent of total billed charges,75% of total billed charges for outpatient setting,201.85,70,,161.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.69,80,,184.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,187.43,65,,149.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,100,,,Fee Schedule,100% of Custom Fee Schedule,259.52,90,,207.62,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,259.52,
LAP SCISSOR EPIX  5mm x 35cm CB030,69161567,CDM,272,RC,,,Outpatient,,,267.35,267.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.15,70,,149.72,percent of total billed charges,70% of total billed charges for outpatient setting,226.93,84.88,,181.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.68,50,,106.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.51,75,,160.41,percent of total billed charges,75% of total billed charges for outpatient setting,187.15,70,,149.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,12.84,,27.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.88,80,,171.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,12.84,,27.46,percent of total billed charges,12.84% of total billed charges,34.33,12.84,,27.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.78,65,,139.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.57,35,,74.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.62,90,,192.5,percent of total billed charges,90% of total billed charges for outpatient setting,34.33,240.62,
LAP SPNG 18X18 W/O RINGS / MDS241518,6150051,CDM,272,RC,,,Outpatient,,,11.25,11.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,9.55,84.88,,7.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.63,50,,4.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.44,75,,6.75,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,80,,7.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.31,65,,5.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,35,,3.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.13,90,,8.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.44,10.13,
LAPRA TY SUTURE CLIP / XC200,69160286,CDM,272,RC,,,Outpatient,,,225.08,225.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.56,70,,126.05,percent of total billed charges,70% of total billed charges for outpatient setting,191.05,84.88,,152.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.54,50,,90.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.81,75,,135.05,percent of total billed charges,75% of total billed charges for outpatient setting,157.56,70,,126.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.9,12.84,,23.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.06,80,,144.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.9,12.84,,23.12,percent of total billed charges,12.84% of total billed charges,28.9,12.84,,23.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.3,65,,117.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.78,35,,63.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.57,90,,162.06,percent of total billed charges,90% of total billed charges for outpatient setting,28.9,202.57,
LARGE BORE TUBING,3302230,CDM,272,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LARYNGSCP BL MILLER 2 / 00467002,69169636,CDM,271,RC,,,Outpatient,,,109.68,109.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,93.1,84.88,,74.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.84,50,,43.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.26,75,,65.81,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,80,,70.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.29,65,,57.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,35,,30.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.71,90,,78.97,percent of total billed charges,90% of total billed charges for outpatient setting,14.08,98.71,
LARYNGSCP BL MILLER 3 / 004670003,69169637,CDM,271,RC,,,Outpatient,,,109.68,109.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,93.1,84.88,,74.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.84,50,,43.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.26,75,,65.81,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,70,,61.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,80,,70.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,14.08,12.84,,11.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.29,65,,57.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.39,35,,30.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.71,90,,78.97,percent of total billed charges,90% of total billed charges for outpatient setting,14.08,98.71,
LASER,6051502,CDM,360,RC,,,Outpatient,,,1136.23,1136.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.36,70,,636.29,percent of total billed charges,70% of total billed charges for outpatient setting,964.43,84.88,,771.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,568.12,50,,454.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.17,75,,681.74,percent of total billed charges,75% of total billed charges for outpatient setting,795.36,70,,636.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.89,12.84,,116.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.98,80,,727.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.89,12.84,,116.71,percent of total billed charges,12.84% of total billed charges,145.89,12.84,,116.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.68,35,,318.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1022.61,90,,818.09,percent of total billed charges,90% of total billed charges for outpatient setting,145.89,1022.61,
LASER FIBER 150 BALL TIP / TFL-FBX150BS,69169597,CDM,272,RC,,,Outpatient,,,1932,1932,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.4,70,,1081.92,percent of total billed charges,70% of total billed charges for outpatient setting,1639.88,84.88,,1311.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,966,50,,772.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1449,75,,1159.2,percent of total billed charges,75% of total billed charges for outpatient setting,1352.4,70,,1081.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1545.6,80,,1236.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,248.07,12.84,,198.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1255.8,65,,1004.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.2,35,,540.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1738.8,90,,1391.04,percent of total billed charges,90% of total billed charges for outpatient setting,248.07,1738.8,
LASER FIBER 150 TFL /TFL-FBX150S,69169596,CDM,272,RC,,,Outpatient,,,1222.2,1222.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.54,70,,684.43,percent of total billed charges,70% of total billed charges for outpatient setting,1037.4,84.88,,829.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,611.1,50,,488.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,916.65,75,,733.32,percent of total billed charges,75% of total billed charges for outpatient setting,855.54,70,,684.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.93,12.84,,125.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,977.76,80,,782.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.93,12.84,,125.54,percent of total billed charges,12.84% of total billed charges,156.93,12.84,,125.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,794.43,65,,635.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.77,35,,342.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1099.98,90,,879.98,percent of total billed charges,90% of total billed charges for outpatient setting,156.93,1099.98,
LASER FIBER 200 BALL TIP /TFL-FBX200BS,69169595,CDM,272,RC,,,Outpatient,,,1638,1638,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1146.6,70,,917.28,percent of total billed charges,70% of total billed charges for outpatient setting,1390.33,84.88,,1112.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,819,50,,655.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1228.5,75,,982.8,percent of total billed charges,75% of total billed charges for outpatient setting,1146.6,70,,917.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.32,12.84,,168.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1310.4,80,,1048.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.32,12.84,,168.26,percent of total billed charges,12.84% of total billed charges,210.32,12.84,,168.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1064.7,65,,851.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,35,,458.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1474.2,90,,1179.36,percent of total billed charges,90% of total billed charges for outpatient setting,210.32,1474.2,
LASER FIBER 200 MICRON / TFL-FBX200S,69160250,CDM,272,RC,,,Outpatient,,,1591.8,1591.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.26,70,,891.41,percent of total billed charges,70% of total billed charges for outpatient setting,1351.12,84.88,,1080.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,795.9,50,,636.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.85,75,,955.08,percent of total billed charges,75% of total billed charges for outpatient setting,1114.26,70,,891.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.39,12.84,,163.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.44,80,,1018.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.39,12.84,,163.51,percent of total billed charges,12.84% of total billed charges,204.39,12.84,,163.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1034.67,65,,827.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.13,35,,445.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1432.62,90,,1146.1,percent of total billed charges,90% of total billed charges for outpatient setting,204.39,1432.62,
LASER FIBER 365 MICRON /TFL-FBX365S,69160249,CDM,272,RC,,,Outpatient,,,1591.8,1591.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.26,70,,891.41,percent of total billed charges,70% of total billed charges for outpatient setting,1351.12,84.88,,1080.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,795.9,50,,636.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.85,75,,955.08,percent of total billed charges,75% of total billed charges for outpatient setting,1114.26,70,,891.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.39,12.84,,163.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.44,80,,1018.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.39,12.84,,163.51,percent of total billed charges,12.84% of total billed charges,204.39,12.84,,163.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1034.67,65,,827.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.13,35,,445.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1432.62,90,,1146.1,percent of total billed charges,90% of total billed charges for outpatient setting,204.39,1432.62,
LASER FIBER 550 MICRON /TFL-FBX550S,69169594,CDM,272,RC,,,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1228.5,65,,982.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,90,,1360.8,percent of total billed charges,90% of total billed charges for outpatient setting,242.68,1701,
LASER FIBER 940 MICRON / TFL-FBX940S,69160251,CDM,272,RC,,,Outpatient,,,1984.5,1984.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1389.15,70,,1111.32,percent of total billed charges,70% of total billed charges for outpatient setting,1684.44,84.88,,1347.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,992.25,50,,793.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1488.38,75,,1190.7,percent of total billed charges,75% of total billed charges for outpatient setting,1389.15,70,,1111.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.81,12.84,,203.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.6,80,,1270.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.81,12.84,,203.85,percent of total billed charges,12.84% of total billed charges,254.81,12.84,,203.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1289.93,65,,1031.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.58,35,,555.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1786.05,90,,1428.84,percent of total billed charges,90% of total billed charges for outpatient setting,254.81,1786.05,
LASER FIBER PROSTATE / 0010-2400,69162566,CDM,272,RC,,,Outpatient,,,3481.6,3481.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.12,70,,1949.7,percent of total billed charges,70% of total billed charges for outpatient setting,2955.18,84.88,,2364.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1740.8,50,,1392.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.2,75,,2088.96,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.04,12.84,,357.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2785.28,80,,2228.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.04,12.84,,357.63,percent of total billed charges,12.84% of total billed charges,447.04,12.84,,357.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2263.04,65,,1810.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.56,35,,974.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3133.44,90,,2506.75,percent of total billed charges,90% of total billed charges for outpatient setting,447.04,3133.44,
LASER LITHO - SOLTIVE LASER,69160803,CDM,790,RC,,,Outpatient,,,16590.99,16590.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11613.69,70,,9290.95,percent of total billed charges,70% of total billed charges for outpatient setting,14082.43,84.88,,11265.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8295.5,50,,6636.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12443.24,75,,9954.59,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.28,12.84,,1704.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13272.79,80,,10618.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.28,12.84,,1704.22,percent of total billed charges,12.84% of total billed charges,2130.28,12.84,,1704.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5806.85,35,,4645.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14931.89,90,,11945.51,percent of total billed charges,90% of total billed charges for outpatient setting,2000,14931.89,
LASER LITHOTRIPSY STANDBY,69162797,CDM,790,RC,,,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,70,,726.77,percent of total billed charges,70% of total billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,908.46,70,,726.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1168.02,90,,934.42,percent of total billed charges,90% of total billed charges for outpatient setting,166.64,1168.02,
LASER STONELIGHT FIBER 910MIC/ LLF-910,69160801,CDM,272,RC,,,Outpatient,,,2982.59,2982.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2087.81,70,,1670.25,percent of total billed charges,70% of total billed charges for outpatient setting,2531.62,84.88,,2025.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1491.3,50,,1193.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2236.94,75,,1789.55,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.96,12.84,,306.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2386.07,80,,1908.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.96,12.84,,306.37,percent of total billed charges,12.84% of total billed charges,382.96,12.84,,306.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1938.68,65,,1550.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1043.91,35,,835.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2684.33,90,,2147.46,percent of total billed charges,90% of total billed charges for outpatient setting,382.96,2684.33,
LASER SURGERY OF PROSTATE / DYSAER,6151501,CDM,360,RC,,,Outpatient,,,2676.71,2676.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1873.7,70,,1498.96,percent of total billed charges,70% of total billed charges for outpatient setting,2271.99,84.88,,1817.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,1338.36,50,,1070.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2007.53,75,,1606.02,percent of total billed charges,75% of total billed charges for outpatient setting,1873.7,70,,1498.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.69,12.84,,274.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2141.37,80,,1713.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.69,12.84,,274.95,percent of total billed charges,12.84% of total billed charges,343.69,12.84,,274.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936.85,35,,749.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2409.04,90,,1927.23,percent of total billed charges,90% of total billed charges for outpatient setting,343.69,2409.04,
LASER SURGERY PROSTATE / HEALTHTRONICS,69162798,CDM,360,RC,,,Outpatient,,,2271.15,2271.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,70,,1271.85,percent of total billed charges,70% of total billed charges for outpatient setting,1927.75,84.88,,1542.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1135.58,50,,908.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1703.36,75,,1362.69,percent of total billed charges,75% of total billed charges for outpatient setting,1589.81,70,,1271.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,80,,1453.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,291.62,12.84,,233.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.9,35,,635.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,90,,1635.23,percent of total billed charges,90% of total billed charges for outpatient setting,291.62,2044.04,
LASER USAGE GLAUCOMA,69161466,CDM,279,RC,,,Outpatient,,,315,315,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,267.37,84.88,,213.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,157.5,50,,126,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.25,75,,189,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,80,,201.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,204.75,65,,163.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,35,,88.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,283.5,90,,226.8,percent of total billed charges,90% of total billed charges for outpatient setting,40.45,283.5,
LASER USAGE LENSX,69169503,CDM,279,RC,A9270,HCPCS,Outpatient,,,925,925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.5,70,,518,percent of total billed charges,70% of total billed charges for outpatient setting,785.14,84.88,,628.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.75,75,,555,percent of total billed charges,75% of total billed charges for outpatient setting,647.5,70,,518,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.77,12.84,,95.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740,80,,592,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.77,12.84,,95.02,percent of total billed charges,12.84% of total billed charges,118.77,12.84,,95.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,601.25,65,,481,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.75,35,,259,percent of total billed charges,35% of total Billed charges for Outpatient Setting,832.5,90,,666,percent of total billed charges,90% of total billed charges for outpatient setting,118.77,832.5,
LASIX INJ 10MG/ML: 10ML,3302551,CDM,250,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
LASIX INJ 10MG/ML: 2ML,3302552,CDM,250,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
LASIX INJ 10MG/ML: 4ML,3302553,CDM,250,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
LASIX SOL 10MG/ML: 60ML,3302554,CDM,259,RC,,,Outpatient,,,30.85,30.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,70,,17.28,percent of total billed charges,70% of total billed charges for outpatient setting,26.19,84.88,,20.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.43,50,,12.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.14,75,,18.51,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,70,,17.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,12.84,,3.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,80,,19.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,12.84,,3.17,percent of total billed charges,12.84% of total billed charges,3.96,12.84,,3.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.05,65,,16.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,35,,8.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.77,90,,22.22,percent of total billed charges,90% of total billed charges for outpatient setting,3.96,27.77,
LASIX TAB :40MG UD,3302556,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LASIX TAB: 20MG UD,3302555,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
LASIX TAB: 80MG UD,3302557,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LATANOPROST (genXALATAN) 0.005% 2.5ml OP,3301362,CDM,259,RC,,,Outpatient,,,37.52,37.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.26,70,,21.01,percent of total billed charges,70% of total billed charges for outpatient setting,31.85,84.88,,25.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.76,50,,15.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.14,75,,22.51,percent of total billed charges,75% of total billed charges for outpatient setting,26.26,70,,21.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.02,80,,24.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.39,65,,19.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.13,35,,10.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.77,90,,27.02,percent of total billed charges,90% of total billed charges for outpatient setting,4.82,33.77,
LC- HGB ELECTROPHORESIS,220327,CDM,300,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
LC- VITAMIN D-25 HYDROXY,220663,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
LC-ACETONE SERUM,220046,CDM,300,RC,82009,HCPCS,Outpatient,,,20.34,18.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,17.26,84.88,,13.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.26,75,,12.21,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.27,80,,13.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of Custom Fee Schedule,18.31,90,,14.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,18.31,
LC-ACT CLOT TIME,220154,CDM,305,RC,85347,HCPCS,Outpatient,,,19.26,17.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,16.35,84.88,,13.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.45,75,,11.56,percent of total billed charges,75% of total billed charges for outpatient setting,13.48,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,80,,12.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,100,,,Fee Schedule,100% of Custom Fee Schedule,17.33,90,,13.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,17.33,
LC-AFB CULTURE AND SMEAR,220585,CDM,300,RC,87015,HCPCS,Outpatient,,,30.06,27.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,25.51,84.88,,20.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.55,75,,18.04,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,80,,19.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of Custom Fee Schedule,27.05,90,,21.64,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,27.05,
LC-ANA,220451,CDM,300,RC,86038,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.92,100,,,Fee Schedule,100% of Custom Fee Schedule,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,48.97,
LC-ANA TITER BY IFA,220022,CDM,300,RC,86038,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.92,100,,,Fee Schedule,100% of Custom Fee Schedule,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,48.97,
LC-ANA W/REFLEX TO CONFIRMATORY TESTS,220183,CDM,302,RC,86038,HCPCS,Outpatient,,,54.41,48.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,46.18,84.88,,36.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.81,75,,32.65,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,70,,30.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.53,80,,34.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.92,100,,,Fee Schedule,100% of Custom Fee Schedule,48.97,90,,39.18,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,48.97,
"LC-APOLIPOPROTEIN, EACH",220156,CDM,300,RC,82172,HCPCS,Outpatient,,,94.91,85.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,80.56,84.88,,64.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.18,75,,56.94,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.93,80,,60.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of Custom Fee Schedule,85.42,90,,68.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,85.42,
"LC-ARBOVIRUS AB IGG AND IGM, SERUM",220055,CDM,302,RC,86651,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
LC-ASO ANTIBODY,220511,CDM,302,RC,86060,HCPCS,Outpatient,,,32.85,29.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,27.88,84.88,,22.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.64,75,,19.71,percent of total billed charges,75% of total billed charges for outpatient setting,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.28,80,,21.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of Custom Fee Schedule,29.57,90,,23.66,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,29.57,
"LC-BARTONELLA HENSELEA DNA, TISSUE, PCR",220152,CDM,310,RC,87801,HCPCS,Outpatient,,,315.9,284.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.13,70,,176.9,percent of total billed charges,70% of total billed charges for outpatient setting,268.14,84.88,,214.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,120.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,236.93,75,,189.54,percent of total billed charges,75% of total billed charges for outpatient setting,221.13,70,,176.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.72,80,,202.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.11,100,,,Fee Schedule,100% of Custom Fee Schedule,284.31,90,,227.45,percent of total billed charges,90% of total billed charges for outpatient setting,53.11,284.31,
LC-BASIC METABOLIC PANEL W/ CALCIUM,200320,CDM,300,RC,80048,HCPCS,Outpatient,,,38.07,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,32.31,84.88,,25.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.55,75,,22.84,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,80,,24.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,100,,,Fee Schedule,100% of Custom Fee Schedule,34.26,90,,27.41,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,34.26,
LC-BNP  PRO B-TYPE NATRIURETIC PEPTIDE,220543,CDM,301,RC,83880,HCPCS,Outpatient,,,176.67,159,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.67,70,,98.94,percent of total billed charges,70% of total billed charges for outpatient setting,149.96,84.88,,119.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,132.5,75,,106,percent of total billed charges,75% of total billed charges for outpatient setting,123.67,70,,98.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.34,80,,113.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,49.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of Custom Fee Schedule,159,90,,127.2,percent of total billed charges,90% of total billed charges for outpatient setting,39.26,159,
LC-CALPROTECTIN STOOL,220012,CDM,301,RC,83993,HCPCS,Outpatient,,,88.34,79.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,74.98,84.88,,59.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.26,75,,53.01,percent of total billed charges,75% of total billed charges for outpatient setting,61.84,70,,49.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.67,80,,56.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,100,,,Fee Schedule,100% of Custom Fee Schedule,79.51,90,,63.61,percent of total billed charges,90% of total billed charges for outpatient setting,19.63,79.51,
LC-CKMB,220072,CDM,301,RC,82553,HCPCS,Outpatient,,,51.98,46.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.39,70,,29.11,percent of total billed charges,70% of total billed charges for outpatient setting,44.12,84.88,,35.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.99,75,,31.19,percent of total billed charges,75% of total billed charges for outpatient setting,36.39,70,,29.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.58,80,,33.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.86,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,100% of Custom Fee Schedule,46.78,90,,37.42,percent of total billed charges,90% of total billed charges for outpatient setting,11.55,46.78,
LC-CLOS DIFF TOXINS A+ B,220673,CDM,302,RC,87449,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
LC-CULTURE AEROBIC ROUTINE,220498,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
LC-CULTURE ANAEROBIC,220501,CDM,300,RC,87075,HCPCS,Outpatient,,,42.62,38.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,84.88,,28.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.97,75,,25.58,percent of total billed charges,75% of total billed charges for outpatient setting,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,80,,27.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of Custom Fee Schedule,38.36,90,,30.69,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,38.36,
LC-CULTURE BLOOD AERO/ANA,220581,CDM,300,RC,87040,HCPCS,Outpatient,,,46.44,41.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,39.42,84.88,,31.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.83,75,,27.86,percent of total billed charges,75% of total billed charges for outpatient setting,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.15,80,,29.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.07,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of Custom Fee Schedule,41.8,90,,33.44,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,41.8,
LC-CULTURE LOWER RESP.SPUTUM,220369,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
LC-CULTURE RESPIRATORY,220698,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
LC-CULTURE SINUS,220579,CDM,306,RC,87070,HCPCS,Outpatient,,,38.79,34.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,32.92,84.88,,26.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.09,75,,23.27,percent of total billed charges,75% of total billed charges for outpatient setting,27.15,70,,21.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.33,100,,,Fee Schedule,100% of Custom Fee Schedule,34.91,90,,27.93,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,34.91,
LC-CULTURE STOOL,220339,CDM,300,RC,87045,HCPCS,Outpatient,,,42.48,38.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,36.06,84.88,,28.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.86,75,,25.49,percent of total billed charges,75% of total billed charges for outpatient setting,29.74,70,,23.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,80,,27.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,38.23,90,,30.58,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,38.23,
LC-CULTURE URINE,220577,CDM,300,RC,87086,HCPCS,Outpatient,,,36.32,32.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.42,70,,20.34,percent of total billed charges,70% of total billed charges for outpatient setting,30.83,84.88,,24.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.24,75,,21.79,percent of total billed charges,75% of total billed charges for outpatient setting,25.42,70,,20.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,80,,23.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.79,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of Custom Fee Schedule,32.69,90,,26.15,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,32.69,
"LC-CULTURE,TYPING,IMMUNOFLUORESCENT METH",220065,CDM,310,RC,87140,HCPCS,Outpatient,,,25.07,22.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,70,,14.04,percent of total billed charges,70% of total billed charges for outpatient setting,21.28,84.88,,17.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.8,75,,15.04,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,70,,14.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,80,,16.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,100,,,Fee Schedule,100% of Custom Fee Schedule,22.56,90,,18.05,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,22.56,
LC-D-DIMER  QUANTITATIVE,220563,CDM,300,RC,85379,HCPCS,Outpatient,,,45.81,41.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,84.88,,31.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.36,75,,27.49,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,70,,25.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,80,,29.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,100,,,Fee Schedule,100% of Custom Fee Schedule,41.23,90,,32.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,41.23,
LC-DILANTIN,220343,CDM,300,RC,80185,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
LC-DIRECT BILIRUBIN,220928,CDM,300,RC,82248,HCPCS,Outpatient,,,34.74,31.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,29.49,84.88,,23.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.06,75,,20.85,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,80,,22.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,31.27,90,,25.02,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,31.27,
"LC-ENCEPHALITIS, CALIFORNIA LA CROSSE",220089,CDM,302,RC,86651,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"LC-ENCEPHALITIS, EASTERN EQUINE",220048,CDM,302,RC,86652,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"LC-ENCEPHALITIS, ST. LOUIS",220049,CDM,302,RC,86653,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
"LC-ENCEPHALITIS, WESTERN EQUINE",220050,CDM,302,RC,86654,HCPCS,Outpatient,,,59.36,53.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,50.38,84.88,,40.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.52,75,,35.62,percent of total billed charges,75% of total billed charges for outpatient setting,41.55,70,,33.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.49,80,,37.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of Custom Fee Schedule,53.42,90,,42.74,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,53.42,
LC-FEBRILE AGGLUTININS,220488,CDM,302,RC,86000,HCPCS,Outpatient,,,31.41,28.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,26.66,84.88,,21.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.56,75,,18.85,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.13,80,,20.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.19,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,100,,,Fee Schedule,100% of Custom Fee Schedule,28.27,90,,22.62,percent of total billed charges,90% of total billed charges for outpatient setting,6.98,28.27,
LC-FERRITIN,220446,CDM,301,RC,82728,HCPCS,Outpatient,,,61.34,55.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,52.07,84.88,,41.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.01,75,,36.81,percent of total billed charges,75% of total billed charges for outpatient setting,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.07,80,,39.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.84,100,,,Fee Schedule,100% of Custom Fee Schedule,55.21,90,,44.17,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,55.21,
LC-FLUORESCENT NONINFECTIOUS AGENT AB,220121,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
LC-FUNGUS CULTURE,220587,CDM,300,RC,87102,HCPCS,Outpatient,,,37.85,34.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,32.13,84.88,,25.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.39,75,,22.71,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,70,,21.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.28,80,,24.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,100,,,Fee Schedule,100% of Custom Fee Schedule,34.07,90,,27.26,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,34.07,
"LC-GASTROINTESTINAL PROFILE,STOOL,PCR",220229,CDM,306,RC,87507,HCPCS,Outpatient,,,1041.95,937.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.37,70,,583.5,percent of total billed charges,70% of total billed charges for outpatient setting,884.41,84.88,,707.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,715.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,781.46,75,,625.17,percent of total billed charges,75% of total billed charges for outpatient setting,729.37,70,,583.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.56,80,,666.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,567.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.96,100,,,Fee Schedule,100% of Custom Fee Schedule,937.76,90,,750.21,percent of total billed charges,90% of total billed charges for outpatient setting,416.78,937.76,
LC-GRAM STAIN,220168,CDM,306,RC,87205,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
"LC-HELICOBACTER,STOOL ANTIGEN",220230,CDM,306,RC,87338,HCPCS,Outpatient,,,64.71,58.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.3,70,,36.24,percent of total billed charges,70% of total billed charges for outpatient setting,54.93,84.88,,43.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.53,75,,38.82,percent of total billed charges,75% of total billed charges for outpatient setting,45.3,70,,36.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.77,80,,41.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,58.24,90,,46.59,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,58.24,
LC-IMMUNOASSAY/ANALYTE,220122,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
LC-INFECTIOUS AGENT ANTIGEN;NOT SPECIF,220135,CDM,306,RC,87899,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,65.09,
LC-INFECTIOUS AGENT ANTIGEN;STREP GRP B,220134,CDM,310,RC,87802,HCPCS,Outpatient,,,57.29,51.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.1,70,,32.08,percent of total billed charges,70% of total billed charges for outpatient setting,48.63,84.88,,38.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.97,75,,34.38,percent of total billed charges,75% of total billed charges for outpatient setting,40.1,70,,32.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.83,80,,36.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,51.56,90,,41.25,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,51.56,
LC-IRON,220001,CDM,300,RC,83540,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,26.21,
LC-IRON W/TIBC,220100,CDM,300,RC,83550,HCPCS,Outpatient,,,39.33,35.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,84.88,,26.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.5,75,,23.6,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,80,,25.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.58,100,,,Fee Schedule,100% of Custom Fee Schedule,35.4,90,,28.32,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,35.4,
LC-MRSA SCREEN,220752,CDM,300,RC,87149,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
LC-MRSA SCREEN,220926,CDM,300,RC,87149,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
"LC-MRSA SCREEN, PRE-SURGICAL",220753,CDM,300,RC,87149,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
LC-OVA / PARASITES-STOOL,220504,CDM,300,RC,87209,HCPCS,Outpatient,,,80.91,72.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.64,70,,45.31,percent of total billed charges,70% of total billed charges for outpatient setting,68.68,84.88,,54.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.68,75,,48.54,percent of total billed charges,75% of total billed charges for outpatient setting,56.64,70,,45.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.73,80,,51.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.08,100,,,Fee Schedule,100% of Custom Fee Schedule,72.82,90,,58.26,percent of total billed charges,90% of total billed charges for outpatient setting,17.98,72.82,
LC-PHENYTOIN,220293,CDM,300,RC,80185,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
LC-QUANTIFERON-TB GOLD PLUS,220742,CDM,302,RC,86480,HCPCS,Outpatient,,,278.91,251.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.24,70,,156.19,percent of total billed charges,70% of total billed charges for outpatient setting,236.74,84.88,,189.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,106.42,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.18,75,,167.34,percent of total billed charges,75% of total billed charges for outpatient setting,195.24,70,,156.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.13,80,,178.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,90.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.54,100,,,Fee Schedule,100% of Custom Fee Schedule,251.02,90,,200.82,percent of total billed charges,90% of total billed charges for outpatient setting,61.98,251.02,
LC-SED RATE,222036,CDM,305,RC,85652,HCPCS,Outpatient,,,34.74,31.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,29.49,84.88,,23.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.06,75,,20.85,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,80,,22.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,100,,,Fee Schedule,100% of Custom Fee Schedule,31.27,90,,25.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,31.27,
LC-SICKLE CELL SCREEN,220166,CDM,305,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
"LC-SMEAR,FLUORESCENT/ACID FAST STAIN",201536,CDM,300,RC,87206,HCPCS,Outpatient,,,24.26,21.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.59,84.88,,16.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.2,75,,14.56,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,80,,15.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.2,100,,,Fee Schedule,100% of Custom Fee Schedule,21.83,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,21.83,
"LC-STREP A ,STREP PYOGENES, DIR PROBE",220132,CDM,306,RC,87650,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
LC-STREPTOZYME SCREEN,220481,CDM,302,RC,86403,HCPCS,Outpatient,,,51.93,46.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,70,,29.08,percent of total billed charges,70% of total billed charges for outpatient setting,44.08,84.88,,35.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.95,75,,31.16,percent of total billed charges,75% of total billed charges for outpatient setting,36.35,70,,29.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.54,80,,33.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.88,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.32,100,,,Fee Schedule,100% of Custom Fee Schedule,46.74,90,,37.39,percent of total billed charges,90% of total billed charges for outpatient setting,11.54,46.74,
LC-THYROGLOBULIN,220355,CDM,301,RC,84432,HCPCS,Outpatient,,,72.27,65.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.59,70,,40.47,percent of total billed charges,70% of total billed charges for outpatient setting,61.34,84.88,,49.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.2,75,,43.36,percent of total billed charges,75% of total billed charges for outpatient setting,50.59,70,,40.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.82,80,,46.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.45,100,,,Fee Schedule,100% of Custom Fee Schedule,65.04,90,,52.03,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,65.04,
LC-TOBRAMYCIN PEAK,220550,CDM,300,RC,80200,HCPCS,Outpatient,,,72.59,65.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,61.61,84.88,,49.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.44,75,,43.55,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.07,80,,46.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,65.33,90,,52.26,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,65.33,
LC-TOBRAMYCIN QUANT,220040,CDM,300,RC,80200,HCPCS,Outpatient,,,72.59,65.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,61.61,84.88,,49.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.44,75,,43.55,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.07,80,,46.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,65.33,90,,52.26,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,65.33,
LC-TOXOCARA AB IGG,220076,CDM,302,RC,86682,HCPCS,Outpatient,,,58.55,52.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,49.7,84.88,,39.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.91,75,,35.13,percent of total billed charges,75% of total billed charges for outpatient setting,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.84,80,,37.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.67,100,,,Fee Schedule,100% of Custom Fee Schedule,52.7,90,,42.16,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,52.7,
LC-TROPONIN I,220236,CDM,300,RC,84484,HCPCS,Outpatient,,,56.12,50.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.28,70,,31.42,percent of total billed charges,70% of total billed charges for outpatient setting,47.63,84.88,,38.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.09,75,,33.67,percent of total billed charges,75% of total billed charges for outpatient setting,39.28,70,,31.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.9,80,,35.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of Custom Fee Schedule,50.51,90,,40.41,percent of total billed charges,90% of total billed charges for outpatient setting,12.47,50.51,
LC-VITAMIN D-25 HYDROXY,222020,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
LDH,200190,CDM,301,RC,83615,HCPCS,Outpatient,,,27.18,24.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,70,,15.22,percent of total billed charges,70% of total billed charges for outpatient setting,23.07,84.88,,18.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.39,75,,16.31,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,70,,15.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.74,80,,17.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.44,100,,,Fee Schedule,100% of Custom Fee Schedule,24.46,90,,19.57,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,24.46,
LDL DIRECT MEASURE,200478,CDM,301,RC,83721,HCPCS,Outpatient,,,47.25,42.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,70,,26.46,percent of total billed charges,70% of total billed charges for outpatient setting,40.11,84.88,,32.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.44,75,,28.35,percent of total billed charges,75% of total billed charges for outpatient setting,33.08,70,,26.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,80,,30.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.21,100,,,Fee Schedule,100% of Custom Fee Schedule,42.53,90,,34.02,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,42.53,
LEAD,220554,CDM,301,RC,83655,HCPCS,Outpatient,,,54.5,49.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,46.26,84.88,,37.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.88,75,,32.7,percent of total billed charges,75% of total billed charges for outpatient setting,38.15,70,,30.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.6,80,,34.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.67,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.96,100,,,Fee Schedule,100% of Custom Fee Schedule,49.05,90,,39.24,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,49.05,
LEAD  KIT TINED / 1201,69169719,CDM,278,RC,C1897,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
LEAD  NG ACI SPRINT 6847M55,69162206,CDM,275,RC,C1779,HCPCS,Outpatient,,,1225.34,1225.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.74,70,,686.19,percent of total billed charges,70% of total billed charges for outpatient setting,1040.07,84.88,,832.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.01,75,,735.21,percent of total billed charges,75% of total billed charges for outpatient setting,612.67,50,,490.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.33,12.84,,125.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.27,80,,784.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.33,12.84,,125.86,percent of total billed charges,12.84% of total billed charges,157.33,12.84,,125.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1225.34,65,,980.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.87,35,,343.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1102.81,90,,882.25,percent of total billed charges,90% of total billed charges for outpatient setting,157.33,1225.34,
LEAD  VENTRICULAR/5054-52,6122007,CDM,275,RC,C1779,HCPCS,Outpatient,,,1340.75,1340.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.53,70,,750.82,percent of total billed charges,70% of total billed charges for outpatient setting,1138.03,84.88,,910.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1005.56,75,,804.45,percent of total billed charges,75% of total billed charges for outpatient setting,670.38,50,,536.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.15,12.84,,137.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1072.6,80,,858.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.15,12.84,,137.72,percent of total billed charges,12.84% of total billed charges,172.15,12.84,,137.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1340.75,65,,1072.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.26,35,,375.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1206.68,90,,965.34,percent of total billed charges,90% of total billed charges for outpatient setting,172.15,1340.75,
LEAD 2X8 ARTISAN / SC-5216-50,71000613,CDM,278,RC,C1778,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
LEAD ATRL STEROID BIP SILCONE / 5554-45,6150912,CDM,275,RC,C1779,HCPCS,Outpatient,,,1225.34,1225.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.74,70,,686.19,percent of total billed charges,70% of total billed charges for outpatient setting,1040.07,84.88,,832.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.01,75,,735.21,percent of total billed charges,75% of total billed charges for outpatient setting,612.67,50,,490.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.33,12.84,,125.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.27,80,,784.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.33,12.84,,125.86,percent of total billed charges,12.84% of total billed charges,157.33,12.84,,125.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1225.34,65,,980.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.87,35,,343.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1102.81,90,,882.25,percent of total billed charges,90% of total billed charges for outpatient setting,157.33,1225.34,
LEAD BI SIL STEROID SCREW IN / 5076-45,70000095,CDM,275,RC,C1779,HCPCS,Outpatient,,,1687.14,1687.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181,70,,944.8,percent of total billed charges,70% of total billed charges for outpatient setting,1432.04,84.88,,1145.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.36,75,,1012.29,percent of total billed charges,75% of total billed charges for outpatient setting,843.57,50,,674.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.63,12.84,,173.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.71,80,,1079.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.63,12.84,,173.3,percent of total billed charges,12.84% of total billed charges,216.63,12.84,,173.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1687.14,65,,1349.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,35,,472.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1518.43,90,,1214.74,percent of total billed charges,90% of total billed charges for outpatient setting,216.63,1687.14,
LEAD CAPSURE NOVUS / 5076-52,69161674,CDM,275,RC,C1779,HCPCS,Outpatient,,,1687.14,1687.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181,70,,944.8,percent of total billed charges,70% of total billed charges for outpatient setting,1432.04,84.88,,1145.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.36,75,,1012.29,percent of total billed charges,75% of total billed charges for outpatient setting,843.57,50,,674.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.63,12.84,,173.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.71,80,,1079.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.63,12.84,,173.3,percent of total billed charges,12.84% of total billed charges,216.63,12.84,,173.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1687.14,65,,1349.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,35,,472.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1518.43,90,,1214.74,percent of total billed charges,90% of total billed charges for outpatient setting,216.63,1687.14,
LEAD END CAP / 5867-3M,6152133,CDM,272,RC,,,Outpatient,,,152.62,152.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.83,70,,85.46,percent of total billed charges,70% of total billed charges for outpatient setting,129.54,84.88,,103.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.31,50,,61.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.47,75,,91.58,percent of total billed charges,75% of total billed charges for outpatient setting,106.83,70,,85.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.1,80,,97.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,65,,79.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.42,35,,42.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.36,90,,109.89,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,137.36,
LEAD IMPLANT KIT / 1801,69169721,CDM,272,RC,,,Outpatient,,,1512,1512,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.4,70,,846.72,percent of total billed charges,70% of total billed charges for outpatient setting,1283.39,84.88,,1026.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,756,50,,604.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1134,75,,907.2,percent of total billed charges,75% of total billed charges for outpatient setting,1058.4,70,,846.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.14,12.84,,155.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.6,80,,967.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.14,12.84,,155.31,percent of total billed charges,12.84% of total billed charges,194.14,12.84,,155.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,982.8,65,,786.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.2,35,,423.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,90,,1088.64,percent of total billed charges,90% of total billed charges for outpatient setting,194.14,1360.8,
LEAD IMPLANT KIT PNE / 1701,69169716,CDM,272,RC,,,Outpatient,,,1092,1092,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.4,70,,611.52,percent of total billed charges,70% of total billed charges for outpatient setting,926.89,84.88,,741.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,546,50,,436.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,819,75,,655.2,percent of total billed charges,75% of total billed charges for outpatient setting,764.4,70,,611.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.21,12.84,,112.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.6,80,,698.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.21,12.84,,112.17,percent of total billed charges,12.84% of total billed charges,140.21,12.84,,112.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,709.8,65,,567.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.2,35,,305.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,982.8,90,,786.24,percent of total billed charges,90% of total billed charges for outpatient setting,140.21,982.8,
LEAD INTERSTIM TEST URO / 309201,71000542,CDM,278,RC,C1897,HCPCS,Outpatient,,,420,420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,60,,201.6,percent of total billed charges,60% of total Billed charges for outpatient setting,356.5,84.88,,285.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,75,,252,percent of total billed charges,75% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,80,,268.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,420,65,,336,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,35,,117.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,252,60,,201.6,percent of total billed charges,60% of total billed charges for outpatient setting,53.93,420,
LEAD INTERSTIM TEST URO PNE / 306001,71000543,CDM,278,RC,C1897,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
LEAD INTRODUCER KIT / 355018,69161054,CDM,272,RC,C1894,HCPCS,Outpatient,,,1211.28,1211.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.9,70,,678.32,percent of total billed charges,70% of total billed charges for outpatient setting,1028.13,84.88,,822.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,75,,726.77,percent of total billed charges,75% of total billed charges for outpatient setting,847.9,70,,678.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.53,12.84,,124.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,969.02,80,,775.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.53,12.84,,124.42,percent of total billed charges,12.84% of total billed charges,155.53,12.84,,124.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,787.33,65,,629.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,35,,339.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1090.15,90,,872.12,percent of total billed charges,90% of total billed charges for outpatient setting,155.53,1090.15,
LEAD ISTM II TINED 28CM / 978B128,69162192,CDM,278,RC,C1778,HCPCS,Outpatient,,,6975,6975,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4185,60,,3348,percent of total billed charges,60% of total Billed charges for outpatient setting,5920.38,84.88,,4736.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.25,75,,4185,percent of total billed charges,75% of total billed charges for outpatient setting,3487.5,50,,2790,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,895.59,12.84,,716.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5580,80,,4464,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,895.59,12.84,,716.47,percent of total billed charges,12.84% of total billed charges,895.59,12.84,,716.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7323.75,105,,5859,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2441.25,35,,1953,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4185,60,,3348,percent of total billed charges,60% of total billed charges for outpatient setting,895.59,7323.75,
LEAD PENTA 3MM 60CM / 3228,70000123,CDM,278,RC,C1778,HCPCS,Outpatient,,,10000,10000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,60,,4800,percent of total billed charges,60% of total Billed charges for outpatient setting,8488,84.88,,6790.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7500,75,,6000,percent of total billed charges,75% of total billed charges for outpatient setting,5000,50,,4000,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8000,80,,6400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10500,105,,8400,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,35,,2800,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6000,60,,4800,percent of total billed charges,60% of total billed charges for outpatient setting,1284,10500,
LEAD PERENNIAL FLEX 304-20,69161755,CDM,278,RC,C1778,HCPCS,Outpatient,,,11252.8,11252.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6751.68,60,,5401.34,percent of total billed charges,60% of total Billed charges for outpatient setting,9551.38,84.88,,7641.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8439.6,75,,6751.68,percent of total billed charges,75% of total billed charges for outpatient setting,5626.4,50,,4501.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.86,12.84,,1155.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9002.24,80,,7201.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.86,12.84,,1155.89,percent of total billed charges,12.84% of total billed charges,1444.86,12.84,,1155.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11815.44,105,,9452.35,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3938.48,35,,3150.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6751.68,60,,5401.34,percent of total billed charges,60% of total billed charges for outpatient setting,1444.86,11815.44,
LEAD PNE  / TRIAL / 1901,69169717,CDM,278,RC,C1778,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,60,,100.8,percent of total billed charges,60% of total Billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,210,65,,168,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126,60,,100.8,percent of total billed charges,60% of total billed charges for outpatient setting,26.96,210,
LEAD POISONING,201318,CDM,301,RC,,,Outpatient,,,56.83,51.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.78,70,,31.82,percent of total billed charges,70% of total billed charges for outpatient setting,48.24,84.88,,38.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.42,50,,22.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.62,75,,34.1,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,70,,31.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.46,80,,36.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,7.3,12.84,,5.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.89,35,,15.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.15,90,,40.92,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,51.15,
LEAD SPRINT QUATTRO/6944-58,6153068,CDM,275,RC,C1895,HCPCS,Outpatient,,,1363.47,1363.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,954.43,70,,763.54,percent of total billed charges,70% of total billed charges for outpatient setting,1157.31,84.88,,925.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.6,75,,818.08,percent of total billed charges,75% of total billed charges for outpatient setting,681.74,50,,545.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.07,12.84,,140.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.78,80,,872.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.07,12.84,,140.06,percent of total billed charges,12.84% of total billed charges,175.07,12.84,,140.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1363.47,65,,1090.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.21,35,,381.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1227.12,90,,981.7,percent of total billed charges,90% of total billed charges for outpatient setting,175.07,1363.47,
LEGION CR OXIN FEM 5 RT / 71421225,69161104,CDM,278,RC,,,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
LEGIONELLA AB TYPES 1-6 IGG,201438,CDM,300,RC,86713,HCPCS,Outpatient,,,68.85,61.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,58.44,84.88,,46.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.64,75,,41.31,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.08,80,,44.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.02,100,,,Fee Schedule,100% of Custom Fee Schedule,61.97,90,,49.58,percent of total billed charges,90% of total billed charges for outpatient setting,15.3,61.97,
LEGIONELLA PNEUMOPHILA  DFA,201434,CDM,302,RC,87278,HCPCS,Outpatient,,,70.2,63.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.14,70,,39.31,percent of total billed charges,70% of total billed charges for outpatient setting,59.59,84.88,,47.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,52.65,75,,42.12,percent of total billed charges,75% of total billed charges for outpatient setting,49.14,70,,39.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,80,,44.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,63.18,90,,50.54,percent of total billed charges,90% of total billed charges for outpatient setting,15.6,63.18,
LENS INTRAOCULAR ADD ON FOR CORRECTIVE,6916150,CDM,276,RC,V2632,HCPCS,Outpatient,,,1.05,1.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,70,,0.59,percent of total billed charges,70% of total billed charges for outpatient setting,0.89,84.88,,0.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.53,50,,0.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.79,75,,0.63,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,50,,0.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,12.84,,0.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,80,,0.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,12.84,,0.1,percent of total billed charges,12.84% of total billed charges,0.13,12.84,,0.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.05,65,,0.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,90,,0.76,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,1.05,
LENS INTRAOCULAR POST CHMB/ ALCON SA60AT,69160009,CDM,276,RC,V2787,HCPCS,Outpatient,,,436,436,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.2,70,,244.16,percent of total billed charges,70% of total billed charges for outpatient setting,370.08,84.88,,296.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,218,50,,174.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327,75,,261.6,percent of total billed charges,75% of total billed charges for outpatient setting,218,50,,174.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.98,12.84,,44.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.8,80,,279.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.98,12.84,,44.78,percent of total billed charges,12.84% of total billed charges,55.98,12.84,,44.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436,65,,348.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.6,35,,122.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,392.4,90,,313.92,percent of total billed charges,90% of total billed charges for outpatient setting,55.98,436,
LENS IOL  / ALCON SN60WF,69159076,CDM,276,RC,V2632,HCPCS,Outpatient,,,562.8,562.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.96,70,,315.17,percent of total billed charges,70% of total billed charges for outpatient setting,477.7,84.88,,382.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.4,50,,225.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422.1,75,,337.68,percent of total billed charges,75% of total billed charges for outpatient setting,281.4,50,,225.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,12.84,,57.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.24,80,,360.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,12.84,,57.81,percent of total billed charges,12.84% of total billed charges,72.26,12.84,,57.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.8,65,,450.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.52,90,,405.22,percent of total billed charges,90% of total billed charges for outpatient setting,72.26,562.8,
LENS IOL  TORIC CLAREON/ CNW0T0,71000288,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL / B&L /  MX60E,69162871,CDM,276,RC,V2632,HCPCS,Outpatient,,,420,420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,70,,235.2,percent of total billed charges,70% of total billed charges for outpatient setting,356.5,84.88,,285.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315,75,,252,percent of total billed charges,75% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,80,,268.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,420,65,,336,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,90,,302.4,percent of total billed charges,90% of total billed charges for outpatient setting,53.93,420,
LENS IOL / HOYA  FY-60AD,69162676,CDM,276,RC,C1780,HCPCS,Outpatient,,,378.53,378.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,70,,211.98,percent of total billed charges,70% of total billed charges for outpatient setting,321.3,84.88,,257.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.9,75,,227.12,percent of total billed charges,75% of total billed charges for outpatient setting,189.27,50,,151.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,12.84,,38.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,80,,242.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,12.84,,38.88,percent of total billed charges,12.84% of total billed charges,48.6,12.84,,38.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,378.53,65,,302.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.49,35,,105.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,340.68,90,,272.54,percent of total billed charges,90% of total billed charges for outpatient setting,48.6,378.53,
LENS IOL / SNGL PIECE/ ALCON SN60AT,69169815,CDM,276,RC,V2632,HCPCS,Outpatient,,,596,596,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.2,70,,333.76,percent of total billed charges,70% of total billed charges for outpatient setting,505.88,84.88,,404.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447,75,,357.6,percent of total billed charges,75% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.8,80,,381.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,596,65,,476.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.4,90,,429.12,percent of total billed charges,90% of total billed charges for outpatient setting,76.53,596,
LENS IOL 3PC CLEAR / MA60AC,69169842,CDM,276,RC,V2632,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.2,70,,277.76,percent of total billed charges,70% of total billed charges for outpatient setting,421,84.88,,336.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,248,50,,198.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372,75,,297.6,percent of total billed charges,75% of total billed charges for outpatient setting,248,50,,198.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.69,12.84,,50.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.8,80,,317.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.69,12.84,,50.95,percent of total billed charges,12.84% of total billed charges,63.69,12.84,,50.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,496,65,,396.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.4,90,,357.12,percent of total billed charges,90% of total billed charges for outpatient setting,63.69,496,
LENS IOL 3PC YELW / MN60AC,69160025,CDM,276,RC,V2632,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.2,70,,277.76,percent of total billed charges,70% of total billed charges for outpatient setting,421,84.88,,336.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,248,50,,198.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372,75,,297.6,percent of total billed charges,75% of total billed charges for outpatient setting,248,50,,198.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.69,12.84,,50.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.8,80,,317.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.69,12.84,,50.95,percent of total billed charges,12.84% of total billed charges,63.69,12.84,,50.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,496,65,,396.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.4,90,,357.12,percent of total billed charges,90% of total billed charges for outpatient setting,63.69,496,
LENS IOL ANTERIOR ALCON / MTA4U0,69162824,CDM,276,RC,V2630,HCPCS,Outpatient,,,340,340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,190.4,percent of total billed charges,70% of total billed charges for outpatient setting,288.59,84.88,,230.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255,75,,204,percent of total billed charges,75% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272,80,,217.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,340,65,,272,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,90,,244.8,percent of total billed charges,90% of total billed charges for outpatient setting,43.66,340,
LENS IOL ANTERIOR ALCON / MTA5U0,69169899,CDM,276,RC,V2630,HCPCS,Outpatient,,,340,340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,190.4,percent of total billed charges,70% of total billed charges for outpatient setting,288.59,84.88,,230.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255,75,,204,percent of total billed charges,75% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272,80,,217.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,340,65,,272,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,90,,244.8,percent of total billed charges,90% of total billed charges for outpatient setting,43.66,340,
LENS IOL CLAREON / ALCON SY60WF,71000477,CDM,276,RC,V2632,HCPCS,Outpatient,,,536,536,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,454.96,84.88,,363.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402,75,,321.6,percent of total billed charges,75% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.8,80,,343.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,536,65,,428.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,90,,385.92,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,536,
LENS IOL CLAREON AUTONOME / ALCON CNA0T0,69169862,CDM,276,RC,V2632,HCPCS,Outpatient,,,596,596,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.2,70,,333.76,percent of total billed charges,70% of total billed charges for outpatient setting,505.88,84.88,,404.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447,75,,357.6,percent of total billed charges,75% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.8,80,,381.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,596,65,,476.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.4,90,,429.12,percent of total billed charges,90% of total billed charges for outpatient setting,76.53,596,
LENS IOL CLAREON UV / ALCON CCA0T0,71000229,CDM,276,RC,V2632,HCPCS,Outpatient,,,596,596,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.2,70,,333.76,percent of total billed charges,70% of total billed charges for outpatient setting,505.88,84.88,,404.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447,75,,357.6,percent of total billed charges,75% of total billed charges for outpatient setting,298,50,,238.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.8,80,,381.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,76.53,12.84,,61.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,596,65,,476.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.4,90,,429.12,percent of total billed charges,90% of total billed charges for outpatient setting,76.53,596,
LENS IOL MULTIPIECE/  MA60MA,69169219,CDM,276,RC,V2632,HCPCS,Outpatient,,,677.19,677.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.03,70,,379.22,percent of total billed charges,70% of total billed charges for outpatient setting,574.8,84.88,,459.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.6,50,,270.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.89,75,,406.31,percent of total billed charges,75% of total billed charges for outpatient setting,338.6,50,,270.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.95,12.84,,69.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.75,80,,433.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.95,12.84,,69.56,percent of total billed charges,12.84% of total billed charges,86.95,12.84,,69.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,677.19,65,,541.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.47,90,,487.58,percent of total billed charges,90% of total billed charges for outpatient setting,86.95,677.19,
LENS IOL PANOPTIX CLRN / CNWTT0,71000287,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL PANOPTIX MULTIFOCL/TFNT00,69169376,CDM,276,RC,V2788,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.64,70,,2047.71,percent of total billed charges,70% of total billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3290.97,90,,2632.78,percent of total billed charges,90% of total billed charges for outpatient setting,469.51,3839.46,
LENS IOL PANOPTIX TORIC / TFNT50,69169641,CDM,276,RC,V2788,HCPCS,Outpatient,,,3482.5,3482.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.75,70,,1950.2,percent of total billed charges,70% of total billed charges for outpatient setting,2955.95,84.88,,2364.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.88,75,,2089.5,percent of total billed charges,75% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786,80,,2228.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.63,105,,2925.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.88,35,,975.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3134.25,90,,2507.4,percent of total billed charges,90% of total billed charges for outpatient setting,447.15,3656.63,
LENS IOL PANOPTIX TORIC /TFNT30,69169374,CDM,276,RC,V2788,HCPCS,Outpatient,,,3482,3482,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.4,70,,1949.92,percent of total billed charges,70% of total billed charges for outpatient setting,2955.52,84.88,,2364.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,1741,50,,1392.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.5,75,,2089.2,percent of total billed charges,75% of total billed charges for outpatient setting,1741,50,,1392.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.09,12.84,,357.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2785.6,80,,2228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.09,12.84,,357.67,percent of total billed charges,12.84% of total billed charges,447.09,12.84,,357.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.1,105,,2924.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.7,35,,974.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3133.8,90,,2507.04,percent of total billed charges,90% of total billed charges for outpatient setting,447.09,3656.1,
LENS IOL PANOPTIX TORIC /TFNT40,69169375,CDM,276,RC,V2788,HCPCS,Outpatient,,,3482.5,3482.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.75,70,,1950.2,percent of total billed charges,70% of total billed charges for outpatient setting,2955.95,84.88,,2364.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.88,75,,2089.5,percent of total billed charges,75% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786,80,,2228.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.63,105,,2925.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.88,35,,975.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3134.25,90,,2507.4,percent of total billed charges,90% of total billed charges for outpatient setting,447.15,3656.63,
LENS IOL PANOPTIX TORIC /TFNT60,69169642,CDM,276,RC,V2788,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.64,70,,2047.71,percent of total billed charges,70% of total billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3290.97,90,,2632.78,percent of total billed charges,90% of total billed charges for outpatient setting,469.51,3839.46,
LENS IOL PANOPTIX TORIC CLRN / CNWTT3,71000298,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL PANOPTIX TORIC CLRN / CNWTT4,71000299,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL PANOPTIX TORIC CLRN / CNWTT5,71000300,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL PANOPTIX TORIC CLRN / CNWTT6,71000301,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL PC iSERT / HOYA  230,69161662,CDM,276,RC,V2632,HCPCS,Outpatient,,,380,380,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266,70,,212.8,percent of total billed charges,70% of total billed charges for outpatient setting,322.54,84.88,,258.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,190,50,,152,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285,75,,228,percent of total billed charges,75% of total billed charges for outpatient setting,190,50,,152,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.79,12.84,,39.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304,80,,243.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.79,12.84,,39.03,percent of total billed charges,12.84% of total billed charges,48.79,12.84,,39.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,380,65,,304,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,90,,273.6,percent of total billed charges,90% of total billed charges for outpatient setting,48.79,380,
LENS IOL RESTOR / SV25T0,69169169,CDM,276,RC,V2788,HCPCS,Outpatient,,,3387.8,3387.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2371.46,70,,1897.17,percent of total billed charges,70% of total billed charges for outpatient setting,2875.56,84.88,,2300.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1693.9,50,,1355.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2540.85,75,,2032.68,percent of total billed charges,75% of total billed charges for outpatient setting,1693.9,50,,1355.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.99,12.84,,347.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2710.24,80,,2168.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.99,12.84,,347.99,percent of total billed charges,12.84% of total billed charges,434.99,12.84,,347.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3557.19,105,,2845.75,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1185.73,35,,948.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3049.02,90,,2439.22,percent of total billed charges,90% of total billed charges for outpatient setting,434.99,3557.19,
LENS IOL RESTORE / ALCON SN6AD1,69161738,CDM,276,RC,V2788,HCPCS,Outpatient,,,3289.13,3289.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2302.39,70,,1841.91,percent of total billed charges,70% of total billed charges for outpatient setting,2791.81,84.88,,2233.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1644.57,50,,1315.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2466.85,75,,1973.48,percent of total billed charges,75% of total billed charges for outpatient setting,1644.57,50,,1315.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2631.3,80,,2105.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3453.59,105,,2762.87,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1151.2,35,,920.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2960.22,90,,2368.18,percent of total billed charges,90% of total billed charges for outpatient setting,422.32,3453.59,
LENS IOL RESTORE TORIC/ SND1T3,69169323,CDM,276,RC,V2788,HCPCS,Outpatient,,,3289.13,3289.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2302.39,70,,1841.91,percent of total billed charges,70% of total billed charges for outpatient setting,2791.81,84.88,,2233.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1644.57,50,,1315.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2466.85,75,,1973.48,percent of total billed charges,75% of total billed charges for outpatient setting,1644.57,50,,1315.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2631.3,80,,2105.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3453.59,105,,2762.87,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1151.2,35,,920.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2960.22,90,,2368.18,percent of total billed charges,90% of total billed charges for outpatient setting,422.32,3453.59,
LENS IOL TECNIS /  DCB00,70000014,CDM,276,RC,V2632,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,70,,294,percent of total billed charges,70% of total billed charges for outpatient setting,445.62,84.88,,356.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,262.5,50,,210,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.75,75,,315,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,50,,210,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.41,12.84,,53.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,80,,336,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.41,12.84,,53.93,percent of total billed charges,12.84% of total billed charges,67.41,12.84,,53.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,525,65,,420,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,90,,378,percent of total billed charges,90% of total billed charges for outpatient setting,67.41,525,
LENS IOL TECNIS / ABBOTT  PCB00,69162318,CDM,276,RC,V2632,HCPCS,Outpatient,,,809.91,809.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.94,70,,453.55,percent of total billed charges,70% of total billed charges for outpatient setting,687.45,84.88,,549.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,404.96,50,,323.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,607.43,75,,485.94,percent of total billed charges,75% of total billed charges for outpatient setting,404.96,50,,323.97,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,12.84,,83.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.93,80,,518.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,12.84,,83.19,percent of total billed charges,12.84% of total billed charges,103.99,12.84,,83.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,809.91,65,,647.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.92,90,,583.14,percent of total billed charges,90% of total billed charges for outpatient setting,103.99,809.91,
LENS IOL TECNIS EYHANCE / DIB00,69169850,CDM,276,RC,V2632,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350,70,,280,percent of total billed charges,70% of total billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450,90,,360,percent of total billed charges,90% of total billed charges for outpatient setting,64.2,500,
LENS IOL TORIC / ALCON SN6AT3,69160869,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT4,69160130,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT5,69160142,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT6,69161374,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT7,69161757,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT8,69161546,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC / ALCON SN6AT9,69161716,CDM,276,RC,V2787,HCPCS,Outpatient,,,1982.4,1982.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.68,70,,1110.14,percent of total billed charges,70% of total billed charges for outpatient setting,1682.66,84.88,,1346.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1486.8,75,,1189.44,percent of total billed charges,75% of total billed charges for outpatient setting,991.2,50,,792.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.92,80,,1268.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,254.54,12.84,,203.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1982.4,65,,1585.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.84,35,,555.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1784.16,90,,1427.33,percent of total billed charges,90% of total billed charges for outpatient setting,254.54,1982.4,
LENS IOL TORIC CLAREON / CNW0T3,71000344,CDM,276,RC,V2787,HCPCS,Outpatient,,,1928,1928,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,70,,1079.68,percent of total billed charges,70% of total billed charges for outpatient setting,1636.49,84.88,,1309.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1446,75,,1156.8,percent of total billed charges,75% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.4,80,,1233.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1928,65,,1542.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.8,35,,539.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.2,90,,1388.16,percent of total billed charges,90% of total billed charges for outpatient setting,247.56,1928,
LENS IOL TORIC CLAREON / CNW0T4,71000343,CDM,276,RC,V2788,HCPCS,Outpatient,,,1928,1928,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,70,,1079.68,percent of total billed charges,70% of total billed charges for outpatient setting,1636.49,84.88,,1309.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1446,75,,1156.8,percent of total billed charges,75% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.4,80,,1233.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1928,65,,1542.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.8,35,,539.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.2,90,,1388.16,percent of total billed charges,90% of total billed charges for outpatient setting,247.56,1928,
LENS IOL TORIC CLAREON / CNW0T5,71000345,CDM,276,RC,V2788,HCPCS,Outpatient,,,1928,1928,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,70,,1079.68,percent of total billed charges,70% of total billed charges for outpatient setting,1636.49,84.88,,1309.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1446,75,,1156.8,percent of total billed charges,75% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.4,80,,1233.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1928,65,,1542.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.8,35,,539.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.2,90,,1388.16,percent of total billed charges,90% of total billed charges for outpatient setting,247.56,1928,
LENS IOL TORIC CLAREON / CNW0T6,71000346,CDM,276,RC,V2788,HCPCS,Outpatient,,,1928,1928,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,70,,1079.68,percent of total billed charges,70% of total billed charges for outpatient setting,1636.49,84.88,,1309.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1446,75,,1156.8,percent of total billed charges,75% of total billed charges for outpatient setting,964,50,,771.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.4,80,,1233.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,247.56,12.84,,198.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1928,65,,1542.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.8,35,,539.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1735.2,90,,1388.16,percent of total billed charges,90% of total billed charges for outpatient setting,247.56,1928,
LENS IOL TORIC ENVISTA / MX60ET,69169860,CDM,276,RC,V2787,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,70,,1008,percent of total billed charges,70% of total billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,90,,1296,percent of total billed charges,90% of total billed charges for outpatient setting,231.12,1800,
LENS IOL TORIC TECNIS / DIU150,69169853,CDM,276,RC,V2787,HCPCS,Outpatient,,,2082.5,2082.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1457.75,70,,1166.2,percent of total billed charges,70% of total billed charges for outpatient setting,1767.63,84.88,,1414.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1041.25,50,,833,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1561.88,75,,1249.5,percent of total billed charges,75% of total billed charges for outpatient setting,1041.25,50,,833,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.39,12.84,,213.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1666,80,,1332.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.39,12.84,,213.91,percent of total billed charges,12.84% of total billed charges,267.39,12.84,,213.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2082.5,65,,1666,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.88,35,,583.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.25,90,,1499.4,percent of total billed charges,90% of total billed charges for outpatient setting,267.39,2082.5,
LENS IOL UVA CLAREON / CC60WF,71000525,CDM,276,RC,V2632,HCPCS,Outpatient,,,536,536,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,70,,300.16,percent of total billed charges,70% of total billed charges for outpatient setting,454.96,84.88,,363.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402,75,,321.6,percent of total billed charges,75% of total billed charges for outpatient setting,268,50,,214.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.8,80,,343.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,68.82,12.84,,55.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,536,65,,428.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,90,,385.92,percent of total billed charges,90% of total billed charges for outpatient setting,68.82,536,
LENS IOL VIVITY CLAREON TORIC / CNWET3,71000645,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL VIVITY CLAREON TORIC / CNWET4,71000646,CDM,276,RC,V2788,HCPCS,Outpatient,,,2030,2030,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421,70,,1136.8,percent of total billed charges,70% of total billed charges for outpatient setting,1723.06,84.88,,1378.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.5,75,,1218,percent of total billed charges,75% of total billed charges for outpatient setting,1015,50,,812,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,80,,1299.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,260.65,12.84,,208.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2030,65,,1624,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.5,35,,568.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1827,90,,1461.6,percent of total billed charges,90% of total billed charges for outpatient setting,260.65,2030,
LENS IOL VIVITY EXT VISION / DFT015,71000818,CDM,276,RC,V2788,HCPCS,Outpatient,,,3482.5,3482.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.75,70,,1950.2,percent of total billed charges,70% of total billed charges for outpatient setting,2955.95,84.88,,2364.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.88,75,,2089.5,percent of total billed charges,75% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786,80,,2228.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.63,105,,2925.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.88,35,,975.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3134.25,90,,2507.4,percent of total billed charges,90% of total billed charges for outpatient setting,447.15,3656.63,
LENS IOL VIVITY EXT VISION /CNWET0,69169894,CDM,276,RC,V2788,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.64,70,,2047.71,percent of total billed charges,70% of total billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3290.97,90,,2632.78,percent of total billed charges,90% of total billed charges for outpatient setting,469.51,3839.46,
LENS IOL VIVITY TOR / DFT315,71000817,CDM,276,RC,V2788,HCPCS,Outpatient,,,3482.5,3482.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.75,70,,1950.2,percent of total billed charges,70% of total billed charges for outpatient setting,2955.95,84.88,,2364.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.88,75,,2089.5,percent of total billed charges,75% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786,80,,2228.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.63,105,,2925.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.88,35,,975.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3134.25,90,,2507.4,percent of total billed charges,90% of total billed charges for outpatient setting,447.15,3656.63,
LENS IOL VIVITY TORIC UV  DAT315,69169866,CDM,276,RC,V2788,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.64,70,,2047.71,percent of total billed charges,70% of total billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3290.97,90,,2632.78,percent of total billed charges,90% of total billed charges for outpatient setting,469.51,3839.46,
LENS IOL VIVITY UV  DAT015,69169865,CDM,276,RC,V2788,HCPCS,Outpatient,,,3656.63,3656.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2559.64,70,,2047.71,percent of total billed charges,70% of total billed charges for outpatient setting,3103.75,84.88,,2483,percent of total billed charges,84.88% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2742.47,75,,2193.98,percent of total billed charges,75% of total billed charges for outpatient setting,1828.32,50,,1462.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925.3,80,,2340.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,469.51,12.84,,375.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3839.46,105,,3071.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.82,35,,1023.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3290.97,90,,2632.78,percent of total billed charges,90% of total billed charges for outpatient setting,469.51,3839.46,
LEPIRUDIN (REFLUDAN) INJ: 50 MG,3301363,CDM,250,RC,,,Outpatient,,,4201.3,4201.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.91,70,,2352.73,percent of total billed charges,70% of total billed charges for outpatient setting,3566.06,84.88,,2852.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,2100.65,50,,1680.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3150.98,75,,2520.78,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.45,12.84,,431.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3361.04,80,,2688.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.45,12.84,,431.56,percent of total billed charges,12.84% of total billed charges,539.45,12.84,,431.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730.85,65,,2184.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470.46,35,,1176.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3781.17,90,,3024.94,percent of total billed charges,90% of total billed charges for outpatient setting,539.45,3781.17,
LETROZOLE (FEMARA) 2.5MG: TAB,3303232,CDM,259,RC,,,Outpatient,,,34.98,34.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.49,70,,19.59,percent of total billed charges,70% of total billed charges for outpatient setting,29.69,84.88,,23.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.49,50,,13.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.24,75,,20.99,percent of total billed charges,75% of total billed charges for outpatient setting,24.49,70,,19.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.98,80,,22.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.74,65,,18.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,35,,9.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.48,90,,25.18,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.48,
LEUCOVORIN (WELLCOVORIN) TAB : 5 MG,3301364,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LEUKOCYTE ALKALINE PHOSPHATASE LAP SCORE,202562,CDM,302,RC,85540,HCPCS,Outpatient,,,38.7,34.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.09,70,,21.67,percent of total billed charges,70% of total billed charges for outpatient setting,32.85,84.88,,26.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.03,75,,23.22,percent of total billed charges,75% of total billed charges for outpatient setting,27.09,70,,21.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.96,80,,24.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,100,,,Fee Schedule,100% of Custom Fee Schedule,34.83,90,,27.86,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,34.83,
LEUPROLIDE (LUPRON DEPOT) KIT : 22.5 MG,3301365,CDM,250,RC,,,Outpatient,,,5680.97,5680.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3976.68,70,,3181.34,percent of total billed charges,70% of total billed charges for outpatient setting,4822.01,84.88,,3857.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,2840.49,50,,2272.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4260.73,75,,3408.58,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.44,12.84,,583.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4544.78,80,,3635.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.44,12.84,,583.55,percent of total billed charges,12.84% of total billed charges,729.44,12.84,,583.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3692.63,65,,2954.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1988.34,35,,1590.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5112.87,90,,4090.3,percent of total billed charges,90% of total billed charges for outpatient setting,729.44,5112.87,
LEVALBUTEROL 0.63MG 3CC NEB(genXOPENEX),3302859,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVALBUTEROL 1.25 MG NEB (XOPENEX GENERI,3301366,CDM,250,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LEVAQUIN 250MG: TAB,3302936,CDM,259,RC,,,Outpatient,,,57.62,57.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.33,70,,32.26,percent of total billed charges,70% of total billed charges for outpatient setting,48.91,84.88,,39.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.81,50,,23.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,75,,34.58,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,70,,32.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,12.84,,5.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.1,80,,36.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.4,12.84,,5.92,percent of total billed charges,12.84% of total billed charges,7.4,12.84,,5.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.45,65,,29.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.17,35,,16.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.86,90,,41.49,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,51.86,
LEVETIRACETAM,220767,CDM,300,RC,80177,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.09,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
LEVETIRACETAM (genKEPPRA) 500MG/5ML INJ,3314074,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVETIRACETAM (KEPPRA GENERIC)500MG TAB,3303147,CDM,259,RC,,,Outpatient,,,3.1,3.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,2.63,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.33,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.02,65,,1.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,35,,0.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.79,90,,2.23,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.79,
LEVETIRACETAM KEPPRA 250MG TAB,3313718,CDM,259,RC,,,Outpatient,,,81.9,81.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.33,70,,45.86,percent of total billed charges,70% of total billed charges for outpatient setting,69.52,84.88,,55.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.95,50,,32.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.43,75,,49.14,percent of total billed charges,75% of total billed charges for outpatient setting,57.33,70,,45.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,12.84,,8.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.52,80,,52.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.52,12.84,,8.42,percent of total billed charges,12.84% of total billed charges,10.52,12.84,,8.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.24,65,,42.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.67,35,,22.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.71,90,,58.97,percent of total billed charges,90% of total billed charges for outpatient setting,10.52,73.71,
LEVOBUNOLOL (BETAGAN) 0.5% OPTH SOLN 5ML,3303336,CDM,259,RC,,,Outpatient,,,56.72,56.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.7,70,,31.76,percent of total billed charges,70% of total billed charges for outpatient setting,48.14,84.88,,38.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.36,50,,22.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.54,75,,34.03,percent of total billed charges,75% of total billed charges for outpatient setting,39.7,70,,31.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,12.84,,5.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.38,80,,36.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,12.84,,5.82,percent of total billed charges,12.84% of total billed charges,7.28,12.84,,5.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.87,65,,29.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,35,,15.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.05,90,,40.84,percent of total billed charges,90% of total billed charges for outpatient setting,7.28,51.05,
LEVOBUNOLOL (BETAGAN) OPTH SOL 0.25%:5ML,3301367,CDM,259,RC,,,Outpatient,,,42.66,42.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.86,70,,23.89,percent of total billed charges,70% of total billed charges for outpatient setting,36.21,84.88,,28.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.33,50,,17.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32,75,,25.6,percent of total billed charges,75% of total billed charges for outpatient setting,29.86,70,,23.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,12.84,,4.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.13,80,,27.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.48,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.73,65,,22.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.93,35,,11.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.39,90,,30.71,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,38.39,
LEVOBUNOLOL (BETAGAN) OPTH SOL 0.25%:5ML,3301369,CDM,259,RC,,,Outpatient,,,63.08,63.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.16,70,,35.33,percent of total billed charges,70% of total billed charges for outpatient setting,53.54,84.88,,42.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.54,50,,25.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.31,75,,37.85,percent of total billed charges,75% of total billed charges for outpatient setting,44.16,70,,35.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,12.84,,6.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.46,80,,40.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,12.84,,6.48,percent of total billed charges,12.84% of total billed charges,8.1,12.84,,6.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41,65,,32.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,35,,17.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.77,90,,45.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.1,56.77,
LEVOBUNOLOL (BETAGAN) OPTH SOL 0.5%:5ML,3301368,CDM,259,RC,,,Outpatient,,,42.32,42.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,70,,23.7,percent of total billed charges,70% of total billed charges for outpatient setting,35.92,84.88,,28.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.16,50,,16.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.74,75,,25.39,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,70,,23.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,12.84,,4.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.86,80,,27.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,12.84,,4.34,percent of total billed charges,12.84% of total billed charges,5.43,12.84,,4.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.51,65,,22.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,35,,11.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.09,90,,30.47,percent of total billed charges,90% of total billed charges for outpatient setting,5.43,38.09,
LEVOFLOXACIN (genLEVAQUIN) TAB 500 MG,3301370,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVOFLOXACIN/D5W(LEVAQUIN)IV 250MG/50ML,3301371,CDM,636,RC,J1956,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVOFLOXACIN/D5W(LEVAQUIN)IV 500MG/100ML,3301372,CDM,636,RC,J1956,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVOFLOXACIN/D5W(LEVAQUIN)IV 750MG/150ML,3303313,CDM,636,RC,J1956,HCPCS,Outpatient,,,30.06,30.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,25.51,84.88,,20.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.55,75,,18.04,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,70,,16.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,12.84,,3.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,80,,19.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,12.84,,3.09,percent of total billed charges,12.84% of total billed charges,3.86,12.84,,3.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.54,65,,15.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,100,,,Fee Schedule,100% of Custom Fee Schedule,27.05,90,,21.64,percent of total billed charges,90% of total billed charges for outpatient setting,0.69,27.05,
LEVOTHYROXINE (genSYNTHROID)25microgram,3301374,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVOTHYROXINE (LEVOXYL) TAB : 75MCG,3301383,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LEVOTHYROXINE (LEVOXYL) TAB 125MCG,3301384,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LEVOTHYROXINE (SYNTHROID) INJ  200MCG,3301373,CDM,250,RC,,,Outpatient,,,105.71,105.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74,70,,59.2,percent of total billed charges,70% of total billed charges for outpatient setting,89.73,84.88,,71.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.86,50,,42.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.28,75,,63.42,percent of total billed charges,75% of total billed charges for outpatient setting,74,70,,59.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,12.84,,10.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.57,80,,67.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,12.84,,10.86,percent of total billed charges,12.84% of total billed charges,13.57,12.84,,10.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.71,65,,54.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37,35,,29.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.14,90,,76.11,percent of total billed charges,90% of total billed charges for outpatient setting,13.57,95.14,
LEVOTHYROXINE (SYNTHROID) TAB  112MCG,3301379,CDM,259,RC,,,Outpatient,,,12.15,12.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,10.31,84.88,,8.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.08,50,,4.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.11,75,,7.29,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.56,12.84,,1.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,80,,7.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.56,12.84,,1.25,percent of total billed charges,12.84% of total billed charges,1.56,12.84,,1.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.9,65,,6.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,35,,3.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.94,90,,8.75,percent of total billed charges,90% of total billed charges for outpatient setting,1.56,10.94,
LEVOTHYROXINE (SYNTHROID) TAB : 50MCG,3301375,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LEVOTHYROXINE (SYNTHROID) TAB : 75MCG,3301385,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LEVOTHYROXINE (SYNTHROID) TAB :75MCG U/D,3301387,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LEVOTHYROXINE (SYNTHROID) TAB 100MCG,3301378,CDM,259,RC,,,Outpatient,,,3.7,3.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,70,,2.07,percent of total billed charges,70% of total billed charges for outpatient setting,3.14,84.88,,2.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.85,50,,1.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.78,75,,2.22,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,70,,2.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,80,,2.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.41,65,,1.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,35,,1.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.33,90,,2.66,percent of total billed charges,90% of total billed charges for outpatient setting,0.48,3.33,
LEVOTHYROXINE (SYNTHROID) TAB 125MCG,3301380,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LEVOTHYROXINE (SYNTHROID) TAB 150MCG,3301381,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LEVOTHYROXINE (SYNTHROID) TAB 175 MCG,3303335,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LEVOTHYROXINE (SYNTHROID) TAB 50MCG UD,3301376,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LEVOTHYROXINE (SYNTHROID) TAB 75MCG,3301377,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LEVOTHYROXINE (SYNTHROID) TAB 88MCG,3301386,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LEVSIN 0.5 MG/ML INJ,3302938,CDM,636,RC,J1980,HCPCS,Outpatient,,,63.81,63.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,54.16,84.88,,43.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.86,75,,38.29,percent of total billed charges,75% of total billed charges for outpatient setting,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,12.84,,6.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.05,80,,40.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,12.84,,6.55,percent of total billed charges,12.84% of total billed charges,8.19,12.84,,6.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.48,65,,33.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.18,100,,,Fee Schedule,100% of Custom Fee Schedule,57.43,90,,45.94,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,57.43,
LEVSIN(HYOSCYAMINE)0.5 MG/ML 1 ML,3302776,CDM,250,RC,,,Outpatient,,,83.33,83.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.33,70,,46.66,percent of total billed charges,70% of total billed charges for outpatient setting,70.73,84.88,,56.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.67,50,,33.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,75,,50,percent of total billed charges,75% of total billed charges for outpatient setting,58.33,70,,46.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.7,12.84,,8.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,80,,53.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.7,12.84,,8.56,percent of total billed charges,12.84% of total billed charges,10.7,12.84,,8.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.16,65,,43.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.17,35,,23.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75,90,,60,percent of total billed charges,90% of total billed charges for outpatient setting,10.7,75,
LG COLD PK 6.25X9 / MDS148000,5150006,CDM,270,RC,,,Outpatient,,,10.98,10.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.69,70,,6.15,percent of total billed charges,70% of total billed charges for outpatient setting,9.32,84.88,,7.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.49,50,,4.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.24,75,,6.59,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,70,,6.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,80,,7.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.14,65,,5.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,35,,3.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.88,90,,7.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,9.88,
LG HOT PK 6X9 / MDS139009,5150007,CDM,270,RC,,,Outpatient,,,8.46,8.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.92,70,,4.74,percent of total billed charges,70% of total billed charges for outpatient setting,7.18,84.88,,5.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.23,50,,3.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.35,75,,5.08,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,70,,4.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,80,,5.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.5,65,,4.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,35,,2.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.61,90,,6.09,percent of total billed charges,90% of total billed charges for outpatient setting,1.09,7.61,
LH-LUTENIZING HORMONE,220484,CDM,300,RC,83002,HCPCS,Outpatient,,,83.34,75.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.34,70,,46.67,percent of total billed charges,70% of total billed charges for outpatient setting,70.74,84.88,,56.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.51,75,,50.01,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,70,,46.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,80,,53.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.11,100,,,Fee Schedule,100% of Custom Fee Schedule,75.01,90,,60.01,percent of total billed charges,90% of total billed charges for outpatient setting,18.52,75.01,
LIBRIUM AMP: 100MG,3302544,CDM,250,RC,,,Outpatient,,,70.97,70.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.68,70,,39.74,percent of total billed charges,70% of total billed charges for outpatient setting,60.24,84.88,,48.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.49,50,,28.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.23,75,,42.58,percent of total billed charges,75% of total billed charges for outpatient setting,49.68,70,,39.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,80,,45.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,9.11,12.84,,7.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.13,65,,36.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,35,,19.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.87,90,,51.1,percent of total billed charges,90% of total billed charges for outpatient setting,9.11,63.87,
LIBRIUM CAP : 10MG,3302545,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LIBRIUM CAP : 25MG,3302546,CDM,259,RC,,,Outpatient,,,10.42,10.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,84.88,,7.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.21,50,,4.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.82,75,,6.26,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,80,,6.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.77,65,,5.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,35,,2.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.38,90,,7.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.38,
LIDOCAINE (LIDODERM) PATCH 5% :,3301408,CDM,250,RC,,,Outpatient,,,12.82,12.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,70,,7.18,percent of total billed charges,70% of total billed charges for outpatient setting,10.88,84.88,,8.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.41,50,,5.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.62,75,,7.7,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,70,,7.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.26,80,,8.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.33,65,,6.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,35,,3.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.54,90,,9.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.54,
LIDOCAINE (XYLO EPI)1/100000 INJ:20ML,3301410,CDM,250,RC,,,Outpatient,,,8.22,8.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,70,,4.6,percent of total billed charges,70% of total billed charges for outpatient setting,6.98,84.88,,5.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.11,50,,3.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.17,75,,4.94,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,70,,4.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,80,,5.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.34,65,,4.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,35,,2.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.4,90,,5.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.06,7.4,
LIDOCAINE (XYLO EPI)1/200000 INJ:50ML,3301412,CDM,250,RC,,,Outpatient,,,38.68,38.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.08,70,,21.66,percent of total billed charges,70% of total billed charges for outpatient setting,32.83,84.88,,26.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.34,50,,15.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.01,75,,23.21,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,70,,21.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.94,80,,24.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.97,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.14,65,,20.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,35,,10.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.81,90,,27.85,percent of total billed charges,90% of total billed charges for outpatient setting,4.97,34.81,
LIDOCAINE (XYLO EPI)MPF SDV 1% : 30ML,3301411,CDM,250,RC,J2001,HCPCS,Outpatient,,,32.45,32.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.72,70,,18.18,percent of total billed charges,70% of total billed charges for outpatient setting,27.54,84.88,,22.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.34,75,,19.47,percent of total billed charges,75% of total billed charges for outpatient setting,22.72,70,,18.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.96,80,,20.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.09,65,,16.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,29.21,90,,23.37,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,29.21,
LIDOCAINE (XYLO GLUC) AMP 5% : 2ML,3301413,CDM,250,RC,,,Outpatient,,,31.36,31.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.95,70,,17.56,percent of total billed charges,70% of total billed charges for outpatient setting,26.62,84.88,,21.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.68,50,,12.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.52,75,,18.82,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,70,,17.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,12.84,,3.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.09,80,,20.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,12.84,,3.22,percent of total billed charges,12.84% of total billed charges,4.03,12.84,,3.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.38,65,,16.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.98,35,,8.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.22,90,,22.58,percent of total billed charges,90% of total billed charges for outpatient setting,4.03,28.22,
LIDOCAINE (XYLO SF) INJ 0.50% : 50ML,3301405,CDM,250,RC,J2001,HCPCS,Outpatient,,,25.77,25.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.04,70,,14.43,percent of total billed charges,70% of total billed charges for outpatient setting,21.87,84.88,,17.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.33,75,,15.46,percent of total billed charges,75% of total billed charges for outpatient setting,18.04,70,,14.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.62,80,,16.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.75,65,,13.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,23.19,90,,18.55,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,23.19,
LIDOCAINE (XYLO VISC) LIQ 2% : 100ML,3301395,CDM,250,RC,,,Outpatient,,,52.97,52.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,44.96,84.88,,35.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.49,50,,21.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.73,75,,31.78,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,70,,29.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.38,80,,33.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.43,65,,27.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,35,,14.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.67,90,,38.14,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.67,
LIDOCAINE (XYLO VISC) LIQ 2% : 20ML UD,3301399,CDM,250,RC,J3490,HCPCS,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LIDOCAINE (XYLO) 1% 20ML MDV,3301392,CDM,250,RC,J2001,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,2.92,
LIDOCAINE (XYLO) 1% 30ML SDV PF,3301391,CDM,250,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
LIDOCAINE (XYLO) 1% 5ML SDV PF,3313174,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIDOCAINE (XYLO) GEL 2% : 5ML,3301406,CDM,250,RC,,,Outpatient,,,39.72,39.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.8,70,,22.24,percent of total billed charges,70% of total billed charges for outpatient setting,33.71,84.88,,26.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.86,50,,15.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.79,75,,23.83,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,70,,22.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.78,80,,25.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.82,65,,20.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.9,35,,11.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.75,90,,28.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,35.75,
LIDOCAINE (XYLO) INJ 2%: 20ML,3301403,CDM,250,RC,,,Outpatient,,,30.64,30.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.45,70,,17.16,percent of total billed charges,70% of total billed charges for outpatient setting,26.01,84.88,,20.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.32,50,,12.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.98,75,,18.38,percent of total billed charges,75% of total billed charges for outpatient setting,21.45,70,,17.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,12.84,,3.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.51,80,,19.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,3.93,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.92,65,,15.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.72,35,,8.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.58,90,,22.06,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,27.58,
LIDOCAINE (XYLO) MDV 0.5% : 50ML,3301390,CDM,250,RC,J2001,HCPCS,Outpatient,,,14.07,14.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,11.94,84.88,,9.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.55,75,,8.44,percent of total billed charges,75% of total billed charges for outpatient setting,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,80,,9.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.15,65,,7.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,12.66,90,,10.13,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,12.66,
LIDOCAINE (XYLO) MDV 1% UD  2ML,3301402,CDM,250,RC,J2001,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,2.92,
LIDOCAINE (XYLO) MDV 2% : 50ML,3301393,CDM,250,RC,,,Outpatient,,,11.88,11.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.91,75,,7.13,percent of total billed charges,75% of total billed charges for outpatient setting,8.32,70,,6.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,35,,3.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.69,90,,8.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.53,10.69,
LIDOCAINE (XYLO) MDV 2% 20 MLS,3304402,CDM,250,RC,,,Outpatient,,,17.04,17.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,70,,9.54,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,84.88,,11.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.52,50,,6.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.78,75,,10.22,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,70,,9.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,80,,10.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.08,65,,8.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.96,35,,4.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.34,90,,12.27,percent of total billed charges,90% of total billed charges for outpatient setting,2.19,15.34,
LIDOCAINE (XYLO) SDV 1% : 2ML,3301396,CDM,250,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
LIDOCAINE (XYLO) SDV 2% 2ML,3301398,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIDOCAINE (XYLO) TOPICAL  SOL 4% 50ML,3301389,CDM,250,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
LIDOCAINE (XYLO)MPF AMP 4% : 5ML,3301404,CDM,250,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LIDOCAINE 0.5% WITH EPI: 50 ml,3302987,CDM,250,RC,,,Outpatient,,,49.36,49.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.55,70,,27.64,percent of total billed charges,70% of total billed charges for outpatient setting,41.9,84.88,,33.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.68,50,,19.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.02,75,,29.62,percent of total billed charges,75% of total billed charges for outpatient setting,34.55,70,,27.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,12.84,,5.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,80,,31.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,12.84,,5.07,percent of total billed charges,12.84% of total billed charges,6.34,12.84,,5.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.08,65,,25.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,35,,13.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.42,90,,35.54,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,44.42,
LIDOCAINE 1% EPI 1:100000 50ml MDV UDchg,3301409,CDM,250,RC,J2001,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,2.92,
LIDOCAINE 1% EPI 1:200000 30ML MPF,3313790,CDM,250,RC,J2001,HCPCS,Outpatient,,,26.53,26.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,70,,14.86,percent of total billed charges,70% of total billed charges for outpatient setting,22.52,84.88,,18.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.9,75,,15.92,percent of total billed charges,75% of total billed charges for outpatient setting,18.57,70,,14.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,12.84,,2.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.22,80,,16.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,12.84,,2.73,percent of total billed charges,12.84% of total billed charges,3.41,12.84,,2.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.24,65,,13.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,23.88,90,,19.1,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,23.88,
LIDOCAINE 1% MPF: 5 ML,3302726,CDM,250,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
LIDOCAINE 2 GMS/D5W 250MLS,3312968,CDM,636,RC,J2001,HCPCS,Outpatient,,,24.44,24.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.11,70,,13.69,percent of total billed charges,70% of total billed charges for outpatient setting,20.74,84.88,,16.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.33,75,,14.66,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,70,,13.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.55,80,,15.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,3.14,12.84,,2.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.89,65,,12.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,22,90,,17.6,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,22,
LIDOCAINE 2% 20MG/ML INJ 5 ML VIAL,3302954,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIDOCAINE 2% 30ML JELLY,3301394,CDM,250,RC,J3490,HCPCS,Outpatient,,,312.98,312.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.09,70,,175.27,percent of total billed charges,70% of total billed charges for outpatient setting,265.66,84.88,,212.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,234.74,75,,187.79,percent of total billed charges,75% of total billed charges for outpatient setting,219.09,70,,175.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.19,12.84,,32.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.38,80,,200.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.19,12.84,,32.15,percent of total billed charges,12.84% of total billed charges,40.19,12.84,,32.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.44,65,,162.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.54,35,,87.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.68,90,,225.34,percent of total billed charges,90% of total billed charges for outpatient setting,40.19,281.68,
LIDOCAINE 2% JELLY 6ML TOPICAL SYRINGE,3314218,CDM,250,RC,J3490,HCPCS,Outpatient,,,28.85,28.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.2,70,,16.16,percent of total billed charges,70% of total billed charges for outpatient setting,24.49,84.88,,19.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.64,75,,17.31,percent of total billed charges,75% of total billed charges for outpatient setting,20.2,70,,16.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.08,80,,18.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.75,65,,15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,35,,8.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.97,90,,20.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.97,
LIDOCAINE 2% UROJET 10 ML,3302759,CDM,259,RC,,,Outpatient,,,43.68,43.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.58,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,37.08,84.88,,29.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.84,50,,17.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.76,75,,26.21,percent of total billed charges,75% of total billed charges for outpatient setting,30.58,70,,24.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.94,80,,27.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.39,65,,22.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,35,,12.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.31,90,,31.45,percent of total billed charges,90% of total billed charges for outpatient setting,5.61,39.31,
LIDOCAINE HCL 1% INJ 20ML,3302639,CDM,250,RC,J2001,HCPCS,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,10.53,
LIDOCAINE MPF 1.5% WITH EPI:30 ML,3303175,CDM,250,RC,,,Outpatient,,,54.96,54.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.47,70,,30.78,percent of total billed charges,70% of total billed charges for outpatient setting,46.65,84.88,,37.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.48,50,,21.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.22,75,,32.98,percent of total billed charges,75% of total billed charges for outpatient setting,38.47,70,,30.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,12.84,,5.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.97,80,,35.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.72,65,,28.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.24,35,,15.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.46,90,,39.57,percent of total billed charges,90% of total billed charges for outpatient setting,7.06,49.46,
LIDOCAINE PATCH 4%,3314188,CDM,259,RC,,,Outpatient,,,3.07,3.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,75,,1.84,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.76,90,,2.21,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.76,
LIDOCAINE PATCH 5%,3302980,CDM,259,RC,,,Outpatient,,,19.09,19.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.36,70,,10.69,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,84.88,,12.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.55,50,,7.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.32,75,,11.46,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,70,,10.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.27,80,,12.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,2.45,12.84,,1.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.41,65,,9.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,35,,5.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.18,90,,13.74,percent of total billed charges,90% of total billed charges for outpatient setting,2.45,17.18,
LIDOCAINE PRILO 1gUDchg(genEMLA)30gmTUBE,3301415,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIDOCAINE PRILOCAINE (EMLA) CRM: 5 GM,3301414,CDM,259,RC,,,Outpatient,,,25.5,25.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.85,70,,14.28,percent of total billed charges,70% of total billed charges for outpatient setting,21.64,84.88,,17.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.75,50,,10.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,75,,15.3,percent of total billed charges,75% of total billed charges for outpatient setting,17.85,70,,14.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,80,,16.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.58,65,,13.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,35,,7.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.95,90,,18.36,percent of total billed charges,90% of total billed charges for outpatient setting,3.27,22.95,
LIDOCAINE PRILOCAINE (genEMLA) CRM 5 GM,3305532,CDM,259,RC,,,Outpatient,,,56.49,56.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.54,70,,31.63,percent of total billed charges,70% of total billed charges for outpatient setting,47.95,84.88,,38.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.25,50,,22.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.37,75,,33.9,percent of total billed charges,75% of total billed charges for outpatient setting,39.54,70,,31.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.19,80,,36.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,7.25,12.84,,5.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.72,65,,29.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.77,35,,15.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.84,90,,40.67,percent of total billed charges,90% of total billed charges for outpatient setting,7.25,50.84,
LIDOCAINE(XYLO)2% 100MG/5ML SYRINGE,3301397,CDM,250,RC,J2001,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,2.92,
LIDOCAINE/LIDO VISC LIQ 2% 100ML,3301388,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIDOCAINE/XYLO GEL 2%  5ML,3301407,CDM,250,RC,J3490,HCPCS,Outpatient,,,50.13,50.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,70,,28.07,percent of total billed charges,70% of total billed charges for outpatient setting,42.55,84.88,,34.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.6,75,,30.08,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,70,,28.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,12.84,,5.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.1,80,,32.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,12.84,,5.15,percent of total billed charges,12.84% of total billed charges,6.44,12.84,,5.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.58,65,,26.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,35,,14.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.12,90,,36.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.44,45.12,
LIGACLIP 10MM CLIP APPLIER / ER320,6150348,CDM,272,RC,,,Outpatient,,,224.76,224.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.33,70,,125.86,percent of total billed charges,70% of total billed charges for outpatient setting,190.78,84.88,,152.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.38,50,,89.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.57,75,,134.86,percent of total billed charges,75% of total billed charges for outpatient setting,157.33,70,,125.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.86,12.84,,23.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.81,80,,143.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.86,12.84,,23.09,percent of total billed charges,12.84% of total billed charges,28.86,12.84,,23.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.09,65,,116.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.67,35,,62.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.28,90,,161.82,percent of total billed charges,90% of total billed charges for outpatient setting,28.86,202.28,
LIGAMENT REPAIR INTRBRCE KT / AR-1678-CP,69162477,CDM,278,RC,C1713,HCPCS,Outpatient,,,3690.62,3690.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2214.37,60,,1771.5,percent of total billed charges,60% of total Billed charges for outpatient setting,3132.6,84.88,,2506.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2767.97,75,,2214.38,percent of total billed charges,75% of total billed charges for outpatient setting,1845.31,50,,1476.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2952.5,80,,2362,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3875.15,105,,3100.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.72,35,,1033.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2214.37,60,,1771.5,percent of total billed charges,60% of total billed charges for outpatient setting,473.88,3875.15,
LIGASURE 37CM RETRACT L-HOOK  / LF5637,69162846,CDM,272,RC,,,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1251.25,65,,1001,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1732.5,90,,1386,percent of total billed charges,90% of total billed charges for outpatient setting,247.17,1732.5,
LIGASURE 44CM RETRACT L-HOOK / LF5644,70000561,CDM,272,RC,,,Outpatient,,,2273.74,2273.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.62,70,,1273.3,percent of total billed charges,70% of total billed charges for outpatient setting,1929.95,84.88,,1543.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1136.87,50,,909.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1705.31,75,,1364.25,percent of total billed charges,75% of total billed charges for outpatient setting,1591.62,70,,1273.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.95,12.84,,233.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1818.99,80,,1455.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.95,12.84,,233.56,percent of total billed charges,12.84% of total billed charges,291.95,12.84,,233.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1477.93,65,,1182.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.81,35,,636.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046.37,90,,1637.1,percent of total billed charges,90% of total billed charges for outpatient setting,291.95,2046.37,
LIGASURE 5MM 37CM BLUNT TIP / LF1837,69169736,CDM,272,RC,,,Outpatient,,,1729.4,1729.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1210.58,70,,968.46,percent of total billed charges,70% of total billed charges for outpatient setting,1467.91,84.88,,1174.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,864.7,50,,691.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.05,75,,1037.64,percent of total billed charges,75% of total billed charges for outpatient setting,1210.58,70,,968.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.05,12.84,,177.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1383.52,80,,1106.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.05,12.84,,177.64,percent of total billed charges,12.84% of total billed charges,222.05,12.84,,177.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1124.11,65,,899.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.29,35,,484.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1556.46,90,,1245.17,percent of total billed charges,90% of total billed charges for outpatient setting,222.05,1556.46,
LIGASURE 5MMX37CM LAP BLT,69169810,CDM,272,RC,,,Outpatient,,,2320.66,2320.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624.46,70,,1299.57,percent of total billed charges,70% of total billed charges for outpatient setting,1969.78,84.88,,1575.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1160.33,50,,928.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1740.5,75,,1392.4,percent of total billed charges,75% of total billed charges for outpatient setting,1624.46,70,,1299.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.97,12.84,,238.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.53,80,,1485.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.97,12.84,,238.38,percent of total billed charges,12.84% of total billed charges,297.97,12.84,,238.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1508.43,65,,1206.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,812.23,35,,649.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2088.59,90,,1670.87,percent of total billed charges,90% of total billed charges for outpatient setting,297.97,2088.59,
LIGASURE IMPACT / LF4418,69161071,CDM,272,RC,,,Outpatient,,,1925,1925,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,1633.94,84.88,,1307.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,962.5,50,,770,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1443.75,75,,1155,percent of total billed charges,75% of total billed charges for outpatient setting,1347.5,70,,1078,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,80,,1232,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,247.17,12.84,,197.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1251.25,65,,1001,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.75,35,,539,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1732.5,90,,1386,percent of total billed charges,90% of total billed charges for outpatient setting,247.17,1732.5,
LIGASURE SM JAW CURVED / LF1212A,69161134,CDM,272,RC,,,Outpatient,,,1893.36,1893.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1325.35,70,,1060.28,percent of total billed charges,70% of total billed charges for outpatient setting,1607.08,84.88,,1285.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,946.68,50,,757.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1420.02,75,,1136.02,percent of total billed charges,75% of total billed charges for outpatient setting,1325.35,70,,1060.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.11,12.84,,194.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.69,80,,1211.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.11,12.84,,194.49,percent of total billed charges,12.84% of total billed charges,243.11,12.84,,194.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1230.68,65,,984.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.68,35,,530.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1704.02,90,,1363.22,percent of total billed charges,90% of total billed charges for outpatient setting,243.11,1704.02,
LIGASURE TISSUE FUS ELECT CURVED 2.5CM,69162054,CDM,272,RC,,,Outpatient,,,902.78,902.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.95,70,,505.56,percent of total billed charges,70% of total billed charges for outpatient setting,766.28,84.88,,613.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,451.39,50,,361.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,677.09,75,,541.67,percent of total billed charges,75% of total billed charges for outpatient setting,631.95,70,,505.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,12.84,,92.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.22,80,,577.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,12.84,,92.74,percent of total billed charges,12.84% of total billed charges,115.92,12.84,,92.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,586.81,65,,469.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.97,35,,252.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,812.5,90,,650,percent of total billed charges,90% of total billed charges for outpatient setting,115.92,812.5,
LIGATOR 2.8MM ESOPHAGEAL / M00542253,592913,CDM,278,RC,C1889,HCPCS,Outpatient,,,798.96,798.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.38,60,,383.5,percent of total billed charges,60% of total Billed charges for outpatient setting,678.16,84.88,,542.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.22,75,,479.38,percent of total billed charges,75% of total billed charges for outpatient setting,399.48,50,,319.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.59,12.84,,82.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.17,80,,511.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.59,12.84,,82.07,percent of total billed charges,12.84% of total billed charges,102.59,12.84,,82.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,798.96,65,,639.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.64,35,,223.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,479.38,60,,383.5,percent of total billed charges,60% of total billed charges for outpatient setting,102.59,798.96,
LIGATOR 210CM STIEGMAN GOFF / 100225,370423,CDM,272,RC,,,Outpatient,,,185.6,185.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.92,70,,103.94,percent of total billed charges,70% of total billed charges for outpatient setting,157.54,84.88,,126.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.8,50,,74.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.2,75,,111.36,percent of total billed charges,75% of total billed charges for outpatient setting,129.92,70,,103.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.83,12.84,,19.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.48,80,,118.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.83,12.84,,19.06,percent of total billed charges,12.84% of total billed charges,23.83,12.84,,19.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.64,65,,96.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.96,35,,51.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.04,90,,133.63,percent of total billed charges,90% of total billed charges for outpatient setting,23.83,167.04,
LIGHT HANDLE COVER (STERIS) / LB53A,69161590,CDM,272,RC,,,Outpatient,,,9.54,9.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,84.88,,6.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.77,50,,3.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.16,75,,5.73,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,80,,6.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.2,65,,4.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,35,,2.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.59,90,,6.87,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.59,
LIGHT SHIELD PURPLE PK/2 / 8002,69169234,CDM,270,RC,,,Outpatient,,,21.17,21.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,17.97,84.88,,14.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.59,50,,8.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.88,75,,12.7,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,80,,13.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.76,65,,11.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,35,,5.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.05,90,,15.24,percent of total billed charges,90% of total billed charges for outpatient setting,2.72,19.05,
LIGHTNING BUR 4.5MM / H9133,69159604,CDM,272,RC,,,Outpatient,,,259.59,259.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.71,70,,145.37,percent of total billed charges,70% of total billed charges for outpatient setting,220.34,84.88,,176.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.8,50,,103.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.69,75,,155.75,percent of total billed charges,75% of total billed charges for outpatient setting,181.71,70,,145.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.67,80,,166.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.73,65,,134.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.86,35,,72.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.63,90,,186.9,percent of total billed charges,90% of total billed charges for outpatient setting,33.33,233.63,
LIMB HOLDER FOAM W/SGL Q/R,5150019,CDM,270,RC,,,Outpatient,,,50.91,50.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.64,70,,28.51,percent of total billed charges,70% of total billed charges for outpatient setting,43.21,84.88,,34.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.46,50,,20.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.18,75,,30.54,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,70,,28.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,80,,32.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.09,65,,26.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,35,,14.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.82,90,,36.66,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.82,
LINCOMYCIN (LINCOCIN) 300MG/ML: 2ML,3308543,CDM,636,RC,J1580,HCPCS,Outpatient,,,123.55,123.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.49,70,,69.19,percent of total billed charges,70% of total billed charges for outpatient setting,104.87,84.88,,83.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,92.66,75,,74.13,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,70,,69.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,12.84,,12.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.84,80,,79.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,12.84,,12.69,percent of total billed charges,12.84% of total billed charges,15.86,12.84,,12.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.31,65,,64.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,100,,,Fee Schedule,100% of Custom Fee Schedule,111.2,90,,88.96,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,111.2,
LINDANE (KWELL) 1% LOTION : 5ML,3301417,CDM,259,RC,,,Outpatient,,,273.35,273.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.35,70,,153.08,percent of total billed charges,70% of total billed charges for outpatient setting,232.02,84.88,,185.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.68,50,,109.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.01,75,,164.01,percent of total billed charges,75% of total billed charges for outpatient setting,191.35,70,,153.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,12.84,,28.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.68,80,,174.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,12.84,,28.08,percent of total billed charges,12.84% of total billed charges,35.1,12.84,,28.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.68,65,,142.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,35,,76.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,246.02,90,,196.82,percent of total billed charges,90% of total billed charges for outpatient setting,35.1,246.02,
LINDANE (KWELL) SHAMPOO 1% : 5ML,3301418,CDM,259,RC,,,Outpatient,,,309.88,309.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.92,70,,173.54,percent of total billed charges,70% of total billed charges for outpatient setting,263.03,84.88,,210.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,154.94,50,,123.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.41,75,,185.93,percent of total billed charges,75% of total billed charges for outpatient setting,216.92,70,,173.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,12.84,,31.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.9,80,,198.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,12.84,,31.83,percent of total billed charges,12.84% of total billed charges,39.79,12.84,,31.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,201.42,65,,161.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.46,35,,86.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,278.89,90,,223.11,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,278.89,
LINDANE (KWELL) SHAMPOO 1% : 60ML,3301416,CDM,259,RC,,,Outpatient,,,49.61,49.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.73,70,,27.78,percent of total billed charges,70% of total billed charges for outpatient setting,42.11,84.88,,33.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.81,50,,19.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.21,75,,29.77,percent of total billed charges,75% of total billed charges for outpatient setting,34.73,70,,27.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,12.84,,5.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.69,80,,31.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,6.37,12.84,,5.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.25,65,,25.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,35,,13.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.65,90,,35.72,percent of total billed charges,90% of total billed charges for outpatient setting,6.37,44.65,
LINER 3000ML CANNISTER LIPO / 418276,71000240,CDM,272,RC,,,Outpatient,,,61.52,61.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.06,70,,34.45,percent of total billed charges,70% of total billed charges for outpatient setting,52.22,84.88,,41.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.76,50,,24.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.14,75,,36.91,percent of total billed charges,75% of total billed charges for outpatient setting,43.06,70,,34.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.9,12.84,,6.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.22,80,,39.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.9,12.84,,6.32,percent of total billed charges,12.84% of total billed charges,7.9,12.84,,6.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.99,65,,31.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,35,,17.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.37,90,,44.3,percent of total billed charges,90% of total billed charges for outpatient setting,7.9,55.37,
LINER 32X48MM ACETABULAR / 1221-32-048,71000925,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 32X48MM ACETABULAR / 1221-32-148,71000699,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 32X48MM ACETABULAR / 1221-32-448,71000912,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 32X50MM ACETABULAR / 1221-32-150,71000806,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 32X50MM ACETABULAR / 1221-32-450,69169886,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36MM ACETABULAR G7 / 30103606,71000065,CDM,278,RC,C1776,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36MM HIGH WALL G7 / 30123607,71000354,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36MM NEUTRAL G7 / 30103604,71000038,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36MM VIT E NEUTRAL G7 / 30103605,71000048,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36MM VIT E NTRL G7 / 30103607,71000155,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36MM VIVACIT G7 / 30123605,71000290,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
LINER 36X52MM ACETABULAR / 1221-36-052,71000670,CDM,278,RC,C1713,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X52MM ACETABULAR / 1221-36-152,71000442,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X54MM 10 DEG ACBLR / 1221-36-154,69162289,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X54MM ACETABULAR / 1221-36-054,71000656,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X54MM ACETABULAR / 1221-36-454,71000555,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X56MM ACETABULAR / 1221-36-056,71000577,CDM,278,RC,C1713,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X56MM ACETABULAR / 1221-36-156,71000421,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X56MM ACETABULAR / 1221-36-456,69169878,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X58MM ACETABULAR / 1221-36-058,71000848,CDM,278,RC,C1713,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X58MM ACETABULAR / 1221-36-158,71000546,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X58MM ACETABULAR / 1221-36-458,71000548,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X60MM ACETABULAR / 1221-36-160,71000904,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 36X60MM ACETABULAR XLPE / 71332405,71000866,CDM,278,RC,C1776,HCPCS,Outpatient,,,10750,10750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6450,60,,5160,percent of total billed charges,60% of total Billed charges for outpatient setting,9124.6,84.88,,7299.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8062.5,75,,6450,percent of total billed charges,75% of total billed charges for outpatient setting,5375,50,,4300,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380.3,12.84,,1104.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8600,80,,6880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380.3,12.84,,1104.24,percent of total billed charges,12.84% of total billed charges,1380.3,12.84,,1104.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11287.5,105,,9030,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3762.5,35,,3010,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6450,60,,5160,percent of total billed charges,60% of total billed charges for outpatient setting,1380.3,11287.5,
LINER 38X60MM ACETABULAR / 1221-36-460,71000905,CDM,278,RC,C1776,HCPCS,Outpatient,,,2891,2891,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.6,60,,1387.68,percent of total billed charges,60% of total Billed charges for outpatient setting,2453.88,84.88,,1963.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2168.25,75,,1734.6,percent of total billed charges,75% of total billed charges for outpatient setting,1445.5,50,,1156.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.8,80,,1850.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,371.2,12.84,,296.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3035.55,105,,2428.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.85,35,,809.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1734.6,60,,1387.68,percent of total billed charges,60% of total billed charges for outpatient setting,371.2,3035.55,
LINER 50MM OSSEOTI G7 / 110010243,69169845,CDM,278,RC,C1713,HCPCS,Outpatient,,,5086,5086,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3051.6,60,,2441.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4317,84.88,,3453.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3814.5,75,,3051.6,percent of total billed charges,75% of total billed charges for outpatient setting,2543,50,,2034.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4068.8,80,,3255.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5340.3,105,,4272.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.1,35,,1424.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3051.6,60,,2441.28,percent of total billed charges,60% of total billed charges for outpatient setting,653.04,5340.3,
LINER 50MM OSSEOTI G7 / 110010245,71000064,CDM,278,RC,C1713,HCPCS,Outpatient,,,5086,5086,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3051.6,60,,2441.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4317,84.88,,3453.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3814.5,75,,3051.6,percent of total billed charges,75% of total billed charges for outpatient setting,2543,50,,2034.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4068.8,80,,3255.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5340.3,105,,4272.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.1,35,,1424.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3051.6,60,,2441.28,percent of total billed charges,60% of total billed charges for outpatient setting,653.04,5340.3,
LINER 50MM OSSEOTI G7 / 110010263,71000035,CDM,278,RC,C1713,HCPCS,Outpatient,,,6142,6142,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3685.2,60,,2948.16,percent of total billed charges,60% of total Billed charges for outpatient setting,5213.33,84.88,,4170.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4606.5,75,,3685.2,percent of total billed charges,75% of total billed charges for outpatient setting,3071,50,,2456.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.63,12.84,,630.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4913.6,80,,3930.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.63,12.84,,630.9,percent of total billed charges,12.84% of total billed charges,788.63,12.84,,630.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6449.1,105,,5159.28,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2149.7,35,,1719.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3685.2,60,,2948.16,percent of total billed charges,60% of total billed charges for outpatient setting,788.63,6449.1,
LINER 52MM OSSEOTI G7 / 110010244,71000047,CDM,278,RC,C1713,HCPCS,Outpatient,,,5086,5086,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3051.6,60,,2441.28,percent of total billed charges,60% of total Billed charges for outpatient setting,4317,84.88,,3453.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3814.5,75,,3051.6,percent of total billed charges,75% of total billed charges for outpatient setting,2543,50,,2034.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4068.8,80,,3255.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,653.04,12.84,,522.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5340.3,105,,4272.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1780.1,35,,1424.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3051.6,60,,2441.28,percent of total billed charges,60% of total billed charges for outpatient setting,653.04,5340.3,
LINERS /LIPO/ CNLINERS,69161952,CDM,272,RC,,,Outpatient,,,97.34,97.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,84.88,,66.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.67,50,,38.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.01,75,,58.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.87,80,,62.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.27,65,,50.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.07,35,,27.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.61,90,,70.09,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,87.61,
LINEZOLID (genZYVOX) 600MG/300ML IVPB,3313710,CDM,636,RC,J1450,HCPCS,Outpatient,,,119.34,119.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.54,70,,66.83,percent of total billed charges,70% of total billed charges for outpatient setting,101.3,84.88,,81.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,89.51,75,,71.61,percent of total billed charges,75% of total billed charges for outpatient setting,83.54,70,,66.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.47,80,,76.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.57,65,,62.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,100,,,Fee Schedule,100% of Custom Fee Schedule,107.41,90,,85.93,percent of total billed charges,90% of total billed charges for outpatient setting,3.43,107.41,
LINEZOLID (ZYVOX) TAB : 600MG,3301419,CDM,636,RC,J2020,HCPCS,Outpatient,,,205.41,205.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.79,70,,115.03,percent of total billed charges,70% of total billed charges for outpatient setting,174.35,84.88,,139.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,154.06,75,,123.25,percent of total billed charges,75% of total billed charges for outpatient setting,143.79,70,,115.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,12.84,,21.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.33,80,,131.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,26.37,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.52,65,,106.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,100,,,Fee Schedule,100% of Custom Fee Schedule,184.87,90,,147.9,percent of total billed charges,90% of total billed charges for outpatient setting,5.84,184.87,
LINEZOLID (ZYVOX)600MG:TAB,3303254,CDM,259,RC,,,Outpatient,,,326.01,326.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.21,70,,182.57,percent of total billed charges,70% of total billed charges for outpatient setting,276.72,84.88,,221.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,163.01,50,,130.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.51,75,,195.61,percent of total billed charges,75% of total billed charges for outpatient setting,228.21,70,,182.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.86,12.84,,33.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.81,80,,208.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.86,12.84,,33.49,percent of total billed charges,12.84% of total billed charges,41.86,12.84,,33.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,211.91,65,,169.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.1,35,,91.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,293.41,90,,234.73,percent of total billed charges,90% of total billed charges for outpatient setting,41.86,293.41,
LINEZOLID 200MG/100ML IVPB (ZYVOX),3303333,CDM,636,RC,J1450,HCPCS,Outpatient,,,270.06,270.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.04,70,,151.23,percent of total billed charges,70% of total billed charges for outpatient setting,229.23,84.88,,183.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,202.55,75,,162.04,percent of total billed charges,75% of total billed charges for outpatient setting,189.04,70,,151.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,12.84,,27.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.05,80,,172.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,12.84,,27.74,percent of total billed charges,12.84% of total billed charges,34.68,12.84,,27.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.54,65,,140.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,100,,,Fee Schedule,100% of Custom Fee Schedule,243.05,90,,194.44,percent of total billed charges,90% of total billed charges for outpatient setting,3.43,243.05,
LIOTHYRONINE(CYTOMEL)TAB:25 MCG,3302673,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LIOTHYRONINE(genCYTOMEL) 5 MCG TAB,3313931,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LIPASE,200890,CDM,300,RC,83690,HCPCS,Outpatient,,,31.01,27.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,26.32,84.88,,21.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.26,75,,18.61,percent of total billed charges,75% of total billed charges for outpatient setting,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.81,80,,19.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.07,100,,,Fee Schedule,100% of Custom Fee Schedule,27.91,90,,22.33,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,27.91,
LIPASE,220000,CDM,300,RC,83690,HCPCS,Outpatient,,,31.01,27.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,26.32,84.88,,21.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.26,75,,18.61,percent of total billed charges,75% of total billed charges for outpatient setting,21.71,70,,17.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.81,80,,19.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.07,100,,,Fee Schedule,100% of Custom Fee Schedule,27.91,90,,22.33,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,27.91,
LIPID PANEL,200020,CDM,300,RC,80061,HCPCS,Outpatient,,,60.26,54.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,84.88,,40.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.2,75,,36.16,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.21,80,,38.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.67,100,,,Fee Schedule,100% of Custom Fee Schedule,54.23,90,,43.38,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,54.23,
LIPO TUBING- MICROAIRE / PAL1200,69159040,CDM,272,RC,,,Outpatient,,,100.1,100.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.07,70,,56.06,percent of total billed charges,70% of total billed charges for outpatient setting,84.96,84.88,,67.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.05,50,,40.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.08,75,,60.06,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,70,,56.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,12.84,,10.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.08,80,,64.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,12.84,,10.28,percent of total billed charges,12.84% of total billed charges,12.85,12.84,,10.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.07,65,,52.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.04,35,,28.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.09,90,,72.07,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,90.09,
LIPOPROTEIN A,220386,CDM,300,RC,82172,HCPCS,Outpatient,,,94.91,85.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,80.56,84.88,,64.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.18,75,,56.94,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.93,80,,60.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of Custom Fee Schedule,85.42,90,,68.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,85.42,
LIPOPROTEIN B,220929,CDM,300,RC,82172,HCPCS,Outpatient,,,94.91,85.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,80.56,84.88,,64.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.18,75,,56.94,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,70,,53.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.93,80,,60.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,12.19,12.84,,9.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of Custom Fee Schedule,85.42,90,,68.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,85.42,
LIPOPROTEIN DIRECT MEASUREMENT,201458,CDM,301,RC,83718,HCPCS,Outpatient,,,36.86,33.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,31.29,84.88,,25.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.65,75,,22.12,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,70,,20.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,80,,23.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.96,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,100,,,Fee Schedule,100% of Custom Fee Schedule,33.17,90,,26.54,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,33.17,
"LIPOPROTEIN,HIGH RESOLUTION FRACTIONATIO",201460,CDM,301,RC,83701,HCPCS,Outpatient,,,152.37,137.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.66,70,,85.33,percent of total billed charges,70% of total billed charges for outpatient setting,129.33,84.88,,103.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,114.28,75,,91.42,percent of total billed charges,75% of total billed charges for outpatient setting,106.66,70,,85.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.9,80,,97.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,36.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.07,100,,,Fee Schedule,100% of Custom Fee Schedule,137.13,90,,109.7,percent of total billed charges,90% of total billed charges for outpatient setting,33.47,137.13,
LISINOPRIL (genericPRINIVIL) 5MG TAB,3301421,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LISINOPRIL (PRINIVIL) TAB: 10 MG,3301422,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LISINOPRIL (PRINIVIL) TAB: 2.5 MG,3301420,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LISINOPRIL (PRINIVIL) TAB: 20 MG,3301423,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LISINOPRIL (ZESTRIL) TAB: 10 MG,3301424,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LISINOPRIL (ZESTRIL) TAB: 20 MG,3301425,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LISINOPRIL 10MG TAB,3303002,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LISINOPRIL 40MG: TAB,3302915,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
"LISTERIA ANTIBODY, SERUM",201529,CDM,302,RC,86609,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
LITHIUM,220340,CDM,300,RC,80178,HCPCS,Outpatient,,,29.75,26.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,84.88,,20.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.31,75,,17.85,percent of total billed charges,75% of total billed charges for outpatient setting,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.8,80,,19.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,100,,,Fee Schedule,100% of Custom Fee Schedule,26.78,90,,21.42,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,26.78,
LITHIUM C (ESKALITH) TAB : 300 MG,3301426,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LITHIUM C (ESKALITH) TAB : 450 MG,3301427,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LITHOTRIPSY,6100035,CDM,790,RC,,,Outpatient,,,15066.52,15066.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10546.56,70,,8437.25,percent of total billed charges,70% of total billed charges for outpatient setting,12788.46,84.88,,10230.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,7533.26,50,,6026.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11299.89,75,,9039.91,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1934.54,12.84,,1547.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.22,80,,9642.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1934.54,12.84,,1547.63,percent of total billed charges,12.84% of total billed charges,1934.54,12.84,,1547.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5273.28,35,,4218.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13559.87,90,,10847.9,percent of total billed charges,90% of total billed charges for outpatient setting,1934.54,13559.87,
LITHOTRIPSY,6151500,CDM,790,RC,,,Outpatient,,,16590.99,16590.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11613.69,70,,9290.95,percent of total billed charges,70% of total billed charges for outpatient setting,14082.43,84.88,,11265.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8295.5,50,,6636.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12443.24,75,,9954.59,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.28,12.84,,1704.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13272.79,80,,10618.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2130.28,12.84,,1704.22,percent of total billed charges,12.84% of total billed charges,2130.28,12.84,,1704.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5806.85,35,,4645.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14931.89,90,,11945.51,percent of total billed charges,90% of total billed charges for outpatient setting,2000,14931.89,
LITHOTRIPSY  CANCELLED PRIOR TO PROC,6151503,CDM,790,RC,,,Outpatient,,,216.95,216.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.87,70,,121.5,percent of total billed charges,70% of total billed charges for outpatient setting,184.15,84.88,,147.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.48,50,,86.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.71,75,,130.17,percent of total billed charges,75% of total billed charges for outpatient setting,151.87,70,,121.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,12.84,,22.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.56,80,,138.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,12.84,,22.29,percent of total billed charges,12.84% of total billed charges,27.86,12.84,,22.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.93,35,,60.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,195.26,90,,156.21,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,195.26,
LITHOTRIPSYCANCELLED PROC,6151504,CDM,790,RC,,,Outpatient,,,1410.13,1410.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.09,70,,789.67,percent of total billed charges,70% of total billed charges for outpatient setting,1196.92,84.88,,957.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,705.07,50,,564.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1057.6,75,,846.08,percent of total billed charges,75% of total billed charges for outpatient setting,987.09,70,,789.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.06,12.84,,144.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.1,80,,902.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.06,12.84,,144.85,percent of total billed charges,12.84% of total billed charges,181.06,12.84,,144.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.55,35,,394.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1269.12,90,,1015.3,percent of total billed charges,90% of total billed charges for outpatient setting,181.06,1269.12,
LIVER AND SPLEEN IMAGING W VASCULAR FLOW,3000280,CDM,341,RC,78216,HCPCS,Outpatient,,,811.23,608.42,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,688.57,84.88,,550.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,608.42,75,,486.74,percent of total billed charges,75% of total billed charges for outpatient setting,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,104.16,12.84,,83.328,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,648.98,80,,519.18,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.2,100,,,Fee Schedule,100% of Custom Fee Schedule,730.11,90,,584.09,percent of total billed charges,90% of total billed charges for outpatient setting,104.16,774,
LIVER PROFILE,200030,CDM,300,RC,80076,HCPCS,Outpatient,,,36.77,33.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,31.21,84.88,,24.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.58,75,,22.06,percent of total billed charges,75% of total billed charges for outpatient setting,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,80,,23.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of Custom Fee Schedule,33.09,90,,26.47,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,33.09,
LIVER/KIDNEY MICROSOMAL ANTIBODY,220429,CDM,302,RC,86376,HCPCS,Outpatient,,,65.48,58.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,70,,36.67,percent of total billed charges,70% of total billed charges for outpatient setting,55.58,84.88,,44.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.11,75,,39.29,percent of total billed charges,75% of total billed charges for outpatient setting,45.84,70,,36.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.38,80,,41.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.59,100,,,Fee Schedule,100% of Custom Fee Schedule,58.93,90,,47.14,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,58.93,
L-LYCINE 500 MG: tab,3303145,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LMA 1.0 SUPREME / 175010,69162901,CDM,270,RC,,,Outpatient,,,86.89,86.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.82,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,73.75,84.88,,59,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.45,50,,34.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.17,75,,52.14,percent of total billed charges,75% of total billed charges for outpatient setting,60.82,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.51,80,,55.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.48,65,,45.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.41,35,,24.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.2,90,,62.56,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,78.2,
LMA 1.5 SUPREME / 175015,6153117,CDM,270,RC,,,Outpatient,,,71.05,71.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.74,70,,39.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.31,84.88,,48.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.53,50,,28.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.29,75,,42.63,percent of total billed charges,75% of total billed charges for outpatient setting,49.74,70,,39.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,12.84,,7.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.84,80,,45.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,9.12,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.18,65,,36.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.87,35,,19.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.95,90,,51.16,percent of total billed charges,90% of total billed charges for outpatient setting,9.12,63.95,
LMA 2.0 SUPREME / 175020,6153118,CDM,270,RC,,,Outpatient,,,71.05,71.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.74,70,,39.79,percent of total billed charges,70% of total billed charges for outpatient setting,60.31,84.88,,48.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.53,50,,28.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.29,75,,42.63,percent of total billed charges,75% of total billed charges for outpatient setting,49.74,70,,39.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,12.84,,7.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.84,80,,45.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,9.12,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.18,65,,36.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.87,35,,19.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.95,90,,51.16,percent of total billed charges,90% of total billed charges for outpatient setting,9.12,63.95,
LMA 2.5 SUPREME / 175025,6152104,CDM,270,RC,,,Outpatient,,,77.18,77.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.03,70,,43.22,percent of total billed charges,70% of total billed charges for outpatient setting,65.51,84.88,,52.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.59,50,,30.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,75,,46.31,percent of total billed charges,75% of total billed charges for outpatient setting,54.03,70,,43.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,12.84,,7.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.74,80,,49.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,12.84,,7.93,percent of total billed charges,12.84% of total billed charges,9.91,12.84,,7.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.17,65,,40.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.01,35,,21.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.46,90,,55.57,percent of total billed charges,90% of total billed charges for outpatient setting,9.91,69.46,
LMA 2.5 UNIQUE / 105200-000025,1924177,CDM,272,RC,,,Outpatient,,,37.8,37.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,70,,21.17,percent of total billed charges,70% of total billed charges for outpatient setting,32.08,84.88,,25.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.9,50,,15.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,75,,22.68,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,70,,21.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,80,,24.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.57,65,,19.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,35,,10.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.02,90,,27.22,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,34.02,
LMA 3.0 EVO / 1D2030,70000512,CDM,270,RC,,,Outpatient,,,54.76,54.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.33,70,,30.66,percent of total billed charges,70% of total billed charges for outpatient setting,46.48,84.88,,37.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.38,50,,21.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.07,75,,32.86,percent of total billed charges,75% of total billed charges for outpatient setting,38.33,70,,30.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.03,12.84,,5.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.81,80,,35.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.03,12.84,,5.62,percent of total billed charges,12.84% of total billed charges,7.03,12.84,,5.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.59,65,,28.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.17,35,,15.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,90% of total billed charges for outpatient setting,7.03,49.28,
LMA 3.0 SUPREME / 175030,70000798,CDM,270,RC,,,Outpatient,,,62.11,62.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.48,70,,34.78,percent of total billed charges,70% of total billed charges for outpatient setting,52.72,84.88,,42.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.06,50,,24.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,75,,37.26,percent of total billed charges,75% of total billed charges for outpatient setting,43.48,70,,34.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,12.84,,6.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.69,80,,39.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,12.84,,6.38,percent of total billed charges,12.84% of total billed charges,7.97,12.84,,6.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.37,65,,32.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.74,35,,17.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.9,90,,44.72,percent of total billed charges,90% of total billed charges for outpatient setting,7.97,55.9,
LMA 3.0 UNIQUE / 105200-000030,1915181,CDM,272,RC,,,Outpatient,,,37.45,37.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,84.88,,25.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.73,50,,14.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.09,75,,22.47,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.96,80,,23.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.34,65,,19.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,35,,10.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.71,90,,26.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,33.71,
LMA 3.5 AIR Q / 225-10-3035,6152105,CDM,270,RC,,,Outpatient,,,84.7,84.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.29,70,,47.43,percent of total billed charges,70% of total billed charges for outpatient setting,71.89,84.88,,57.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.35,50,,33.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.53,75,,50.82,percent of total billed charges,75% of total billed charges for outpatient setting,59.29,70,,47.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,12.84,,8.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.76,80,,54.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,12.84,,8.7,percent of total billed charges,12.84% of total billed charges,10.88,12.84,,8.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.06,65,,44.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.65,35,,23.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.23,90,,60.98,percent of total billed charges,90% of total billed charges for outpatient setting,10.88,76.23,
LMA 4.0 EVO / 1D2040,70000513,CDM,270,RC,,,Outpatient,,,50.57,50.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,70,,28.32,percent of total billed charges,70% of total billed charges for outpatient setting,42.92,84.88,,34.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.29,50,,20.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.93,75,,30.34,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,70,,28.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.46,80,,32.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.87,65,,26.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,35,,14.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.51,90,,36.41,percent of total billed charges,90% of total billed charges for outpatient setting,6.49,45.51,
LMA 4.0 SUPREME / 175040,70000796,CDM,270,RC,,,Outpatient,,,73.5,73.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,62.39,84.88,,49.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.75,50,,29.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.13,75,,44.1,percent of total billed charges,75% of total billed charges for outpatient setting,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,80,,47.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.78,65,,38.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,35,,20.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.15,90,,52.92,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,66.15,
LMA 4.0 UNIQUE / 105200-000040,1915182,CDM,272,RC,,,Outpatient,,,37.45,37.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,84.88,,25.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.73,50,,14.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.09,75,,22.47,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.96,80,,23.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.34,65,,19.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,35,,10.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.71,90,,26.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,33.71,
LMA 4.5 AIR Q / 225-10-3045,6152106,CDM,270,RC,,,Outpatient,,,103.18,103.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.23,70,,57.78,percent of total billed charges,70% of total billed charges for outpatient setting,87.58,84.88,,70.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.59,50,,41.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.39,75,,61.91,percent of total billed charges,75% of total billed charges for outpatient setting,72.23,70,,57.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.54,80,,66.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,13.25,12.84,,10.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.07,65,,53.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.11,35,,28.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.86,90,,74.29,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,92.86,
LMA 5.0 EVO / 1D2050,6152911,CDM,270,RC,,,Outpatient,,,50.57,50.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,70,,28.32,percent of total billed charges,70% of total billed charges for outpatient setting,42.92,84.88,,34.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.29,50,,20.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.93,75,,30.34,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,70,,28.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.46,80,,32.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.87,65,,26.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,35,,14.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.51,90,,36.41,percent of total billed charges,90% of total billed charges for outpatient setting,6.49,45.51,
LMA 5.0 SUPREME / 175050,70000797,CDM,270,RC,,,Outpatient,,,74.97,74.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.48,70,,41.98,percent of total billed charges,70% of total billed charges for outpatient setting,63.63,84.88,,50.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.49,50,,29.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.23,75,,44.98,percent of total billed charges,75% of total billed charges for outpatient setting,52.48,70,,41.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.63,12.84,,7.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.98,80,,47.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.63,12.84,,7.7,percent of total billed charges,12.84% of total billed charges,9.63,12.84,,7.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.73,65,,38.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.24,35,,20.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.47,90,,53.98,percent of total billed charges,90% of total billed charges for outpatient setting,9.63,67.47,
LMA 5.0 UNIQUE / 105200-000050,1915183,CDM,272,RC,,,Outpatient,,,37.45,37.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,84.88,,25.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.73,50,,14.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.09,75,,22.47,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,70,,20.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.96,80,,23.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,4.81,12.84,,3.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.34,65,,19.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,35,,10.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.71,90,,26.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,33.71,
LMA PRO SEAL SIZE 3 REUSABLE / 15130,69160944,CDM,272,RC,,,Outpatient,,,85.22,85.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,72.33,84.88,,57.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.61,50,,34.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.92,75,,51.14,percent of total billed charges,75% of total billed charges for outpatient setting,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.18,80,,54.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.39,65,,44.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,35,,23.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.7,90,,61.36,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,76.7,
LOCKING CAP QUARTEX THRDED / 1149.0002,69162649,CDM,278,RC,C1713,HCPCS,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,60,,288,percent of total billed charges,60% of total Billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600,65,,480,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360,60,,288,percent of total billed charges,60% of total billed charges for outpatient setting,77.04,600,
LOCKING CAP REVOLVE / 185.000,69162303,CDM,278,RC,C1713,HCPCS,Outpatient,,,360,360,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,60,,172.8,percent of total billed charges,60% of total Billed charges for outpatient setting,305.57,84.88,,244.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270,75,,216,percent of total billed charges,75% of total billed charges for outpatient setting,180,50,,144,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.22,12.84,,36.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,80,,230.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.22,12.84,,36.98,percent of total billed charges,12.84% of total billed charges,46.22,12.84,,36.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,360,65,,288,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,35,,100.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216,60,,172.8,percent of total billed charges,60% of total billed charges for outpatient setting,46.22,360,
LOCKING CAP THREADED / 1149.0001,69162618,CDM,278,RC,C1713,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,60,,144,percent of total billed charges,60% of total Billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,300,65,,240,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,60,,144,percent of total billed charges,60% of total billed charges for outpatient setting,38.52,300,
LOCKING CAP/ E2002,69169281,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
LODOXAMIDE (ALOMIDE) OPTH SOL 0.1% :10ML,3301428,CDM,259,RC,,,Outpatient,,,138.16,138.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.71,70,,77.37,percent of total billed charges,70% of total billed charges for outpatient setting,117.27,84.88,,93.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.08,50,,55.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.62,75,,82.9,percent of total billed charges,75% of total billed charges for outpatient setting,96.71,70,,77.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.74,12.84,,14.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.53,80,,88.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.74,12.84,,14.19,percent of total billed charges,12.84% of total billed charges,17.74,12.84,,14.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.8,65,,71.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.36,35,,38.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.34,90,,99.47,percent of total billed charges,90% of total billed charges for outpatient setting,17.74,124.34,
LOOP 20X8MM ELECTRODE TAN / 0490,6150429,CDM,272,RC,,,Outpatient,,,79.51,79.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.66,70,,44.53,percent of total billed charges,70% of total billed charges for outpatient setting,67.49,84.88,,53.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.76,50,,31.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,75,,47.7,percent of total billed charges,75% of total billed charges for outpatient setting,55.66,70,,44.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,12.84,,8.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.61,80,,50.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,12.84,,8.17,percent of total billed charges,12.84% of total billed charges,10.21,12.84,,8.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.68,65,,41.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.83,35,,22.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.56,90,,57.25,percent of total billed charges,90% of total billed charges for outpatient setting,10.21,71.56,
LOPERAMIDE (IMODIUM) CAP 2MG UD,3301429,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LOPRO S1 SINGLE USE BLADE / 0270-0876,69169390,CDM,272,RC,,,Outpatient,,,218.4,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,185.38,84.88,,148.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.2,50,,87.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.8,75,,131.04,percent of total billed charges,75% of total billed charges for outpatient setting,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,80,,139.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.96,65,,113.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.44,35,,61.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.56,90,,157.25,percent of total billed charges,90% of total billed charges for outpatient setting,28.04,196.56,
LOPRO S2 SINGLE USE BLADE / 0270-0877,69169391,CDM,272,RC,,,Outpatient,,,218.4,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,185.38,84.88,,148.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.2,50,,87.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.8,75,,131.04,percent of total billed charges,75% of total billed charges for outpatient setting,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,80,,139.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.96,65,,113.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.44,35,,61.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.56,90,,157.25,percent of total billed charges,90% of total billed charges for outpatient setting,28.04,196.56,
LOPRO S3 SINGLE NON STR / 0270-1078,69169544,CDM,272,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
LOPRO S3 SINGLE USE BLADE / 0270-0938,69169232,CDM,272,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
LOPRO S4 SINGLE NON STR / 0270-1079,69169545,CDM,272,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
LOPRO S4 SINGLE USE BLADE / 0270-0939,69169233,CDM,272,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
LORATADINE (genCLARITIN) 10MG TAB,3301430,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LORATADINE/PSEUDOEPH 5/120MG 12HR TAB,3303308,CDM,259,RC,,,Outpatient,,,22.65,22.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,70,,12.69,percent of total billed charges,70% of total billed charges for outpatient setting,19.23,84.88,,15.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.33,50,,9.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.99,75,,13.59,percent of total billed charges,75% of total billed charges for outpatient setting,15.86,70,,12.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.12,80,,14.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.72,65,,11.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,35,,6.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.39,90,,16.31,percent of total billed charges,90% of total billed charges for outpatient setting,2.91,20.39,
LORAZEPAM (ATIVAN) INJ 2MG/ML 1ML,3301431,CDM,636,RC,J2060,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LORAZEPAM (ATIVAN) SDV 2MG/ML :,3301438,CDM,250,RC,,,Outpatient,,,8.9,8.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,84.88,,6.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.45,50,,3.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.68,75,,5.34,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,80,,5.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.79,65,,4.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.01,90,,6.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,8.01,
LORAZEPAM (ATIVAN) SDV 2MG/ML : 1ML,3301433,CDM,250,RC,,,Outpatient,,,10.05,10.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.04,70,,5.63,percent of total billed charges,70% of total billed charges for outpatient setting,8.53,84.88,,6.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.03,50,,4.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.54,75,,6.03,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,70,,5.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.04,80,,6.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.53,65,,5.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.52,35,,2.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.05,90,,7.24,percent of total billed charges,90% of total billed charges for outpatient setting,1.29,9.05,
LORAZEPAM (ATIVAN) SDV 2MG/ML : 1ML,3301432,CDM,250,RC,,,Outpatient,,,18.06,18.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,70,,10.11,percent of total billed charges,70% of total billed charges for outpatient setting,15.33,84.88,,12.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.03,50,,7.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.55,75,,10.84,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,70,,10.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,12.84,,1.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,80,,11.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,2.32,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.74,65,,9.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.32,35,,5.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.25,90,,13,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,16.25,
LORAZEPAM (ATIVAN) TAB : 0.5 MG,3301435,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LORAZEPAM (ATIVAN) TAB 1 MG,3301436,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LORAZEPAM (ATIVAN) TAB:0.5MG UD,3301434,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LORTAB 500MG TAB:,3302582,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
LOSARTAN (COZAAR) TAB : 25 MG,3301439,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LOSARTAN (genericCOZAAR) 50 MG TAB,3302757,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
LOTREL 5/10MG AMLODIPINE/BENZAPRIL : CAP,3303058,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LOTREL 5/20: CAP,3302883,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LOTREL10/20MG AMLODIPINE/BENZAPRIL : CAP,3303123,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LOTREL10/40MG AMLODIPINE/BENZAPRIL : CAP,3303245,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
LOVASTATIN (MEVACOR) 20MG,3304695,CDM,259,RC,,,Outpatient,,,13.39,13.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.7,50,,5.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.04,75,,8.03,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,80,,8.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.7,65,,6.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.05,90,,9.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.05,
LOVASTATIN (MEVACOR) TAB: 20 MG,3301440,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
LOVENOX INJ 30MG/0.3ML:0.3ML,3302520,CDM,250,RC,,,Outpatient,,,74.43,74.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.1,70,,41.68,percent of total billed charges,70% of total billed charges for outpatient setting,63.18,84.88,,50.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.22,50,,29.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.82,75,,44.66,percent of total billed charges,75% of total billed charges for outpatient setting,52.1,70,,41.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,12.84,,7.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.54,80,,47.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,12.84,,7.65,percent of total billed charges,12.84% of total billed charges,9.56,12.84,,7.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.38,65,,38.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.05,35,,20.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.99,90,,53.59,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,66.99,
LOVENOX INJ 40MG/0.4ML:0.4ML,3302519,CDM,250,RC,,,Outpatient,,,65.99,65.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.19,70,,36.95,percent of total billed charges,70% of total billed charges for outpatient setting,56.01,84.88,,44.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,33,50,,26.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.49,75,,39.59,percent of total billed charges,75% of total billed charges for outpatient setting,46.19,70,,36.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,12.84,,6.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.79,80,,42.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,12.84,,6.78,percent of total billed charges,12.84% of total billed charges,8.47,12.84,,6.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.89,65,,34.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.1,35,,18.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.39,90,,47.51,percent of total billed charges,90% of total billed charges for outpatient setting,8.47,59.39,
LOVENOX INJ 60MG/0.6ML: 0.6ML,3302521,CDM,250,RC,,,Outpatient,,,99.08,99.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.36,70,,55.49,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,84.88,,67.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.54,50,,39.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.31,75,,59.45,percent of total billed charges,75% of total billed charges for outpatient setting,69.36,70,,55.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,12.84,,10.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.26,80,,63.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,12.84,,10.18,percent of total billed charges,12.84% of total billed charges,12.72,12.84,,10.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.4,65,,51.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,35,,27.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.17,90,,71.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.72,89.17,
LOWER EXT INFANT 2 VWS BILATERAL,2400417,CDM,320,RC,73592,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
LOWER EXT INFANT 2 VWS LEFT,2400416,CDM,320,RC,73592,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
LOWER EXT INFANT 2 VWS RIGHT,2400415,CDM,320,RC,73592,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
LR IRRIG 3000ML BAG / 072828-08,69162927,CDM,272,RC,,,Outpatient,,,69.27,69.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.49,70,,38.79,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,84.88,,47.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.64,50,,27.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.95,75,,41.56,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,70,,38.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.89,12.84,,7.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.42,80,,44.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.89,12.84,,7.11,percent of total billed charges,12.84% of total billed charges,8.89,12.84,,7.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.03,65,,36.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.24,35,,19.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.34,90,,49.87,percent of total billed charges,90% of total billed charges for outpatient setting,8.89,62.34,
L-SPINE 2 OR 3 VWS,2400255,CDM,320,RC,72100,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
L-SPINE BENDING VWS,2400270,CDM,320,RC,72120,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
L-SPINE MIN 4 VWS,2400260,CDM,320,RC,72120,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
L-SPINE W/BEND VWS,2400265,CDM,320,RC,72114,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
LT HT CATH,2200640,CDM,481,RC,93452,HCPCS,Outpatient,,,7607.1,7607.1,,4157.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5324.97,70,,4259.98,percent of total billed charges,70% of total billed charges for outpatient setting,6456.91,84.88,,5165.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,3913.15,50,,3130.52,percent of total billed charges,50% of total Billed charges for outpatient setting,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5705.33,75,,4564.26,percent of total billed charges,75% of total billed charges for outpatient setting,5000,70,,4000,percent of total billed charges,70% of total billed charges for outpatient setting,4417.43,170,,,Fee Schedule,170% of Medicare OPPS rate,5586.76,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,976.75,12.84,,781.4,percent of total billed charges,12.84% of total billed charges,4547.37,175,,,Fee Schedule,175% of Medicare OPPS rate,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6085.68,80,,4868.54,percent of total billed charges,80% of total billed charges for outpatient setting,3637.88,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,3248.12,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,976.75,12.84,,781.4,percent of total billed charges,12.84% of total billed charges,976.75,12.84,,781.4,percent of total billed charges,12.84% of total billed charges,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3733,65,,2986.4,percent of total billed charges,65% of total billed charges for outpatient setting,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2598.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3077.42,100,,,Fee Schedule,100% of Custom Fee Schedule,6846.39,90,,5477.11,percent of total billed charges,90% of total billed charges for outpatient setting,976.75,6846.39,
LUBIPROSTONE (AMITIZA) 24 MCG:CAP,3303293,CDM,259,RC,,,Outpatient,,,15.37,15.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,70,,8.61,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,84.88,,10.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.69,50,,6.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.53,75,,9.22,percent of total billed charges,75% of total billed charges for outpatient setting,10.76,70,,8.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,80,,9.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.99,65,,7.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,35,,4.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.83,90,,11.06,percent of total billed charges,90% of total billed charges for outpatient setting,1.97,13.83,
LUBRIDERM: 6 0Z,3303297,CDM,259,RC,,,Outpatient,,,13.55,13.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,11.5,84.88,,9.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.78,50,,5.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.16,75,,8.13,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,80,,8.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.81,65,,7.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,35,,3.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.2,90,,9.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.2,
LUGOL'S SOLUTION: 10ML UD,3302687,CDM,259,RC,,,Outpatient,,,153.66,153.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.56,70,,86.05,percent of total billed charges,70% of total billed charges for outpatient setting,130.43,84.88,,104.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.83,50,,61.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.25,75,,92.2,percent of total billed charges,75% of total billed charges for outpatient setting,107.56,70,,86.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,12.84,,15.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.93,80,,98.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,19.73,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.88,65,,79.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.78,35,,43.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.29,90,,110.63,percent of total billed charges,90% of total billed charges for outpatient setting,19.73,138.29,
LUKENS TUBE 20CC 6 1/4IN / 888684604,6150039,CDM,272,RC,,,Outpatient,,,27.04,27.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,70,,15.14,percent of total billed charges,70% of total billed charges for outpatient setting,22.95,84.88,,18.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.52,50,,10.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.28,75,,16.22,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,70,,15.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,12.84,,2.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,80,,17.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,12.84,,2.78,percent of total billed charges,12.84% of total billed charges,3.47,12.84,,2.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.58,65,,14.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,35,,7.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.34,90,,19.47,percent of total billed charges,90% of total billed charges for outpatient setting,3.47,24.34,
LUMBAR PUNCTURE-PAIN MANAGEMENT,6100005,CDM,360,RC,,,Outpatient,,,798.54,798.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.98,70,,447.18,percent of total billed charges,70% of total billed charges for outpatient setting,677.8,84.88,,542.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,399.27,50,,319.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,598.91,75,,479.13,percent of total billed charges,75% of total billed charges for outpatient setting,558.98,70,,447.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.53,12.84,,82.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638.83,80,,511.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.53,12.84,,82.02,percent of total billed charges,12.84% of total billed charges,102.53,12.84,,82.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.49,35,,223.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,718.69,90,,574.95,percent of total billed charges,90% of total billed charges for outpatient setting,102.53,718.69,
LUMBAR PUNCTURE-PAIN MANAGEMENT,6000010,CDM,360,RC,,,Outpatient,,,1084.09,1084.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.86,70,,607.09,percent of total billed charges,70% of total billed charges for outpatient setting,920.18,84.88,,736.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,542.05,50,,433.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.07,75,,650.46,percent of total billed charges,75% of total billed charges for outpatient setting,758.86,70,,607.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,12.84,,111.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.27,80,,693.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,12.84,,111.36,percent of total billed charges,12.84% of total billed charges,139.2,12.84,,111.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.43,35,,303.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,975.68,90,,780.54,percent of total billed charges,90% of total billed charges for outpatient setting,139.2,975.68,
LUMIGAN OPTH DROPS: 2.5 ML,3302985,CDM,259,RC,,,Outpatient,,,255.6,255.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.92,70,,143.14,percent of total billed charges,70% of total billed charges for outpatient setting,216.95,84.88,,173.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.8,50,,102.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.7,75,,153.36,percent of total billed charges,75% of total billed charges for outpatient setting,178.92,70,,143.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.82,12.84,,26.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.48,80,,163.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.82,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,32.82,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.14,65,,132.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.46,35,,71.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.04,90,,184.03,percent of total billed charges,90% of total billed charges for outpatient setting,32.82,230.04,
LUNESTA (ESZOPICLONE):3 MG,3303266,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LUVOX (FLUVOXAMINE): 50 MG,3303163,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
LYME DISEASE (LYMERIX) INJ 30MCG :0.05ML,3301441,CDM,250,RC,,,Outpatient,,,169.23,169.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.46,70,,94.77,percent of total billed charges,70% of total billed charges for outpatient setting,143.64,84.88,,114.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.62,50,,67.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.92,75,,101.54,percent of total billed charges,75% of total billed charges for outpatient setting,118.46,70,,94.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,12.84,,17.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.38,80,,108.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,21.73,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110,65,,88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.23,35,,47.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.31,90,,121.85,percent of total billed charges,90% of total billed charges for outpatient setting,21.73,152.31,
LYME DISEASE (LYMERIX) SDV 30MCG :0.05ML,3301442,CDM,250,RC,,,Outpatient,,,169.23,169.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.46,70,,94.77,percent of total billed charges,70% of total billed charges for outpatient setting,143.64,84.88,,114.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.62,50,,67.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.92,75,,101.54,percent of total billed charges,75% of total billed charges for outpatient setting,118.46,70,,94.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,12.84,,17.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.38,80,,108.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,21.73,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110,65,,88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.23,35,,47.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.31,90,,121.85,percent of total billed charges,90% of total billed charges for outpatient setting,21.73,152.31,
LYME DISEASE ANTIBODIES,220510,CDM,302,RC,86618,HCPCS,Outpatient,,,76.64,68.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,65.05,84.88,,52.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.48,75,,45.98,percent of total billed charges,75% of total billed charges for outpatient setting,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.31,80,,49.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.87,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,100% of Custom Fee Schedule,68.98,90,,55.18,percent of total billed charges,90% of total billed charges for outpatient setting,17.03,68.98,
LYRICA PREGABALIN,200798,CDM,305,RC,80366,HCPCS,Outpatient,,,110.37,99.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.26,70,,61.81,percent of total billed charges,70% of total billed charges for outpatient setting,93.68,84.88,,74.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.78,75,,66.22,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,70,,61.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.17,12.84,,11.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.3,80,,70.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.17,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,14.17,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.33,90,,79.46,percent of total billed charges,90% of total billed charges for outpatient setting,14.17,99.33,
LYSOZYME,220856,CDM,302,RC,85549,HCPCS,Outpatient,,,84.38,75.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.07,70,,47.26,percent of total billed charges,70% of total billed charges for outpatient setting,71.62,84.88,,57.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.2,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,63.29,75,,50.63,percent of total billed charges,75% of total billed charges for outpatient setting,59.07,70,,47.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,80,,54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.39,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.57,100,,,Fee Schedule,100% of Custom Fee Schedule,75.94,90,,60.75,percent of total billed charges,90% of total billed charges for outpatient setting,18.75,75.94,
LYTES CARB (SALIVA SUB) SOL : 120 ML,3301443,CDM,259,RC,,,Outpatient,,,14.61,14.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,12.4,84.88,,9.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.31,50,,5.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.96,75,,8.77,percent of total billed charges,75% of total billed charges for outpatient setting,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.69,80,,9.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.5,65,,7.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,35,,4.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.15,90,,10.52,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.15,
MAALOX T.C. LIQ : 150ML,3302659,CDM,259,RC,,,Outpatient,,,13.55,13.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,11.5,84.88,,9.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.78,50,,5.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.16,75,,8.13,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,70,,7.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.84,80,,8.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.81,65,,7.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,35,,3.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.2,90,,9.76,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.2,
MACROBID 100MG: CAP,3302829,CDM,259,RC,,,Outpatient,,,10.42,10.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,84.88,,7.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.21,50,,4.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.82,75,,6.26,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,70,,5.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,80,,6.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,1.34,12.84,,1.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.77,65,,5.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,35,,2.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.38,90,,7.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.34,9.38,
MACROPLASTIQUE INJ 2.5ML / MPQ-2.5,69162547,CDM,274,RC,L8606,HCPCS,Outpatient,,,2061.68,2061.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.18,70,,1154.54,percent of total billed charges,70% of total billed charges for outpatient setting,1749.95,84.88,,1399.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1030.84,50,,824.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1546.26,75,,1237.01,percent of total billed charges,75% of total billed charges for outpatient setting,1030.84,50,,824.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.72,12.84,,211.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1649.34,80,,1319.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.72,12.84,,211.78,percent of total billed charges,12.84% of total billed charges,264.72,12.84,,211.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2061.68,65,,1649.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1855.51,90,,1484.41,percent of total billed charges,90% of total billed charges for outpatient setting,264.72,2061.68,
MAG CARB ALUM SUSP 355ML(GAVISCON GENERI,3301444,CDM,259,RC,,,Outpatient,,,27.43,27.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,70,,15.36,percent of total billed charges,70% of total billed charges for outpatient setting,23.28,84.88,,18.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.72,50,,10.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.57,75,,16.46,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,70,,15.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.52,12.84,,2.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.94,80,,17.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.52,12.84,,2.82,percent of total billed charges,12.84% of total billed charges,3.52,12.84,,2.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.83,65,,14.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,35,,7.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.69,90,,19.75,percent of total billed charges,90% of total billed charges for outpatient setting,3.52,24.69,
MAG HYDRO AL (MAALOX PLUS) LIQ : 30ML UD,3301446,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MAG HYDROX AL SIM(genMAALOXmax) 12oz,3301445,CDM,259,RC,,,Outpatient,,,27.76,27.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,70,,15.54,percent of total billed charges,70% of total billed charges for outpatient setting,23.56,84.88,,18.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.88,50,,11.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.82,75,,16.66,percent of total billed charges,75% of total billed charges for outpatient setting,19.43,70,,15.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,12.84,,2.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.21,80,,17.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,12.84,,2.85,percent of total billed charges,12.84% of total billed charges,3.56,12.84,,2.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.04,65,,14.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,35,,7.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,90% of total billed charges for outpatient setting,3.56,24.98,
MAG HYDROX AL SIM(genMAALOXmax) 30MLchg,3301447,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MAG TRISIL AL (GAVISCON FOAM) TAB :,3301448,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MAG/AL/SIM (genericMAALOX) 355ML,3302684,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
MAGNEBIND 400 RX TAB 200MG-1MG-400MG {20,3303102,CDM,250,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MAGNESIUM,200510,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
MAGNESIUM,201201,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
MAGNESIUM,220265,CDM,300,RC,83735,HCPCS,Outpatient,,,31.91,28.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,70,,17.87,percent of total billed charges,70% of total billed charges for outpatient setting,27.09,84.88,,21.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.93,75,,19.14,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,70,,17.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.53,80,,20.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,28.72,90,,22.98,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,28.72,
MAGNESIUM CHLORIDE (MAGDELAY) TAB: 64 MG,3301450,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MAGNESIUM CITRATE SOLN 296ML,3301451,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MAGNESIUM GLUC (MAGNESIUM) TAB : 27MG,3301452,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
MAGNESIUM GLUCONATE (MAGTRATE) TAB: 500,3301453,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MAGNESIUM OX (MAG OXIDE) TAB 400 MG,3301457,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MAGNESIUM OX (MAG-OXIDE) TAB: 400 MG,3301458,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MAGNESIUM SULF SDV 50% : 10ML,3301459,CDM,250,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MAGNESIUM SULF SDV 50% : 20ML,3301461,CDM,250,RC,,,Outpatient,,,16.72,16.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.7,70,,9.36,percent of total billed charges,70% of total billed charges for outpatient setting,14.19,84.88,,11.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.36,50,,6.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.54,75,,10.03,percent of total billed charges,75% of total billed charges for outpatient setting,11.7,70,,9.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.38,80,,10.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,2.15,12.84,,1.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.87,65,,8.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.85,35,,4.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.05,90,,12.04,percent of total billed charges,90% of total billed charges for outpatient setting,2.15,15.05,
MAGNESIUM SULF SDV 50% 2ML,3301460,CDM,636,RC,J3475,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MAGNESIUM SULFATE 1 GM/100ML D5W,3302906,CDM,250,RC,J3475,HCPCS,Outpatient,,,39.63,39.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.74,70,,22.19,percent of total billed charges,70% of total billed charges for outpatient setting,33.64,84.88,,26.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.72,75,,23.78,percent of total billed charges,75% of total billed charges for outpatient setting,27.74,70,,22.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,12.84,,4.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,80,,25.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,12.84,,4.07,percent of total billed charges,12.84% of total billed charges,5.09,12.84,,4.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.76,65,,20.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,100,,,Fee Schedule,100% of Custom Fee Schedule,35.67,90,,28.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,35.67,
"MAGNESIUM, RBC",220920,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
MAGNETIC PAD / 25-001,6152187,CDM,270,RC,,,Outpatient,,,36.72,36.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,31.17,84.88,,24.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.36,50,,14.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.54,75,,22.03,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,80,,23.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.87,65,,19.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,35,,10.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.05,90,,26.44,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,33.05,
MAGNETIC RESONANCE IMAGING TEMPO,2400115,CDM,610,RC,70336,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MAGNETIC RESONANCE IMG GUID FOR AND,2100290,CDM,610,RC,77022,HCPCS,Outpatient,,,528.58,528.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.01,70,,296.01,percent of total billed charges,70% of total billed charges for outpatient setting,448.66,84.88,,358.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.44,75,,317.15,percent of total billed charges,75% of total billed charges for outpatient setting,370.01,70,,296.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.87,12.84,,54.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.86,80,,338.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.87,12.84,,54.3,percent of total billed charges,12.84% of total billed charges,67.87,12.84,,54.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.72,90,,380.58,percent of total billed charges,90% of total billed charges for outpatient setting,67.87,1937,
MAGNETIC RESONANCE IMG GUID FOR NDL,2100285,CDM,610,RC,77021,HCPCS,Outpatient,,,881.14,881.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.8,70,,493.44,percent of total billed charges,70% of total billed charges for outpatient setting,747.91,84.88,,598.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.86,75,,528.69,percent of total billed charges,75% of total billed charges for outpatient setting,616.8,70,,493.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.14,12.84,,90.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.91,80,,563.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.14,12.84,,90.51,percent of total billed charges,12.84% of total billed charges,113.14,12.84,,90.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.03,90,,634.42,percent of total billed charges,90% of total billed charges for outpatient setting,113.14,1937,
"M-ALBUMIN, SERUM",221052,CDM,300,RC,82040,HCPCS,Outpatient,,,22.28,20.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,84.88,,15.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.71,75,,13.37,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,70,,12.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,80,,14.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.38,100,,,Fee Schedule,100% of Custom Fee Schedule,20.05,90,,16.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,20.05,
MALCITONIN (MIACALCIN) INJ 200U/ML : 2ML,3300722,CDM,250,RC,,,Outpatient,,,117.65,117.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.36,70,,65.89,percent of total billed charges,70% of total billed charges for outpatient setting,99.86,84.88,,79.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.83,50,,47.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.24,75,,70.59,percent of total billed charges,75% of total billed charges for outpatient setting,82.36,70,,65.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.11,12.84,,12.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.12,80,,75.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.11,12.84,,12.09,percent of total billed charges,12.84% of total billed charges,15.11,12.84,,12.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.47,65,,61.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,35,,32.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.89,90,,84.71,percent of total billed charges,90% of total billed charges for outpatient setting,15.11,105.89,
MALYUGIN RING 2.0-6.25MM / MAL-1001,69169485,CDM,272,RC,,,Outpatient,,,583.32,583.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.32,70,,326.66,percent of total billed charges,70% of total billed charges for outpatient setting,495.12,84.88,,396.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,291.66,50,,233.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437.49,75,,349.99,percent of total billed charges,75% of total billed charges for outpatient setting,408.32,70,,326.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.9,12.84,,59.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.66,80,,373.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.9,12.84,,59.92,percent of total billed charges,12.84% of total billed charges,74.9,12.84,,59.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,379.16,65,,303.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.16,35,,163.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,524.99,90,,419.99,percent of total billed charges,90% of total billed charges for outpatient setting,74.9,524.99,
MALYUGIN RING 2.0-7.0MM MST / MAL-1002,69161464,CDM,272,RC,,,Outpatient,,,559.27,559.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.49,70,,313.19,percent of total billed charges,70% of total billed charges for outpatient setting,474.71,84.88,,379.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,279.64,50,,223.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,419.45,75,,335.56,percent of total billed charges,75% of total billed charges for outpatient setting,391.49,70,,313.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.81,12.84,,57.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.42,80,,357.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.81,12.84,,57.45,percent of total billed charges,12.84% of total billed charges,71.81,12.84,,57.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,363.53,65,,290.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.74,35,,156.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,503.34,90,,402.67,percent of total billed charges,90% of total billed charges for outpatient setting,71.81,503.34,
MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPL,2700015,CDM,401,RC,77054,HCPCS,Outpatient,,,717.13,717.13,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE,2700010,CDM,401,RC,77053,HCPCS,Outpatient,,,717.13,717.13,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
MAMMO BIL SCREEN READING FEE PP,2710046,CDM,972,RC,77067,HCPCS,Outpatient,,,177.5,177.5,,82.31,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,84.88,,142,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,75,,142,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.5,100,,142,percent of total billed charges,100% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.31,175,,,Fee Schedule,175% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.31,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,65,,142,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.31,177.5,
MAMMOGRAPHY IMPLANTS,2700031,CDM,401,RC,77066,HCPCS,Outpatient,,,328.37,328.37,,158.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,278.72,84.88,,222.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,151.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.28,75,,197.02,percent of total billed charges,75% of total billed charges for outpatient setting,229.86,70,,183.89,percent of total billed charges,70% of total billed charges for outpatient setting,340.29,170,,,Fee Schedule,170% of Medicare OPPS rate,213.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.16,12.84,,33.728,percent of total billed charges,12.84% of total billed charges,173.65,175,,,Fee Schedule,175% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.7,80,,210.16,percent of total billed charges,80% of total billed charges for outpatient setting,138.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,124.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,42.16,12.84,,33.73,percent of total billed charges,12.84% of total billed charges,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,165.17,100,,,Fee Schedule,100% of Custom Fee Schedule,295.53,90,,236.42,percent of total billed charges,90% of total billed charges for outpatient setting,42.16,340.29,
MAMMOGRAPHY UNILATERAL DIAGNOSTIC,2700020,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
MAMMOGRAPHY UNILATERAL DX - LTD,2700021,CDM,401,RC,77065,HCPCS,Outpatient,,,301.5,301.5,,124.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,267.02,170,,,Fee Schedule,170% of Medicare OPPS rate,167.4,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,136.26,175,,,Fee Schedule,175% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,109,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,97.33,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.86,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,130.54,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.71,271.35,
M-AMYLASE,221011,CDM,300,RC,82150,HCPCS,Outpatient,,,29.16,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,24.75,84.88,,19.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.87,75,,17.5,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,80,,18.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of Custom Fee Schedule,26.24,90,,20.99,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,26.24,
MANDIBLE 4+ VWS,2400030,CDM,320,RC,70110,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MANDIBLE LESS THAN 4 VIEWS,2400025,CDM,320,RC,70100,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
"MANGANESE, BLOOD",201564,CDM,301,RC,83785,HCPCS,Outpatient,,,119.93,107.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.95,70,,67.16,percent of total billed charges,70% of total billed charges for outpatient setting,101.8,84.88,,81.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,89.95,75,,71.96,percent of total billed charges,75% of total billed charges for outpatient setting,83.95,70,,67.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.94,80,,76.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,35.9,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.44,100,,,Fee Schedule,100% of Custom Fee Schedule,107.94,90,,86.35,percent of total billed charges,90% of total billed charges for outpatient setting,25.98,107.94,
MANNITOL 20% SOLN: 500ML,3302500,CDM,258,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MANNITOL SDV 25% : 50ML,3301462,CDM,250,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MARKER 14G BREAST BIOP / SMUC10R,1766614,CDM,272,RC,,,Outpatient,,,270.2,270.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.14,70,,151.31,percent of total billed charges,70% of total billed charges for outpatient setting,229.35,84.88,,183.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,135.1,50,,108.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.65,75,,162.12,percent of total billed charges,75% of total billed charges for outpatient setting,189.14,70,,151.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.69,12.84,,27.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.16,80,,172.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.69,12.84,,27.75,percent of total billed charges,12.84% of total billed charges,34.69,12.84,,27.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.63,65,,140.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.57,35,,75.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,243.18,90,,194.54,percent of total billed charges,90% of total billed charges for outpatient setting,34.69,243.18,
MARKER FIDUCIAL GOLD 1X5MM W/ NDL,70000580,CDM,270,RC,A4648,HCPCS,Outpatient,,,532.1,532.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.47,70,,297.98,percent of total billed charges,70% of total billed charges for outpatient setting,451.65,84.88,,361.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.08,75,,319.26,percent of total billed charges,75% of total billed charges for outpatient setting,372.47,70,,297.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,12.84,,54.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.68,80,,340.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,12.84,,54.66,percent of total billed charges,12.84% of total billed charges,68.32,12.84,,54.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,345.87,65,,276.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.24,35,,148.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,478.89,90,,383.11,percent of total billed charges,90% of total billed charges for outpatient setting,68.32,478.89,
MARKER SKIN MINI XL STERILE / 250P,6150044,CDM,270,RC,,,Outpatient,,,4.41,4.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,70,,2.47,percent of total billed charges,70% of total billed charges for outpatient setting,3.74,84.88,,2.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.21,50,,1.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.31,75,,2.65,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,70,,2.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,80,,2.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.87,65,,2.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,35,,1.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.97,90,,3.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,3.97,
MARKER SURGICAL TREAD NS / 1451,265413,CDM,271,RC,,,Outpatient,,,2.28,2.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,70,,1.28,percent of total billed charges,70% of total billed charges for outpatient setting,1.94,84.88,,1.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.14,50,,0.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.71,75,,1.37,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,70,,1.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,12.84,,0.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,80,,1.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,12.84,,0.23,percent of total billed charges,12.84% of total billed charges,0.29,12.84,,0.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.48,65,,1.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,35,,0.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.05,90,,1.64,percent of total billed charges,90% of total billed charges for outpatient setting,0.29,2.05,
MARKER SURGI-MARK / 31145884,69162916,CDM,272,RC,,,Outpatient,,,6.36,6.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.45,70,,3.56,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,84.88,,4.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.18,50,,2.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.77,75,,3.82,percent of total billed charges,75% of total billed charges for outpatient setting,4.45,70,,3.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.82,12.84,,0.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,80,,4.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.82,12.84,,0.66,percent of total billed charges,12.84% of total billed charges,0.82,12.84,,0.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.13,65,,3.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.23,35,,1.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.72,90,,4.58,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,5.72,
MARKING PEN W/RULER REG TIP / 31145785,69161750,CDM,272,RC,,,Outpatient,,,4.32,4.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,84.88,,2.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.16,50,,1.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.24,75,,2.59,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,80,,2.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.81,65,,2.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,35,,1.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.89,90,,3.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.89,
MARS PORT 110mm 632.031,69162209,CDM,272,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2384.71,70,,1907.77,percent of total billed charges,70% of total billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2214.37,65,,1771.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3066.06,90,,2452.85,percent of total billed charges,90% of total billed charges for outpatient setting,437.42,3066.06,
MARS PORT 19mm x 100mm 632.030,69162151,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 19mm x 50mm 632.045,69162139,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 19mm x 60mm 632.046,69162076,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 22MM x 40MM 632.024,69162313,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 22mm x 9mm 632.029,69162147,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 22x8mm 632.028,69162250,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 50MM 632.025,69162293,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 60MM  632.446S,69162033,CDM,272,RC,,,Outpatient,,,2172.73,2172.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1520.91,70,,1216.73,percent of total billed charges,70% of total billed charges for outpatient setting,1844.21,84.88,,1475.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1086.37,50,,869.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1629.55,75,,1303.64,percent of total billed charges,75% of total billed charges for outpatient setting,1520.91,70,,1216.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.98,12.84,,223.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1738.18,80,,1390.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.98,12.84,,223.18,percent of total billed charges,12.84% of total billed charges,278.98,12.84,,223.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1412.27,65,,1129.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.46,35,,608.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1955.46,90,,1564.37,percent of total billed charges,90% of total billed charges for outpatient setting,278.98,1955.46,
MARS PORT 60MM 632.026,69162272,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MARS PORT 90MM  632.069,69162177,CDM,272,RC,,,Outpatient,,,3633.84,3633.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2543.69,70,,2034.95,percent of total billed charges,70% of total billed charges for outpatient setting,3084.4,84.88,,2467.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,1816.92,50,,1453.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.38,75,,2180.3,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.07,80,,2325.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,466.59,12.84,,373.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2362,65,,1889.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.84,35,,1017.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3270.46,90,,2616.37,percent of total billed charges,90% of total billed charges for outpatient setting,466.59,3270.46,
MASK 3 IN 1 ADULT 7 FT TUBING  / 1061,69162406,CDM,271,RC,,,Outpatient,,,24.14,24.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.9,70,,13.52,percent of total billed charges,70% of total billed charges for outpatient setting,20.49,84.88,,16.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.07,50,,9.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.11,75,,14.49,percent of total billed charges,75% of total billed charges for outpatient setting,16.9,70,,13.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,80,,15.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,3.1,12.84,,2.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.69,65,,12.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.45,35,,6.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.73,90,,17.38,percent of total billed charges,90% of total billed charges for outpatient setting,3.1,21.73,
MASK 7FT OXYGEN ADULT MED / 001361,834475,CDM,272,RC,,,Outpatient,,,5.67,5.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,70,,3.18,percent of total billed charges,70% of total billed charges for outpatient setting,4.81,84.88,,3.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.84,50,,2.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.25,75,,3.4,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,70,,3.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,80,,3.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.69,65,,2.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,35,,1.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.1,90,,4.08,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,5.1,
MASK CHILD SZ 3 BUBBLEGUM  / 1132,5050157,CDM,270,RC,,,Outpatient,,,11.23,11.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,70,,6.29,percent of total billed charges,70% of total billed charges for outpatient setting,9.53,84.88,,7.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.62,50,,4.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,75,,6.74,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,70,,6.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.98,80,,7.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.3,65,,5.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,35,,3.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.11,90,,8.09,percent of total billed charges,90% of total billed charges for outpatient setting,1.44,10.11,
MASK CHILD SZ4 BUBBLEGUM / 1145,5050206,CDM,272,RC,,,Outpatient,,,11.16,11.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,70,,6.25,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,84.88,,7.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.58,50,,4.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.37,75,,6.7,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,70,,6.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,80,,7.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.25,65,,5.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,35,,3.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.04,90,,8.03,percent of total billed charges,90% of total billed charges for outpatient setting,1.43,10.04,
MASK DUAL DIAL VENTURI/001255,5050216,CDM,270,RC,,,Outpatient,,,12.02,12.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,70,,6.73,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,84.88,,8.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.01,50,,4.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.02,75,,7.22,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,70,,6.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.62,80,,7.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.81,65,,6.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,35,,3.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.82,90,,8.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.82,
MASK INFANT SZ 2 BUBBLEGUM / K1122,5050156,CDM,270,RC,,,Outpatient,,,27.26,27.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,70,,15.26,percent of total billed charges,70% of total billed charges for outpatient setting,23.14,84.88,,18.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.63,50,,10.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.45,75,,16.36,percent of total billed charges,75% of total billed charges for outpatient setting,19.08,70,,15.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,12.84,,2.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.81,80,,17.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,12.84,,2.8,percent of total billed charges,12.84% of total billed charges,3.5,12.84,,2.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.72,65,,14.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,35,,7.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.53,90,,19.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,24.53,
MASK MED ADULT SZ 5 / 1055,6150008,CDM,270,RC,,,Outpatient,,,9.59,9.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.71,70,,5.37,percent of total billed charges,70% of total billed charges for outpatient setting,8.14,84.88,,6.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.8,50,,3.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.19,75,,5.75,percent of total billed charges,75% of total billed charges for outpatient setting,6.71,70,,5.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.23,12.84,,0.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.67,80,,6.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.23,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.23,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.23,65,,4.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,35,,2.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.63,90,,6.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.23,8.63,
MASK OXY PED MD UND CHIN / 1042,5050003,CDM,270,RC,,,Outpatient,,,4.95,4.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,70,,2.78,percent of total billed charges,70% of total billed charges for outpatient setting,4.2,84.88,,3.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.48,50,,1.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.71,75,,2.97,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,70,,2.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,80,,3.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,0.64,12.84,,0.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.22,65,,2.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.46,90,,3.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.64,4.46,
MASK OXYGEN AD HI CONC N/REBR,5050001,CDM,270,RC,,,Outpatient,,,6.56,6.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,70,,3.67,percent of total billed charges,70% of total billed charges for outpatient setting,5.57,84.88,,4.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.28,50,,2.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.92,75,,3.94,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,70,,3.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,80,,4.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,0.84,12.84,,0.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.26,65,,3.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,35,,1.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.9,90,,4.72,percent of total billed charges,90% of total billed charges for outpatient setting,0.84,5.9,
MASK OXYGEN ADULT M CONC W/7 TUBING,5050000,CDM,270,RC,,,Outpatient,,,3.78,3.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,70,,2.12,percent of total billed charges,70% of total billed charges for outpatient setting,3.21,84.88,,2.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.89,50,,1.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.84,75,,2.27,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,70,,2.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,80,,2.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.46,65,,1.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,35,,1.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.4,90,,2.72,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,3.4,
MASK OXYGEN W/TUBING / 001201,5150000,CDM,270,RC,A4620,HCPCS,Outpatient,,,5.94,5.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,70,,3.33,percent of total billed charges,70% of total billed charges for outpatient setting,5.04,84.88,,4.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,75,,3.57,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,70,,3.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,80,,3.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.86,65,,3.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,90,,4.28,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.35,
MASK SZ 3 CHERRY,761940,CDM,270,RC,,,Outpatient,,,18.82,18.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.17,70,,10.54,percent of total billed charges,70% of total billed charges for outpatient setting,15.97,84.88,,12.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.41,50,,7.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.12,75,,11.3,percent of total billed charges,75% of total billed charges for outpatient setting,13.17,70,,10.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,12.84,,1.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.06,80,,12.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.42,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.23,65,,9.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,35,,5.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.94,90,,13.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.42,16.94,
MASTISOL ADHESIVE VIAL 3CC / 0496-0523-4,69162292,CDM,272,RC,,,Outpatient,,,14.22,14.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,84.88,,9.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.11,50,,5.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.67,75,,8.54,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,80,,9.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.24,65,,7.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,35,,3.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.8,90,,10.24,percent of total billed charges,90% of total billed charges for outpatient setting,1.83,12.8,
MASTOID COMPLETE,2400040,CDM,320,RC,70130,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MASTOID LESS THAN THREE VIEWS PER SIDE,2400035,CDM,320,RC,70120,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MAT FLOOR SUCTION / 34500,69160720,CDM,271,RC,,,Outpatient,,,151.88,151.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.32,70,,85.06,percent of total billed charges,70% of total billed charges for outpatient setting,128.92,84.88,,103.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.94,50,,60.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.91,75,,91.13,percent of total billed charges,75% of total billed charges for outpatient setting,106.32,70,,85.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,12.84,,15.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,80,,97.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,12.84,,15.6,percent of total billed charges,12.84% of total billed charges,19.5,12.84,,15.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.72,65,,78.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.16,35,,42.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.69,90,,109.35,percent of total billed charges,90% of total billed charges for outpatient setting,19.5,136.69,
MATRIX 10CC OSTEOCONDUCTIVE / OCMP10,69161747,CDM,278,RC,C9359,HCPCS,Outpatient,,,2625,2625,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,60,,1260,percent of total billed charges,60% of total Billed charges for outpatient setting,2228.1,84.88,,1782.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1968.75,75,,1575,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,50,,1050,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,80,,1680,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,337.05,12.84,,269.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2756.25,105,,2205,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.75,35,,735,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1575,60,,1260,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2756.25,
MATRIX 10X10CM GENTRIX PLUS /MSPL1010,69169103,CDM,278,RC,Q4118,HCPCS,Outpatient,,,5796,5796,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3477.6,60,,2782.08,percent of total billed charges,60% of total Billed charges for outpatient setting,4919.64,84.88,,3935.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,4347,75,,3477.6,percent of total billed charges,75% of total billed charges for outpatient setting,2898,50,,2318.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.21,12.84,,595.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4636.8,80,,3709.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.21,12.84,,595.37,percent of total billed charges,12.84% of total billed charges,744.21,12.84,,595.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6085.8,105,,4868.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3477.6,60,,2782.08,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,6085.8,
MATRIX 10X15CM GENTRIX PLUS /PSMX1015,69162915,CDM,278,RC,Q4118,HCPCS,Outpatient,,,7678.76,7678.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4607.26,60,,3685.81,percent of total billed charges,60% of total Billed charges for outpatient setting,6517.73,84.88,,5214.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,5759.07,75,,4607.26,percent of total billed charges,75% of total billed charges for outpatient setting,3839.38,50,,3071.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.95,12.84,,788.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6143.01,80,,4914.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.95,12.84,,788.76,percent of total billed charges,12.84% of total billed charges,985.95,12.84,,788.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8062.7,105,,6450.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4607.26,60,,3685.81,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,8062.7,
MATRIX 10x15CM GENTRIX PLUS/MSPL1015,69162874,CDM,278,RC,Q4118,HCPCS,Outpatient,,,8694,8694,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5216.4,60,,4173.12,percent of total billed charges,60% of total Billed charges for outpatient setting,7379.47,84.88,,5903.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,6520.5,75,,5216.4,percent of total billed charges,75% of total billed charges for outpatient setting,4347,50,,3477.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.31,12.84,,893.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6955.2,80,,5564.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.31,12.84,,893.05,percent of total billed charges,12.84% of total billed charges,1116.31,12.84,,893.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9128.7,105,,7302.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5216.4,60,,4173.12,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,9128.7,
MATRIX 4X12CM PELVIC FLOOR/PFM0412,69162752,CDM,278,RC,Q4118,HCPCS,Outpatient,,,1483.97,1483.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.38,60,,712.3,percent of total billed charges,60% of total Billed charges for outpatient setting,1259.59,84.88,,1007.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1112.98,75,,890.38,percent of total billed charges,75% of total billed charges for outpatient setting,741.99,50,,593.59,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,12.84,,152.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1187.18,80,,949.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,12.84,,152.43,percent of total billed charges,12.84% of total billed charges,190.54,12.84,,152.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1483.97,65,,1187.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.38,60,,712.3,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,1483.97,
MATRIX 7X10CM GENTRIX PLUS /MSPL0710,69162885,CDM,278,RC,Q4118,HCPCS,Outpatient,,,3283.14,3283.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1969.88,60,,1575.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2786.73,84.88,,2229.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2462.36,75,,1969.89,percent of total billed charges,75% of total billed charges for outpatient setting,1641.57,50,,1313.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.56,12.84,,337.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2626.51,80,,2101.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.56,12.84,,337.25,percent of total billed charges,12.84% of total billed charges,421.56,12.84,,337.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3447.3,105,,2757.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1969.88,60,,1575.9,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,3447.3,
MATRIX 9X12CM PELVIC FLOOR/PFM0912,69162750,CDM,278,RC,Q4118,HCPCS,Outpatient,,,3974.4,3974.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2384.64,60,,1907.71,percent of total billed charges,60% of total Billed charges for outpatient setting,3373.47,84.88,,2698.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2980.8,75,,2384.64,percent of total billed charges,75% of total billed charges for outpatient setting,1987.2,50,,1589.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.31,12.84,,408.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3179.52,80,,2543.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.31,12.84,,408.25,percent of total billed charges,12.84% of total billed charges,510.31,12.84,,408.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4173.12,105,,3338.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2384.64,60,,1907.71,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,4173.12,
MAX CORE BIOPSY 16GX16CM/ MC1616,69169474,CDM,270,RC,,,Outpatient,,,161.95,161.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,137.46,84.88,,109.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.98,50,,64.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.46,75,,97.17,percent of total billed charges,75% of total billed charges for outpatient setting,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,12.84,,16.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.56,80,,103.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,12.84,,16.63,percent of total billed charges,12.84% of total billed charges,20.79,12.84,,16.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.27,65,,84.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.68,35,,45.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.76,90,,116.61,percent of total billed charges,90% of total billed charges for outpatient setting,20.79,145.76,
MAX CORE BX INST / MC1410,2350012,CDM,272,RC,,,Outpatient,,,161.95,161.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,137.46,84.88,,109.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.98,50,,64.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.46,75,,97.17,percent of total billed charges,75% of total billed charges for outpatient setting,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,12.84,,16.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.56,80,,103.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,12.84,,16.63,percent of total billed charges,12.84% of total billed charges,20.79,12.84,,16.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.27,65,,84.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.68,35,,45.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.76,90,,116.61,percent of total billed charges,90% of total billed charges for outpatient setting,20.79,145.76,
MAX CORE BX INST / MC1810,69169099,CDM,270,RC,,,Outpatient,,,229.05,229.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.34,70,,128.27,percent of total billed charges,70% of total billed charges for outpatient setting,194.42,84.88,,155.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.53,50,,91.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.79,75,,137.43,percent of total billed charges,75% of total billed charges for outpatient setting,160.34,70,,128.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.41,12.84,,23.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.24,80,,146.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.41,12.84,,23.53,percent of total billed charges,12.84% of total billed charges,29.41,12.84,,23.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.88,65,,119.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.17,35,,64.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.15,90,,164.92,percent of total billed charges,90% of total billed charges for outpatient setting,29.41,206.15,
MAX CORE BX INST 20GX10 / MC2010,70000811,CDM,270,RC,,,Outpatient,,,224.95,224.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.47,70,,125.98,percent of total billed charges,70% of total billed charges for outpatient setting,190.94,84.88,,152.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.48,50,,89.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.71,75,,134.97,percent of total billed charges,75% of total billed charges for outpatient setting,157.47,70,,125.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.88,12.84,,23.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.96,80,,143.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.88,12.84,,23.1,percent of total billed charges,12.84% of total billed charges,28.88,12.84,,23.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.22,65,,116.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.73,35,,62.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.46,90,,161.97,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,202.46,
MAXCORE BIOPSY 18G 16CM  / MC1816,70000046,CDM,270,RC,,,Outpatient,,,229.05,229.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.34,70,,128.27,percent of total billed charges,70% of total billed charges for outpatient setting,194.42,84.88,,155.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.53,50,,91.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.79,75,,137.43,percent of total billed charges,75% of total billed charges for outpatient setting,160.34,70,,128.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.41,12.84,,23.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.24,80,,146.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.41,12.84,,23.53,percent of total billed charges,12.84% of total billed charges,29.41,12.84,,23.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.88,65,,119.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.17,35,,64.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.15,90,,164.92,percent of total billed charges,90% of total billed charges for outpatient setting,29.41,206.15,
MAXILLARY BALLOON SZ 5 SINS / 1830507MAX,69161897,CDM,272,RC,,,Outpatient,,,1903.44,1903.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1332.41,70,,1065.93,percent of total billed charges,70% of total billed charges for outpatient setting,1615.64,84.88,,1292.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,951.72,50,,761.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1427.58,75,,1142.06,percent of total billed charges,75% of total billed charges for outpatient setting,1332.41,70,,1065.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.75,80,,1218.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1237.24,65,,989.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.2,35,,532.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1713.1,90,,1370.48,percent of total billed charges,90% of total billed charges for outpatient setting,244.4,1713.1,
MAXILLARY BALLOON SZ 6 SINUS /1830607MAX,69161916,CDM,272,RC,,,Outpatient,,,1903.44,1903.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1332.41,70,,1065.93,percent of total billed charges,70% of total billed charges for outpatient setting,1615.64,84.88,,1292.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,951.72,50,,761.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1427.58,75,,1142.06,percent of total billed charges,75% of total billed charges for outpatient setting,1332.41,70,,1065.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.75,80,,1218.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,244.4,12.84,,195.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1237.24,65,,989.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.2,35,,532.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1713.1,90,,1370.48,percent of total billed charges,90% of total billed charges for outpatient setting,244.4,1713.1,
MAXILLARY BALLOON SZ 7 SINUS /1830707MAX,69161910,CDM,272,RC,,,Outpatient,,,1483,1483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,70,,830.48,percent of total billed charges,70% of total billed charges for outpatient setting,1258.77,84.88,,1007.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,741.5,50,,593.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1112.25,75,,889.8,percent of total billed charges,75% of total billed charges for outpatient setting,1038.1,70,,830.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.42,12.84,,152.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.4,80,,949.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.42,12.84,,152.34,percent of total billed charges,12.84% of total billed charges,190.42,12.84,,152.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,963.95,65,,771.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.05,35,,415.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1334.7,90,,1067.76,percent of total billed charges,90% of total billed charges for outpatient setting,190.42,1334.7,
MAXITROL: OPTH SUSP,3303233,CDM,259,RC,,,Outpatient,,,36.68,36.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,70,,20.54,percent of total billed charges,70% of total billed charges for outpatient setting,31.13,84.88,,24.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.34,50,,14.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.51,75,,22.01,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,70,,20.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.34,80,,23.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.84,65,,19.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.84,35,,10.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.01,90,,26.41,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,33.01,
MAYO COVER LARGE 29X55IN / 8339,226915,CDM,272,RC,,,Outpatient,,,14.58,14.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,70,,8.17,percent of total billed charges,70% of total billed charges for outpatient setting,12.38,84.88,,9.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.29,50,,5.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.94,75,,8.75,percent of total billed charges,75% of total billed charges for outpatient setting,10.21,70,,8.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.66,80,,9.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.48,65,,7.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,35,,4.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.12,90,,10.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,13.12,
MAYO COVER REGULAR SIZE / 8337,6150176,CDM,272,RC,,,Outpatient,,,6.75,6.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.73,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.38,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,80,,4.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.39,65,,3.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.08,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.08,
MAYO NEEDLE SIZE 4 1/2IN / SN10-004,6152570,CDM,272,RC,,,Outpatient,,,29.42,29.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.59,70,,16.47,percent of total billed charges,70% of total billed charges for outpatient setting,24.97,84.88,,19.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.71,50,,11.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.07,75,,17.66,percent of total billed charges,75% of total billed charges for outpatient setting,20.59,70,,16.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.54,80,,18.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.12,65,,15.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,35,,8.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.48,90,,21.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.78,26.48,
MAYO NEEDLE SIZE 5 3/8IN / 216705,6152569,CDM,272,RC,,,Outpatient,,,40.11,40.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.08,70,,22.46,percent of total billed charges,70% of total billed charges for outpatient setting,34.05,84.88,,27.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.06,50,,16.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.08,75,,24.06,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,70,,22.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.15,12.84,,4.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.09,80,,25.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.15,12.84,,4.12,percent of total billed charges,12.84% of total billed charges,5.15,12.84,,4.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.07,65,,20.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,35,,11.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.1,90,,28.88,percent of total billed charges,90% of total billed charges for outpatient setting,5.15,36.1,
MAYO NEEDLE SIZE 7 / 6-707-7,6153006,CDM,272,RC,,,Outpatient,,,25.62,25.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.93,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,21.75,84.88,,17.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.81,50,,10.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.22,75,,15.38,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.5,80,,16.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.65,65,,13.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,35,,7.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.06,90,,18.45,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,23.06,
M-BMP W/eGFR,221036,CDM,300,RC,80048,HCPCS,Outpatient,,,38.07,34.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,32.31,84.88,,25.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.55,75,,22.84,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,70,,21.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.46,80,,24.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,100,,,Fee Schedule,100% of Custom Fee Schedule,34.26,90,,27.41,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,34.26,
MBP COLONOSCOPY,6000095,CDM,750,RC,45378,HCPCS,Outpatient,,,920,920,,1137.8,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,644,70,,515.2,percent of total billed charges,70% of total billed charges for outpatient setting,780.9,84.88,,624.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,987.44,50,,789.95,percent of total billed charges,50% of total Billed charges for outpatient setting,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,690,75,,552,percent of total billed charges,75% of total billed charges for outpatient setting,644,70,,515.2,percent of total billed charges,70% of total billed charges for outpatient setting,1208.91,170,,,Fee Schedule,170% of Medicare OPPS rate,1528.93,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,118.13,12.84,,94.504,percent of total billed charges,12.84% of total billed charges,1244.48,175,,,Fee Schedule,175% of Medicare OPPS rate,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,736,80,,588.8,percent of total billed charges,80% of total billed charges for outpatient setting,995.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,888.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,118.13,12.84,,94.5,percent of total billed charges,12.84% of total billed charges,118.13,12.84,,94.5,percent of total billed charges,12.84% of total billed charges,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1129,65,,903.2,percent of total billed charges,65% of total billed charges for outpatient setting,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,711.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.53,100,,,Fee Schedule,100% of Custom Fee Schedule,828,90,,662.4,percent of total billed charges,90% of total billed charges for outpatient setting,118.13,1528.93,
MBP COLONOSCOPY W/BIOPSY,6000096,CDM,750,RC,45380,HCPCS,Outpatient,,,920,920,,1486.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,644,70,,515.2,percent of total billed charges,70% of total billed charges for outpatient setting,780.9,84.88,,624.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1302.33,50,,1041.86,percent of total billed charges,50% of total Billed charges for outpatient setting,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,690,75,,552,percent of total billed charges,75% of total billed charges for outpatient setting,644,70,,515.2,percent of total billed charges,70% of total billed charges for outpatient setting,1579.7,170,,,Fee Schedule,170% of Medicare OPPS rate,1997.85,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,118.13,12.84,,94.504,percent of total billed charges,12.84% of total billed charges,1626.16,175,,,Fee Schedule,175% of Medicare OPPS rate,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,736,80,,588.8,percent of total billed charges,80% of total billed charges for outpatient setting,1300.93,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1161.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,118.13,12.84,,94.5,percent of total billed charges,12.84% of total billed charges,118.13,12.84,,94.5,percent of total billed charges,12.84% of total billed charges,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1129,65,,903.2,percent of total billed charges,65% of total billed charges for outpatient setting,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,929.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.53,100,,,Fee Schedule,100% of Custom Fee Schedule,828,90,,662.4,percent of total billed charges,90% of total billed charges for outpatient setting,118.13,1997.85,
M-CALCIUM,221015,CDM,300,RC,82310,HCPCS,Outpatient,,,23.22,20.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,19.71,84.88,,15.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.42,75,,13.94,percent of total billed charges,75% of total billed charges for outpatient setting,16.25,70,,13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,80,,14.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,100,,,Fee Schedule,100% of Custom Fee Schedule,20.9,90,,16.72,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,20.9,
M-CBC,221016,CDM,305,RC,85025,HCPCS,Outpatient,,,34.97,31.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,29.68,84.88,,23.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.23,75,,20.98,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.98,80,,22.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,100,,,Fee Schedule,100% of Custom Fee Schedule,31.47,90,,25.18,percent of total billed charges,90% of total billed charges for outpatient setting,7.77,31.47,
MCD/UHC GENERAL HEALTH PANEL,200156,CDM,310,RC,80050,HCPCS,Outpatient,,,151.13,136.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.79,70,,84.63,percent of total billed charges,70% of total billed charges for outpatient setting,128.28,84.88,,102.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,113.35,75,,90.68,percent of total billed charges,75% of total billed charges for outpatient setting,105.79,70,,84.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.9,80,,96.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.7,100,,,Fee Schedule,100% of Custom Fee Schedule,136.02,90,,108.82,percent of total billed charges,90% of total billed charges for outpatient setting,45.54,136.02,
M-CMP W/eGFR,221037,CDM,301,RC,80053,HCPCS,Outpatient,,,47.52,42.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,40.33,84.88,,32.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.64,75,,28.51,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,70,,26.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,80,,30.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of Custom Fee Schedule,42.77,90,,34.22,percent of total billed charges,90% of total billed charges for outpatient setting,10.56,42.77,
M-COVID-19 Ag CARD TEST,221042,CDM,310,RC,87811,HCPCS,Outpatient,,,62.07,55.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,52.69,84.88,,42.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.55,75,,37.24,percent of total billed charges,75% of total billed charges for outpatient setting,43.45,70,,34.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.66,80,,39.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.38,100,,,Fee Schedule,100% of Custom Fee Schedule,55.86,90,,44.69,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,55.86,
M-COVID-19 RAPID TEST,221041,CDM,306,RC,87635,HCPCS,Outpatient,,,110.25,99.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,93.58,84.88,,74.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.69,75,,66.15,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,70,,61.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,80,,70.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.33,100,,,Fee Schedule,100% of Custom Fee Schedule,99.23,90,,79.38,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,99.23,
M-CPK,221033,CDM,301,RC,82550,HCPCS,Outpatient,,,29.3,26.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,24.87,84.88,,19.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.98,75,,17.58,percent of total billed charges,75% of total billed charges for outpatient setting,20.51,70,,16.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.44,80,,18.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,100,,,Fee Schedule,100% of Custom Fee Schedule,26.37,90,,21.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,26.37,
M-CRP,221032,CDM,300,RC,86140,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
MD ZIP LOCK BAGS 3X5 49-15:,3300500,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
M-DIRECT BILIRUBIN,221017,CDM,300,RC,82248,HCPCS,Outpatient,,,22.59,20.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,20.33,
MECLIZINE (ANTIVERT) TAB : 12.5 MG,3301463,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (ANTIVERT) TAB : 12.5 MG,3301464,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (ANTIVERT) TAB : 12.5 MG,3301467,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (ANTIVERT) TAB : 25 MG,3301465,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (ANTIVERT) TAB : 25 MG,3301466,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (ANTIVERT) TAB : 25 MG,3301468,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MECLIZINE (genANTIVERT) 12.5 MG TAB,3302937,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
MECLIZINE 25MG TAB (ANTIVERT),3303132,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MEDIAL TIBIAL TRAY SZ B OXFORD PART KNEE,69161903,CDM,278,RC,,,Outpatient,,,3640,3640,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,60,,1747.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3089.63,84.88,,2471.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1820,50,,1456,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2730,75,,2184,percent of total billed charges,75% of total billed charges for outpatient setting,1820,50,,1456,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.38,12.84,,373.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2912,80,,2329.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.38,12.84,,373.9,percent of total billed charges,12.84% of total billed charges,467.38,12.84,,373.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3822,105,,3057.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274,35,,1019.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2184,60,,1747.2,percent of total billed charges,60% of total billed charges for outpatient setting,467.38,3822,
MEDICAL SUPPLY (SURGILUBE) GEL:2OZ,3301575,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEDICAL SUPPLY (SURGILUBE) GEL:3GM,3301574,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEDICATION IDENTIFICATION FEE:,3302964,CDM,259,RC,,,Outpatient,,,34.38,34.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.07,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,29.18,84.88,,23.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.19,50,,13.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.79,75,,20.63,percent of total billed charges,75% of total billed charges for outpatient setting,24.07,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,80,,22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,4.41,12.84,,3.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.35,65,,17.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.03,35,,9.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.94,90,,24.75,percent of total billed charges,90% of total billed charges for outpatient setting,4.41,30.94,
MEDIUM CHAIN TRIGLYCERIDES (MCT) OIL:365,3301469,CDM,259,RC,,,Outpatient,,,140.93,140.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.65,70,,78.92,percent of total billed charges,70% of total billed charges for outpatient setting,119.62,84.88,,95.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.47,50,,56.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.7,75,,84.56,percent of total billed charges,75% of total billed charges for outpatient setting,98.65,70,,78.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.74,80,,90.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,18.1,12.84,,14.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.6,65,,73.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.33,35,,39.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.84,90,,101.47,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,126.84,
MEDRAD 200ML SYRINGE KIT 2PK,69169038,CDM,272,RC,,,Outpatient,,,78.75,78.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,70,,44.1,percent of total billed charges,70% of total billed charges for outpatient setting,66.84,84.88,,53.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.38,50,,31.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.06,75,,47.25,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,70,,44.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.11,12.84,,8.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,80,,50.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.11,12.84,,8.09,percent of total billed charges,12.84% of total billed charges,10.11,12.84,,8.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.19,65,,40.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,35,,22.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.88,90,,56.7,percent of total billed charges,90% of total billed charges for outpatient setting,10.11,70.88,
MEDROXYP (DEPRO PROVERA) SDV : 1MG/ML,3301471,CDM,636,RC,J1050,HCPCS,Outpatient,,,161.96,161.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,137.47,84.88,,109.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,121.47,75,,97.18,percent of total billed charges,75% of total billed charges for outpatient setting,113.37,70,,90.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.57,80,,103.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.27,65,,84.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.59,100,,,Fee Schedule,100% of Custom Fee Schedule,145.76,90,,116.61,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,145.76,
MEDROXYP (DEPRO PROVERA) TAB : 5 MG,3301470,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MEGACE ER SUSP (625MG/5ML),3306149,CDM,259,RC,,,Outpatient,,,91.55,91.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.09,70,,51.27,percent of total billed charges,70% of total billed charges for outpatient setting,77.71,84.88,,62.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.78,50,,36.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.66,75,,54.93,percent of total billed charges,75% of total billed charges for outpatient setting,64.09,70,,51.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,12.84,,9.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.24,80,,58.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,12.84,,9.41,percent of total billed charges,12.84% of total billed charges,11.76,12.84,,9.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.51,65,,47.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.04,35,,25.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.4,90,,65.92,percent of total billed charges,90% of total billed charges for outpatient setting,11.76,82.4,
MEGESTROL (MEGACE) LIQ 40MG/ML :,3301473,CDM,259,RC,J8999,HCPCS,Outpatient,,,88.97,88.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.28,70,,49.82,percent of total billed charges,70% of total billed charges for outpatient setting,75.52,84.88,,60.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,66.73,75,,53.38,percent of total billed charges,75% of total billed charges for outpatient setting,62.28,70,,49.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,12.84,,9.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.18,80,,56.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,12.84,,9.14,percent of total billed charges,12.84% of total billed charges,11.42,12.84,,9.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.83,65,,46.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,35,,24.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.07,90,,64.06,percent of total billed charges,90% of total billed charges for outpatient setting,11.42,80.07,
MEGESTROL (MEGACE) TAB : 40 MG,3301472,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MELATONIN 3MG: TAB,3303062,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MELATONIN 5MG TAB,3313307,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
M-ELECTROLYTE PANEL LYTES,221014,CDM,300,RC,80051,HCPCS,Outpatient,,,31.55,28.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.09,70,,17.67,percent of total billed charges,70% of total billed charges for outpatient setting,26.78,84.88,,21.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.66,75,,18.93,percent of total billed charges,75% of total billed charges for outpatient setting,22.09,70,,17.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.24,80,,20.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,100,,,Fee Schedule,100% of Custom Fee Schedule,28.4,90,,22.72,percent of total billed charges,90% of total billed charges for outpatient setting,7.01,28.4,
MELOXICAM (genericMOBIC) 15 MG TAB,3302994,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MELOXICAM (MOBIC) 7.5MG  TAB,3303039,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MENINGOC VACC(MENACTRA)4MCG/0.5ML:INJ,3307320,CDM,636,RC,90734,HCPCS,Outpatient,,,427.19,427.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.03,70,,239.22,percent of total billed charges,70% of total billed charges for outpatient setting,362.6,84.88,,290.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,161.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,320.39,75,,256.31,percent of total billed charges,75% of total billed charges for outpatient setting,299.03,70,,239.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.85,12.84,,43.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.75,80,,273.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.85,12.84,,43.88,percent of total billed charges,12.84% of total billed charges,54.85,12.84,,43.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,277.67,65,,222.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.07,100,,,Fee Schedule,100% of Custom Fee Schedule,384.47,90,,307.58,percent of total billed charges,90% of total billed charges for outpatient setting,54.85,384.47,
MENINGOCOCCAL POLYS(MENOMUNE):INJ,3307182,CDM,636,RC,90733,HCPCS,Outpatient,,,435.31,435.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.72,70,,243.78,percent of total billed charges,70% of total billed charges for outpatient setting,369.49,84.88,,295.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,140.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,326.48,75,,261.18,percent of total billed charges,75% of total billed charges for outpatient setting,304.72,70,,243.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,12.84,,44.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.25,80,,278.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,12.84,,44.71,percent of total billed charges,12.84% of total billed charges,55.89,12.84,,44.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,282.95,65,,226.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,100% of Custom Fee Schedule,391.78,90,,313.42,percent of total billed charges,90% of total billed charges for outpatient setting,55.89,391.78,
MENISCAL BEARING MED RT 4MM/159576,69169115,CDM,278,RC,,,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2980.89,105,,2384.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.63,35,,794.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1703.36,60,,1362.69,percent of total billed charges,60% of total billed charges for outpatient setting,364.52,2980.89,
MENISCAL BEARING SM RT 4MM OXFORD PART K,69161905,CDM,278,RC,,,Outpatient,,,3221.25,3221.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1932.75,60,,1546.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2734.2,84.88,,2187.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,1610.63,50,,1288.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2415.94,75,,1932.75,percent of total billed charges,75% of total billed charges for outpatient setting,1610.63,50,,1288.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.61,12.84,,330.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2577,80,,2061.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.61,12.84,,330.89,percent of total billed charges,12.84% of total billed charges,413.61,12.84,,330.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3382.31,105,,2705.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.44,35,,901.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1932.75,60,,1546.2,percent of total billed charges,60% of total billed charges for outpatient setting,413.61,3382.31,
MENISCAL BRNG LG LFT OXF PART KNE 159556,69162281,CDM,278,RC,C1776,HCPCS,Outpatient,,,2445.27,2445.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1467.16,60,,1173.73,percent of total billed charges,60% of total Billed charges for outpatient setting,2075.55,84.88,,1660.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.95,75,,1467.16,percent of total billed charges,75% of total billed charges for outpatient setting,1222.64,50,,978.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.97,12.84,,251.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1956.22,80,,1564.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.97,12.84,,251.18,percent of total billed charges,12.84% of total billed charges,313.97,12.84,,251.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2567.53,105,,2054.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.84,35,,684.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1467.16,60,,1173.73,percent of total billed charges,60% of total billed charges for outpatient setting,313.97,2567.53,
MENISCAL BRNG RIGHT MED OXF KNE 159584,69162944,CDM,278,RC,C1776,HCPCS,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2980.89,105,,2384.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.63,35,,794.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1703.36,60,,1362.69,percent of total billed charges,60% of total billed charges for outpatient setting,364.52,2980.89,
MENISCAL CINCH / AR-4500,69160909,CDM,278,RC,,,Outpatient,,,1232.91,1232.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.75,60,,591.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1046.49,84.88,,837.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,616.46,50,,493.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,924.68,75,,739.74,percent of total billed charges,75% of total billed charges for outpatient setting,616.46,50,,493.17,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.31,12.84,,126.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,986.33,80,,789.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.31,12.84,,126.65,percent of total billed charges,12.84% of total billed charges,158.31,12.84,,126.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1232.91,65,,986.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.52,35,,345.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,739.75,60,,591.8,percent of total billed charges,60% of total billed charges for outpatient setting,158.31,1232.91,
MENSCAL BRNG LG 6MM RT MEDLUNI/159585,69169293,CDM,278,RC,C1776,HCPCS,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2980.89,105,,2384.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.63,35,,794.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1703.36,60,,1362.69,percent of total billed charges,60% of total billed charges for outpatient setting,364.52,2980.89,
MENSCL BEARING LT MEDIAL OXF UNI/159549,69162911,CDM,278,RC,C1776,HCPCS,Outpatient,,,2838.94,2838.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.36,60,,1362.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2409.69,84.88,,1927.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2129.21,75,,1703.37,percent of total billed charges,75% of total billed charges for outpatient setting,1419.47,50,,1135.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,80,,1816.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,364.52,12.84,,291.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2980.89,105,,2384.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.63,35,,794.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1703.36,60,,1362.69,percent of total billed charges,60% of total billed charges for outpatient setting,364.52,2980.89,
MENTHOL P (CEPASTAT) LOZ : CHERRY  18EA,3301474,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MEPERIDINE (DEMEROL)  TAB  50MG,3302527,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MEPERIDINE (DEMEROL) 25MG/0.5ML AMP,3312960,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MEPERIDINE (DEMEROL) 25MG/ML1ML INJ,3301482,CDM,250,RC,,,Outpatient,,,42.91,42.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,36.42,84.88,,29.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.46,50,,17.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.18,75,,25.74,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,80,,27.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.89,65,,22.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.02,35,,12.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.62,90,,30.9,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,38.62,
MEPERIDINE (DEMEROL) AMP : 100 MG,3301478,CDM,250,RC,,,Outpatient,,,67.4,67.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,57.21,84.88,,45.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.7,50,,26.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.55,75,,40.44,percent of total billed charges,75% of total billed charges for outpatient setting,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,80,,43.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.81,65,,35.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,35,,18.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.66,90,,48.53,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,60.66,
MEPERIDINE (DEMEROL) INJ 100MG/ML : 1ML,3301476,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MEPERIDINE (DEMEROL) INJ 50MG/ML : 1ML,3301477,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEPERIDINE (DEMEROL) SDV  50MG : 1ML,3301484,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEPERIDINE (DEMEROL) SDV 100MG/ML :1ML,3301486,CDM,636,RC,J2175,HCPCS,Outpatient,,,67.4,67.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,57.21,84.88,,45.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.55,75,,40.44,percent of total billed charges,75% of total billed charges for outpatient setting,47.18,70,,37.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,80,,43.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,8.65,12.84,,6.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.81,65,,35.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,100,,,Fee Schedule,100% of Custom Fee Schedule,60.66,90,,48.53,percent of total billed charges,90% of total billed charges for outpatient setting,4.96,60.66,
MEPERIDINE (DEMEROL) SDV 50MG : 1ML,3301480,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEPERIDINE (DEMEROL) SDV 75MG/ML : 1ML,3301485,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MEPERIDINE (DEMEROL) SDV 75MG/ML:1ML,3301481,CDM,250,RC,,,Outpatient,,,117.74,117.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.42,70,,65.94,percent of total billed charges,70% of total billed charges for outpatient setting,99.94,84.88,,79.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.87,50,,47.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.31,75,,70.65,percent of total billed charges,75% of total billed charges for outpatient setting,82.42,70,,65.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,12.84,,12.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.19,80,,75.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,12.84,,12.1,percent of total billed charges,12.84% of total billed charges,15.12,12.84,,12.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.53,65,,61.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.21,35,,32.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.97,90,,84.78,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,105.97,
MEPERIDINE (DEMEROL) SYRINGE : 10MG/ML,3301488,CDM,250,RC,,,Outpatient,,,64.69,64.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.28,70,,36.22,percent of total billed charges,70% of total billed charges for outpatient setting,54.91,84.88,,43.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.35,50,,25.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.52,75,,38.82,percent of total billed charges,75% of total billed charges for outpatient setting,45.28,70,,36.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,12.84,,6.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.75,80,,41.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,12.84,,6.65,percent of total billed charges,12.84% of total billed charges,8.31,12.84,,6.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.05,65,,33.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.64,35,,18.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.22,90,,46.58,percent of total billed charges,90% of total billed charges for outpatient setting,8.31,58.22,
MEPERIDINE (DEMEROL) SYRUP 50MG/5ML UD,3301487,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MEPERIDINE (DEMEROL) TAB : 50 MG,3301479,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
MEPERIDINE DEMEROL INJ 75MG 1.5ML,3309947,CDM,250,RC,J3490,HCPCS,Outpatient,,,28.36,28.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,70,,15.88,percent of total billed charges,70% of total billed charges for outpatient setting,24.07,84.88,,19.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.27,75,,17.02,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,70,,15.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.69,80,,18.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.43,65,,14.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.93,35,,7.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.52,90,,20.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,25.52,
MEPERIDINE PCA(DEMEROL)500MG/50ML NS:,3302658,CDM,250,RC,,,Outpatient,,,151.74,151.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.22,70,,84.98,percent of total billed charges,70% of total billed charges for outpatient setting,128.8,84.88,,103.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.87,50,,60.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.81,75,,91.05,percent of total billed charges,75% of total billed charges for outpatient setting,106.22,70,,84.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,12.84,,15.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.39,80,,97.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,12.84,,15.58,percent of total billed charges,12.84% of total billed charges,19.48,12.84,,15.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.63,65,,78.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,35,,42.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.57,90,,109.26,percent of total billed charges,90% of total billed charges for outpatient setting,19.48,136.57,
MEPERIDINE/DEMEROL INJ 50MG/ML 1ML,3301475,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MEPERIDINE/DEMEROL INJ 50MG/ML 2ML,3313399,CDM,250,RC,J3490,HCPCS,Outpatient,,,32.26,32.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.58,70,,18.06,percent of total billed charges,70% of total billed charges for outpatient setting,27.38,84.88,,21.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.2,75,,19.36,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,70,,18.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,12.84,,3.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,80,,20.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.14,12.84,,3.31,percent of total billed charges,12.84% of total billed charges,4.14,12.84,,3.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.97,65,,16.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.29,35,,9.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.03,90,,23.22,percent of total billed charges,90% of total billed charges for outpatient setting,4.14,29.03,
MEPILEX 4X10 POST OP DRSG / 496455,70000072,CDM,272,RC,,,Outpatient,,,40.04,40.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.03,70,,22.42,percent of total billed charges,70% of total billed charges for outpatient setting,33.99,84.88,,27.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.02,50,,16.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.03,75,,24.02,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,70,,22.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.14,12.84,,4.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.03,80,,25.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.14,12.84,,4.11,percent of total billed charges,12.84% of total billed charges,5.14,12.84,,4.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.03,65,,20.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,35,,11.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.04,90,,28.83,percent of total billed charges,90% of total billed charges for outpatient setting,5.14,36.04,
MEPILEX 4X12IN POST OP DRSG / 295900,69162223,CDM,272,RC,,,Outpatient,,,36.82,36.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,70,,20.62,percent of total billed charges,70% of total billed charges for outpatient setting,31.25,84.88,,25,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.41,50,,14.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.62,75,,22.1,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,70,,20.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,80,,23.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.93,65,,19.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,35,,10.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.14,90,,26.51,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,33.14,
MEPILEX 4X4 POST OP DRSG / 581300,7554112,CDM,272,RC,,,Outpatient,,,22.86,22.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16,70,,12.8,percent of total billed charges,70% of total billed charges for outpatient setting,19.4,84.88,,15.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.43,50,,9.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.15,75,,13.72,percent of total billed charges,75% of total billed charges for outpatient setting,16,70,,12.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.29,80,,14.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,2.94,12.84,,2.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.86,65,,11.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,35,,6.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.57,90,,16.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.94,20.57,
MEPIVACAINE (POLOCAINE-MPF) 1.5%:INJ.,3303207,CDM,250,RC,,,Outpatient,,,52.98,52.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,44.97,84.88,,35.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.49,50,,21.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.74,75,,31.79,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.38,80,,33.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.44,65,,27.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,35,,14.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.68,90,,38.14,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.68,
MERCAPTOPURINE(PURINETHOL)50MG:TAB,3303314,CDM,259,RC,,,Outpatient,,,16.28,16.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,13.82,84.88,,11.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.14,50,,6.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.21,75,,9.77,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.02,80,,10.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.58,65,,8.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,35,,4.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.65,90,,11.72,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.65,
"MERCURY, BLOOD",220879,CDM,301,RC,83825,HCPCS,Outpatient,,,73.17,65.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.22,70,,40.98,percent of total billed charges,70% of total billed charges for outpatient setting,62.11,84.88,,49.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.91,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.88,75,,43.9,percent of total billed charges,75% of total billed charges for outpatient setting,51.22,70,,40.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.54,80,,46.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,100,,,Fee Schedule,100% of Custom Fee Schedule,65.85,90,,52.68,percent of total billed charges,90% of total billed charges for outpatient setting,16.26,65.85,
MEROCEL EYE SPEARS STERILE,6150053,CDM,272,RC,,,Outpatient,,,22.26,22.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.58,70,,12.46,percent of total billed charges,70% of total billed charges for outpatient setting,18.89,84.88,,15.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,50,,8.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.7,75,,13.36,percent of total billed charges,75% of total billed charges for outpatient setting,15.58,70,,12.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,12.84,,2.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.81,80,,14.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,12.84,,2.29,percent of total billed charges,12.84% of total billed charges,2.86,12.84,,2.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.47,65,,11.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,35,,6.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.03,90,,16.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.86,20.03,
MEROGEL 4x4cm 1517002,69160390,CDM,272,RC,,,Outpatient,,,382.2,382.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.54,70,,214.03,percent of total billed charges,70% of total billed charges for outpatient setting,324.41,84.88,,259.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,191.1,50,,152.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.65,75,,229.32,percent of total billed charges,75% of total billed charges for outpatient setting,267.54,70,,214.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.07,12.84,,39.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.76,80,,244.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.07,12.84,,39.26,percent of total billed charges,12.84% of total billed charges,49.07,12.84,,39.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,248.43,65,,198.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.77,35,,107.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,343.98,90,,275.18,percent of total billed charges,90% of total billed charges for outpatient setting,49.07,343.98,
MEROGEL INJECTION 4ML 1518000,69161831,CDM,272,RC,,,Outpatient,,,327.22,327.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.05,70,,183.24,percent of total billed charges,70% of total billed charges for outpatient setting,277.74,84.88,,222.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,163.61,50,,130.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.42,75,,196.34,percent of total billed charges,75% of total billed charges for outpatient setting,229.05,70,,183.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,12.84,,33.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.78,80,,209.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,12.84,,33.62,percent of total billed charges,12.84% of total billed charges,42.02,12.84,,33.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,212.69,65,,170.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.53,35,,91.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,294.5,90,,235.6,percent of total billed charges,90% of total billed charges for outpatient setting,42.02,294.5,
MEROPENEM (genericMERREM) 1 GRAM INJ,3309595,CDM,636,RC,J2185,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,70,,26.88,percent of total billed charges,70% of total billed charges for outpatient setting,40.74,84.88,,32.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36,75,,28.8,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,70,,26.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,12.84,,4.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,80,,30.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,12.84,,4.93,percent of total billed charges,12.84% of total billed charges,6.16,12.84,,4.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,65,,24.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,100,,,Fee Schedule,100% of Custom Fee Schedule,43.2,90,,34.56,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,43.2,
MEROPENEM (genericMERREM) 500MG INJ,3308784,CDM,636,RC,J2185,HCPCS,Outpatient,,,22.09,22.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,70,,12.37,percent of total billed charges,70% of total billed charges for outpatient setting,18.75,84.88,,15,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.57,75,,13.26,percent of total billed charges,75% of total billed charges for outpatient setting,15.46,70,,12.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.84,12.84,,2.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,80,,14.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.84,12.84,,2.27,percent of total billed charges,12.84% of total billed charges,2.84,12.84,,2.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.36,65,,11.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,100,,,Fee Schedule,100% of Custom Fee Schedule,19.88,90,,15.9,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,19.88,
MESALAMINE (ASACOL) TAB: 400 MG,3301490,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MESALAMINE (PENTASA) CAP: 250 MG,3301489,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MESALAMINE (ROWASA) ENEMA : 4 GM,3301491,CDM,259,RC,,,Outpatient,,,44.54,44.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.18,70,,24.94,percent of total billed charges,70% of total billed charges for outpatient setting,37.81,84.88,,30.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.27,50,,17.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.41,75,,26.73,percent of total billed charges,75% of total billed charges for outpatient setting,31.18,70,,24.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,12.84,,4.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.63,80,,28.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,5.72,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.95,65,,23.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.59,35,,12.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.09,90,,32.07,percent of total billed charges,90% of total billed charges for outpatient setting,5.72,40.09,
MESH 1.8X4IN KEYHOLE / 0112710,6150339,CDM,278,RC,C1781,HCPCS,Outpatient,,,449.6,449.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.76,60,,215.81,percent of total billed charges,60% of total Billed charges for outpatient setting,381.62,84.88,,305.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.2,75,,269.76,percent of total billed charges,75% of total billed charges for outpatient setting,224.8,50,,179.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.73,12.84,,46.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.68,80,,287.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.73,12.84,,46.18,percent of total billed charges,12.84% of total billed charges,57.73,12.84,,46.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,449.6,65,,359.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.36,35,,125.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,269.76,60,,215.81,percent of total billed charges,60% of total billed charges for outpatient setting,57.73,449.6,
MESH 10  X 14  / 0112660,6150338,CDM,278,RC,C1781,HCPCS,Outpatient,,,340.87,340.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.52,60,,163.62,percent of total billed charges,60% of total Billed charges for outpatient setting,289.33,84.88,,231.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.65,75,,204.52,percent of total billed charges,75% of total billed charges for outpatient setting,170.44,50,,136.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.7,80,,218.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,43.77,12.84,,35.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,340.87,65,,272.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.3,35,,95.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.52,60,,163.62,percent of total billed charges,60% of total billed charges for outpatient setting,43.77,340.87,
MESH 12X12IN SOFT BARD / 0117016,69169216,CDM,278,RC,C1781,HCPCS,Outpatient,,,1828.18,1828.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.91,60,,877.53,percent of total billed charges,60% of total Billed charges for outpatient setting,1551.76,84.88,,1241.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1371.14,75,,1096.91,percent of total billed charges,75% of total billed charges for outpatient setting,914.09,50,,731.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.74,12.84,,187.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.54,80,,1170.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.74,12.84,,187.79,percent of total billed charges,12.84% of total billed charges,234.74,12.84,,187.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1828.18,65,,1462.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.86,35,,511.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1096.91,60,,877.53,percent of total billed charges,60% of total billed charges for outpatient setting,234.74,1828.18,
MESH 15X10CM PROGRIP RIGHT / LPG1510AR,69162011,CDM,278,RC,C1781,HCPCS,Outpatient,,,1705.52,1705.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.31,60,,818.65,percent of total billed charges,60% of total Billed charges for outpatient setting,1447.65,84.88,,1158.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.14,75,,1023.31,percent of total billed charges,75% of total billed charges for outpatient setting,852.76,50,,682.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,12.84,,175.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1364.42,80,,1091.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,12.84,,175.19,percent of total billed charges,12.84% of total billed charges,218.99,12.84,,175.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1705.52,65,,1364.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.93,35,,477.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1023.31,60,,818.65,percent of total billed charges,60% of total billed charges for outpatient setting,218.99,1705.52,
MESH 15X10CM SYMBOTEX / SYM1510,69162146,CDM,278,RC,C1781,HCPCS,Outpatient,,,1392.52,1392.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.51,60,,668.41,percent of total billed charges,60% of total Billed charges for outpatient setting,1181.97,84.88,,945.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.39,75,,835.51,percent of total billed charges,75% of total billed charges for outpatient setting,696.26,50,,557.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.8,12.84,,143.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.02,80,,891.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.8,12.84,,143.04,percent of total billed charges,12.84% of total billed charges,178.8,12.84,,143.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1392.52,65,,1114.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.38,35,,389.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,835.51,60,,668.41,percent of total billed charges,60% of total billed charges for outpatient setting,178.8,1392.52,
MESH 15X15CM PROGRIP / TEM1515G,69162683,CDM,278,RC,C1781,HCPCS,Outpatient,,,967.04,967.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.22,60,,464.18,percent of total billed charges,60% of total Billed charges for outpatient setting,820.82,84.88,,656.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.28,75,,580.22,percent of total billed charges,75% of total billed charges for outpatient setting,483.52,50,,386.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.17,12.84,,99.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.63,80,,618.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.17,12.84,,99.34,percent of total billed charges,12.84% of total billed charges,124.17,12.84,,99.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,967.04,65,,773.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.46,35,,270.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,580.22,60,,464.18,percent of total billed charges,60% of total billed charges for outpatient setting,124.17,967.04,
MESH 16X12CM PROGRIP LT LG / LPG1612AL,69162277,CDM,278,RC,C1781,HCPCS,Outpatient,,,1872.68,1872.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1123.61,60,,898.89,percent of total billed charges,60% of total Billed charges for outpatient setting,1589.53,84.88,,1271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.51,75,,1123.61,percent of total billed charges,75% of total billed charges for outpatient setting,936.34,50,,749.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.14,80,,1198.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1872.68,65,,1498.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.44,35,,524.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1123.61,60,,898.89,percent of total billed charges,60% of total billed charges for outpatient setting,240.45,1872.68,
MESH 16X12CM PROGRIP RT LG / LPG1612AR,69162276,CDM,278,RC,C1781,HCPCS,Outpatient,,,1872.68,1872.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1123.61,60,,898.89,percent of total billed charges,60% of total Billed charges for outpatient setting,1589.53,84.88,,1271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.51,75,,1123.61,percent of total billed charges,75% of total billed charges for outpatient setting,936.34,50,,749.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.14,80,,1198.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,240.45,12.84,,192.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1872.68,65,,1498.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.44,35,,524.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1123.61,60,,898.89,percent of total billed charges,60% of total billed charges for outpatient setting,240.45,1872.68,
MESH 20X15CM PROGRIP / TEM2015G,69162662,CDM,278,RC,C1781,HCPCS,Outpatient,,,1566.48,1566.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.89,60,,751.91,percent of total billed charges,60% of total Billed charges for outpatient setting,1329.63,84.88,,1063.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.86,75,,939.89,percent of total billed charges,75% of total billed charges for outpatient setting,783.24,50,,626.59,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.14,12.84,,160.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1253.18,80,,1002.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.14,12.84,,160.91,percent of total billed charges,12.84% of total billed charges,201.14,12.84,,160.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1566.48,65,,1253.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.27,35,,438.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,939.89,60,,751.91,percent of total billed charges,60% of total billed charges for outpatient setting,201.14,1566.48,
MESH 23X15CM OVAL SYMB / SYM2515E,69162136,CDM,278,RC,C1781,HCPCS,Outpatient,,,3082.48,3082.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.49,60,,1479.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2616.41,84.88,,2093.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.86,75,,1849.49,percent of total billed charges,75% of total billed charges for outpatient setting,1541.24,50,,1232.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.79,12.84,,316.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2465.98,80,,1972.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.79,12.84,,316.63,percent of total billed charges,12.84% of total billed charges,395.79,12.84,,316.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3236.6,105,,2589.28,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1078.87,35,,863.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1849.49,60,,1479.59,percent of total billed charges,60% of total billed charges for outpatient setting,395.79,3236.6,
MESH 3D  LIGHT MED LEFT/ 0117310,69161012,CDM,278,RC,C1781,HCPCS,Outpatient,,,917.89,917.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.73,60,,440.58,percent of total billed charges,60% of total Billed charges for outpatient setting,779.11,84.88,,623.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.42,75,,550.74,percent of total billed charges,75% of total billed charges for outpatient setting,458.95,50,,367.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,12.84,,94.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.31,80,,587.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,12.84,,94.29,percent of total billed charges,12.84% of total billed charges,117.86,12.84,,94.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,917.89,65,,734.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.26,35,,257.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,550.73,60,,440.58,percent of total billed charges,60% of total billed charges for outpatient setting,117.86,917.89,
MESH 3D LEFT LARGE MAX MID /0116311,6153072,CDM,278,RC,C1781,HCPCS,Outpatient,,,1651.86,1651.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.12,60,,792.9,percent of total billed charges,60% of total Billed charges for outpatient setting,1402.1,84.88,,1121.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1238.9,75,,991.12,percent of total billed charges,75% of total billed charges for outpatient setting,825.93,50,,660.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1321.49,80,,1057.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1651.86,65,,1321.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.15,35,,462.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,991.12,60,,792.9,percent of total billed charges,60% of total billed charges for outpatient setting,212.1,1651.86,
MESH 3D MED LFT / 0115310,6150342,CDM,278,RC,C1781,HCPCS,Outpatient,,,579.68,579.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.81,60,,278.25,percent of total billed charges,60% of total Billed charges for outpatient setting,492.03,84.88,,393.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,75,,347.81,percent of total billed charges,75% of total billed charges for outpatient setting,289.84,50,,231.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,12.84,,59.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.74,80,,370.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,12.84,,59.54,percent of total billed charges,12.84% of total billed charges,74.43,12.84,,59.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.68,65,,463.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.89,35,,162.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.81,60,,278.25,percent of total billed charges,60% of total billed charges for outpatient setting,74.43,579.68,
MESH 3D MED RIGHT / 0115320,6150343,CDM,278,RC,C1781,HCPCS,Outpatient,,,579.68,579.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.81,60,,278.25,percent of total billed charges,60% of total Billed charges for outpatient setting,492.03,84.88,,393.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,75,,347.81,percent of total billed charges,75% of total billed charges for outpatient setting,289.84,50,,231.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,12.84,,59.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.74,80,,370.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,12.84,,59.54,percent of total billed charges,12.84% of total billed charges,74.43,12.84,,59.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.68,65,,463.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.89,35,,162.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.81,60,,278.25,percent of total billed charges,60% of total billed charges for outpatient setting,74.43,579.68,
MESH 3D RIGHT LARGE MAX MID /0116321,6153075,CDM,278,RC,C1781,HCPCS,Outpatient,,,1651.86,1651.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.12,60,,792.9,percent of total billed charges,60% of total Billed charges for outpatient setting,1402.1,84.88,,1121.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1238.9,75,,991.12,percent of total billed charges,75% of total billed charges for outpatient setting,825.93,50,,660.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1321.49,80,,1057.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,212.1,12.84,,169.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1651.86,65,,1321.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.15,35,,462.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,991.12,60,,792.9,percent of total billed charges,60% of total billed charges for outpatient setting,212.1,1651.86,
MESH 3X6 / 0112680,6152641,CDM,278,RC,C1781,HCPCS,Outpatient,,,221.71,221.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.03,60,,106.42,percent of total billed charges,60% of total Billed charges for outpatient setting,188.19,84.88,,150.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.28,75,,133.02,percent of total billed charges,75% of total billed charges for outpatient setting,110.86,50,,88.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.47,12.84,,22.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.37,80,,141.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.47,12.84,,22.78,percent of total billed charges,12.84% of total billed charges,28.47,12.84,,22.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,221.71,65,,177.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.6,35,,62.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.03,60,,106.42,percent of total billed charges,60% of total billed charges for outpatient setting,28.47,221.71,
MESH 4.3CM VENTRALEX SM / 0010301,69160299,CDM,278,RC,C1781,HCPCS,Outpatient,,,1386,1386,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.6,60,,665.28,percent of total billed charges,60% of total Billed charges for outpatient setting,1176.44,84.88,,941.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1039.5,75,,831.6,percent of total billed charges,75% of total billed charges for outpatient setting,693,50,,554.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.8,80,,887.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1386,65,,1108.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.1,35,,388.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,60,,665.28,percent of total billed charges,60% of total billed charges for outpatient setting,177.96,1386,
MESH 4X6IN SOFT BARD / 0117010,69169214,CDM,278,RC,C1781,HCPCS,Outpatient,,,573.72,573.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.23,60,,275.38,percent of total billed charges,60% of total Billed charges for outpatient setting,486.97,84.88,,389.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.29,75,,344.23,percent of total billed charges,75% of total billed charges for outpatient setting,286.86,50,,229.49,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,12.84,,58.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.98,80,,367.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,12.84,,58.94,percent of total billed charges,12.84% of total billed charges,73.67,12.84,,58.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,573.72,65,,458.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.8,35,,160.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,344.23,60,,275.38,percent of total billed charges,60% of total billed charges for outpatient setting,73.67,573.72,
MESH 6.4CM VENTRALEX MED / 0010302,69160240,CDM,278,RC,C1781,HCPCS,Outpatient,,,1386,1386,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.6,60,,665.28,percent of total billed charges,60% of total Billed charges for outpatient setting,1176.44,84.88,,941.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1039.5,75,,831.6,percent of total billed charges,75% of total billed charges for outpatient setting,693,50,,554.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.8,80,,887.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,177.96,12.84,,142.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1386,65,,1108.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.1,35,,388.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,60,,665.28,percent of total billed charges,60% of total billed charges for outpatient setting,177.96,1386,
MESH 6X6 / 0112720,6150340,CDM,278,RC,C1781,HCPCS,Outpatient,,,250.91,250.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.55,60,,120.44,percent of total billed charges,60% of total Billed charges for outpatient setting,212.97,84.88,,170.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.18,75,,150.54,percent of total billed charges,75% of total billed charges for outpatient setting,125.46,50,,100.37,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.22,12.84,,25.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.73,80,,160.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.22,12.84,,25.78,percent of total billed charges,12.84% of total billed charges,32.22,12.84,,25.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,250.91,65,,200.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.82,35,,70.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.55,60,,120.44,percent of total billed charges,60% of total billed charges for outpatient setting,32.22,250.91,
MESH 6X6IN SOFT BARD / 0117011,69169215,CDM,278,RC,C1781,HCPCS,Outpatient,,,289.38,289.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.63,60,,138.9,percent of total billed charges,60% of total Billed charges for outpatient setting,245.63,84.88,,196.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.04,75,,173.63,percent of total billed charges,75% of total billed charges for outpatient setting,144.69,50,,115.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.16,12.84,,29.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.5,80,,185.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.16,12.84,,29.73,percent of total billed charges,12.84% of total billed charges,37.16,12.84,,29.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,289.38,65,,231.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.28,35,,81.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.63,60,,138.9,percent of total billed charges,60% of total billed charges for outpatient setting,37.16,289.38,
MESH BIO 10X15CM GORE / GKFV1015,69169320,CDM,278,RC,C1781,HCPCS,Outpatient,,,2789.33,2789.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1673.6,60,,1338.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2367.58,84.88,,1894.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2092,75,,1673.6,percent of total billed charges,75% of total billed charges for outpatient setting,1394.67,50,,1115.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.15,12.84,,286.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2231.46,80,,1785.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.15,12.84,,286.52,percent of total billed charges,12.84% of total billed charges,358.15,12.84,,286.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2928.8,105,,2343.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,976.27,35,,781.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1673.6,60,,1338.88,percent of total billed charges,60% of total billed charges for outpatient setting,358.15,2928.8,
MESH BIO 10X20CM GORE / GKFV1520,69169297,CDM,278,RC,C1781,HCPCS,Outpatient,,,3034,3034,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820.4,60,,1456.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2575.26,84.88,,2060.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275.5,75,,1820.4,percent of total billed charges,75% of total billed charges for outpatient setting,1517,50,,1213.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.57,12.84,,311.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2427.2,80,,1941.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.57,12.84,,311.66,percent of total billed charges,12.84% of total billed charges,389.57,12.84,,311.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3185.7,105,,2548.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1061.9,35,,849.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1820.4,60,,1456.32,percent of total billed charges,60% of total billed charges for outpatient setting,389.57,3185.7,
MESH CONVENTIONAL 6X4 / TEC1510,69160146,CDM,278,RC,C1781,HCPCS,Outpatient,,,765.01,765.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.01,60,,367.21,percent of total billed charges,60% of total Billed charges for outpatient setting,649.34,84.88,,519.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.76,75,,459.01,percent of total billed charges,75% of total billed charges for outpatient setting,382.51,50,,306.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.23,12.84,,78.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.01,80,,489.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.23,12.84,,78.58,percent of total billed charges,12.84% of total billed charges,98.23,12.84,,78.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,765.01,65,,612.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.75,35,,214.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,459.01,60,,367.21,percent of total billed charges,60% of total billed charges for outpatient setting,98.23,765.01,
MESH HORSESHOE 9X8CM / PCO2H3,69161619,CDM,278,RC,C1781,HCPCS,Outpatient,,,1337.04,1337.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.22,60,,641.78,percent of total billed charges,60% of total Billed charges for outpatient setting,1134.88,84.88,,907.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.78,75,,802.22,percent of total billed charges,75% of total billed charges for outpatient setting,668.52,50,,534.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.68,12.84,,137.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.63,80,,855.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.68,12.84,,137.34,percent of total billed charges,12.84% of total billed charges,171.68,12.84,,137.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1337.04,65,,1069.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.96,35,,374.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,802.22,60,,641.78,percent of total billed charges,60% of total billed charges for outpatient setting,171.68,1337.04,
MESH KEYHOLE 1.8X4 IN / 0117013,69162606,CDM,278,RC,C1781,HCPCS,Outpatient,,,298.49,298.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.09,60,,143.27,percent of total billed charges,60% of total Billed charges for outpatient setting,253.36,84.88,,202.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.87,75,,179.1,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,50,,119.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.33,12.84,,30.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.79,80,,191.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.33,12.84,,30.66,percent of total billed charges,12.84% of total billed charges,38.33,12.84,,30.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,298.49,65,,238.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.47,35,,83.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.09,60,,143.27,percent of total billed charges,60% of total billed charges for outpatient setting,38.33,298.49,
MESH PHASIX ST 3X4IN / 1200710,69169151,CDM,278,RC,C1781,HCPCS,Outpatient,,,3030.2,3030.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1818.12,60,,1454.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2572.03,84.88,,2057.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2272.65,75,,1818.12,percent of total billed charges,75% of total billed charges for outpatient setting,1515.1,50,,1212.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.08,12.84,,311.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2424.16,80,,1939.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.08,12.84,,311.26,percent of total billed charges,12.84% of total billed charges,389.08,12.84,,311.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3181.71,105,,2545.37,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1060.57,35,,848.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1818.12,60,,1454.5,percent of total billed charges,60% of total billed charges for outpatient setting,389.08,3181.71,
MESH PROCEED 1.7CM VENTRL PATCH / PVPS,69162639,CDM,278,RC,C1781,HCPCS,Outpatient,,,1646.44,1646.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.86,60,,790.29,percent of total billed charges,60% of total Billed charges for outpatient setting,1397.5,84.88,,1118,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1234.83,75,,987.86,percent of total billed charges,75% of total billed charges for outpatient setting,823.22,50,,658.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.4,12.84,,169.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1317.15,80,,1053.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.4,12.84,,169.12,percent of total billed charges,12.84% of total billed charges,211.4,12.84,,169.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1646.44,65,,1317.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.25,35,,461,percent of total billed charges,35% of total Billed charges for Outpatient Setting,987.86,60,,790.29,percent of total billed charges,60% of total billed charges for outpatient setting,211.4,1646.44,
MESH PROCEED 6.4CM VENTRL PATCH / PVPM,69162638,CDM,278,RC,C1781,HCPCS,Outpatient,,,1912.88,1912.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.73,60,,918.18,percent of total billed charges,60% of total Billed charges for outpatient setting,1623.65,84.88,,1298.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.66,75,,1147.73,percent of total billed charges,75% of total billed charges for outpatient setting,956.44,50,,765.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.61,12.84,,196.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.3,80,,1224.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.61,12.84,,196.49,percent of total billed charges,12.84% of total billed charges,245.61,12.84,,196.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1912.88,65,,1530.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.51,35,,535.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1147.73,60,,918.18,percent of total billed charges,60% of total billed charges for outpatient setting,245.61,1912.88,
MESH PROGRIP BILATERAL / LPG1510AK2,69162030,CDM,278,RC,C1781,HCPCS,Outpatient,,,3269.02,3269.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1961.41,60,,1569.13,percent of total billed charges,60% of total Billed charges for outpatient setting,2774.74,84.88,,2219.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2451.77,75,,1961.42,percent of total billed charges,75% of total billed charges for outpatient setting,1634.51,50,,1307.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.74,12.84,,335.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2615.22,80,,2092.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.74,12.84,,335.79,percent of total billed charges,12.84% of total billed charges,419.74,12.84,,335.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3432.47,105,,2745.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1144.16,35,,915.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1961.41,60,,1569.13,percent of total billed charges,60% of total billed charges for outpatient setting,419.74,3432.47,
MESH PROGRIP LEFT 10X15CM / LPG1510AL,69162012,CDM,278,RC,C1781,HCPCS,Outpatient,,,1705.52,1705.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.31,60,,818.65,percent of total billed charges,60% of total Billed charges for outpatient setting,1447.65,84.88,,1158.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.14,75,,1023.31,percent of total billed charges,75% of total billed charges for outpatient setting,852.76,50,,682.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,12.84,,175.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1364.42,80,,1091.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,12.84,,175.19,percent of total billed charges,12.84% of total billed charges,218.99,12.84,,175.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1705.52,65,,1364.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.93,35,,477.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1023.31,60,,818.65,percent of total billed charges,60% of total billed charges for outpatient setting,218.99,1705.52,
MESH RESTORELLE M 15X10CM / 501320,69169725,CDM,278,RC,C1781,HCPCS,Outpatient,,,2715.83,2715.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.5,60,,1303.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2305.2,84.88,,1844.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2036.87,75,,1629.5,percent of total billed charges,75% of total billed charges for outpatient setting,1357.92,50,,1086.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.71,12.84,,278.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2172.66,80,,1738.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.71,12.84,,278.97,percent of total billed charges,12.84% of total billed charges,348.71,12.84,,278.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2851.62,105,,2281.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.54,35,,760.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1629.5,60,,1303.6,percent of total billed charges,60% of total billed charges for outpatient setting,348.71,2851.62,
MESH SYMBOTEX 12CM CIRCLE / SYM12,69162185,CDM,278,RC,C1781,HCPCS,Outpatient,,,1473.76,1473.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.26,60,,707.41,percent of total billed charges,60% of total Billed charges for outpatient setting,1250.93,84.88,,1000.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1105.32,75,,884.26,percent of total billed charges,75% of total billed charges for outpatient setting,736.88,50,,589.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.23,12.84,,151.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179.01,80,,943.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.23,12.84,,151.38,percent of total billed charges,12.84% of total billed charges,189.23,12.84,,151.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1473.76,65,,1179.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.82,35,,412.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,884.26,60,,707.41,percent of total billed charges,60% of total billed charges for outpatient setting,189.23,1473.76,
MESH SYMBOTEX 15CM CIRCLE / SYM15,69162182,CDM,278,RC,C1781,HCPCS,Outpatient,,,2741.43,2741.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1644.86,60,,1315.89,percent of total billed charges,60% of total Billed charges for outpatient setting,2326.93,84.88,,1861.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2056.07,75,,1644.86,percent of total billed charges,75% of total billed charges for outpatient setting,1370.72,50,,1096.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,12.84,,281.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2193.14,80,,1754.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,12.84,,281.6,percent of total billed charges,12.84% of total billed charges,352,12.84,,281.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2878.5,105,,2302.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,959.5,35,,767.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1644.86,60,,1315.89,percent of total billed charges,60% of total billed charges for outpatient setting,352,2878.5,
MESH SYMBOTEX 20X12CM OVAL / SYM2012E,69162145,CDM,278,RC,C1781,HCPCS,Outpatient,,,2961.93,2961.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1777.16,60,,1421.73,percent of total billed charges,60% of total Billed charges for outpatient setting,2514.09,84.88,,2011.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2221.45,75,,1777.16,percent of total billed charges,75% of total billed charges for outpatient setting,1480.97,50,,1184.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.31,12.84,,304.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2369.54,80,,1895.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.31,12.84,,304.25,percent of total billed charges,12.84% of total billed charges,380.31,12.84,,304.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3110.03,105,,2488.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1036.68,35,,829.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1777.16,60,,1421.73,percent of total billed charges,60% of total billed charges for outpatient setting,380.31,3110.03,
MESH SYMBOTEX 34x20CM OVAL / SYM3420E,69162661,CDM,278,RC,C1781,HCPCS,Outpatient,,,5538.4,5538.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3323.04,60,,2658.43,percent of total billed charges,60% of total Billed charges for outpatient setting,4700.99,84.88,,3760.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4153.8,75,,3323.04,percent of total billed charges,75% of total billed charges for outpatient setting,2769.2,50,,2215.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.13,12.84,,568.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4430.72,80,,3544.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.13,12.84,,568.9,percent of total billed charges,12.84% of total billed charges,711.13,12.84,,568.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5815.32,105,,4652.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1938.44,35,,1550.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3323.04,60,,2658.43,percent of total billed charges,60% of total billed charges for outpatient setting,711.13,5815.32,
MESH SYMBOTEX 9CM CIRCLE / SYM9,69162183,CDM,278,RC,C1781,HCPCS,Outpatient,,,1074.64,1074.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.78,60,,515.82,percent of total billed charges,60% of total Billed charges for outpatient setting,912.15,84.88,,729.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.98,75,,644.78,percent of total billed charges,75% of total billed charges for outpatient setting,537.32,50,,429.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.98,12.84,,110.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,859.71,80,,687.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.98,12.84,,110.38,percent of total billed charges,12.84% of total billed charges,137.98,12.84,,110.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1074.64,65,,859.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.12,35,,300.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,644.78,60,,515.82,percent of total billed charges,60% of total billed charges for outpatient setting,137.98,1074.64,
MESH ULTRAPRO 6X6 / UMM3,69159780,CDM,278,RC,,,Outpatient,,,432.09,432.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.25,60,,207.4,percent of total billed charges,60% of total Billed charges for outpatient setting,366.76,84.88,,293.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.05,50,,172.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.07,75,,259.26,percent of total billed charges,75% of total billed charges for outpatient setting,216.05,50,,172.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.48,12.84,,44.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.67,80,,276.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.48,12.84,,44.38,percent of total billed charges,12.84% of total billed charges,55.48,12.84,,44.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,432.09,65,,345.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.23,35,,120.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.25,60,,207.4,percent of total billed charges,60% of total billed charges for outpatient setting,55.48,432.09,
MESH VERSATEX15X10CM / VTX1510,69169689,CDM,278,RC,C1781,HCPCS,Outpatient,,,589.88,589.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.93,60,,283.14,percent of total billed charges,60% of total Billed charges for outpatient setting,500.69,84.88,,400.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.41,75,,353.93,percent of total billed charges,75% of total billed charges for outpatient setting,294.94,50,,235.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.74,12.84,,60.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.9,80,,377.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.74,12.84,,60.59,percent of total billed charges,12.84% of total billed charges,75.74,12.84,,60.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,589.88,65,,471.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.46,35,,165.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,353.93,60,,283.14,percent of total billed charges,60% of total billed charges for outpatient setting,75.74,589.88,
MESH W/ ECHO 4X6IN / 5955460,69161907,CDM,278,RC,,,Outpatient,,,2094.75,2094.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1256.85,60,,1005.48,percent of total billed charges,60% of total Billed charges for outpatient setting,1778.02,84.88,,1422.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,1047.38,50,,837.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1571.06,75,,1256.85,percent of total billed charges,75% of total billed charges for outpatient setting,1047.38,50,,837.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.97,12.84,,215.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1675.8,80,,1340.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.97,12.84,,215.18,percent of total billed charges,12.84% of total billed charges,268.97,12.84,,215.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2094.75,65,,1675.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.16,35,,586.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1256.85,60,,1005.48,percent of total billed charges,60% of total billed charges for outpatient setting,268.97,2094.75,
MESH W/ ECHO 6X8IN / 5955680,69161531,CDM,278,RC,,,Outpatient,,,2460,2460,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1476,60,,1180.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2088.05,84.88,,1670.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,1230,50,,984,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1845,75,,1476,percent of total billed charges,75% of total billed charges for outpatient setting,1230,50,,984,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.86,12.84,,252.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968,80,,1574.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.86,12.84,,252.69,percent of total billed charges,12.84% of total billed charges,315.86,12.84,,252.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2583,105,,2066.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,861,35,,688.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1476,60,,1180.8,percent of total billed charges,60% of total billed charges for outpatient setting,315.86,2583,
MESH W/ ECHO 7X9IN / 5955790,69161487,CDM,278,RC,,,Outpatient,,,4420,4420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2652,60,,2121.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3751.7,84.88,,3001.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,2210,50,,1768,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3315,75,,2652,percent of total billed charges,75% of total billed charges for outpatient setting,2210,50,,1768,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.53,12.84,,454.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3536,80,,2828.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.53,12.84,,454.02,percent of total billed charges,12.84% of total billed charges,567.53,12.84,,454.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4641,105,,3712.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1547,35,,1237.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2652,60,,2121.6,percent of total billed charges,60% of total billed charges for outpatient setting,567.53,4641,
MESH W/ ECHO 8X10 / 5955810,69162155,CDM,278,RC,,,Outpatient,,,3540,3540,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2124,60,,1699.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3004.75,84.88,,2403.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,1770,50,,1416,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2655,75,,2124,percent of total billed charges,75% of total billed charges for outpatient setting,1770,50,,1416,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.54,12.84,,363.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2832,80,,2265.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.54,12.84,,363.63,percent of total billed charges,12.84% of total billed charges,454.54,12.84,,363.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3717,105,,2973.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239,35,,991.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2124,60,,1699.2,percent of total billed charges,60% of total billed charges for outpatient setting,454.54,3717,
MESH Y UPSYLON / 831820,69162841,CDM,278,RC,C1763,HCPCS,Outpatient,,,2079,2079,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.4,60,,997.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1764.66,84.88,,1411.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1559.25,75,,1247.4,percent of total billed charges,75% of total billed charges for outpatient setting,1039.5,50,,831.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1663.2,80,,1330.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,266.94,12.84,,213.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2079,65,,1663.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.65,35,,582.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1247.4,60,,997.92,percent of total billed charges,60% of total billed charges for outpatient setting,266.94,2079,
"MESH, 3D LIGHT LEFT LARGE/  0117311",69161465,CDM,278,RC,C1781,HCPCS,Outpatient,,,975.82,975.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.49,60,,468.39,percent of total billed charges,60% of total Billed charges for outpatient setting,828.28,84.88,,662.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.87,75,,585.5,percent of total billed charges,75% of total billed charges for outpatient setting,487.91,50,,390.33,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.66,80,,624.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,975.82,65,,780.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.54,35,,273.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,585.49,60,,468.39,percent of total billed charges,60% of total billed charges for outpatient setting,125.3,975.82,
"MESH, 3D LIGHT MED RIGHT/ 0117320",69161419,CDM,278,RC,C1781,HCPCS,Outpatient,,,917.89,917.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.73,60,,440.58,percent of total billed charges,60% of total Billed charges for outpatient setting,779.11,84.88,,623.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.42,75,,550.74,percent of total billed charges,75% of total billed charges for outpatient setting,458.95,50,,367.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,12.84,,94.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.31,80,,587.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,12.84,,94.29,percent of total billed charges,12.84% of total billed charges,117.86,12.84,,94.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,917.89,65,,734.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.26,35,,257.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,550.73,60,,440.58,percent of total billed charges,60% of total billed charges for outpatient setting,117.86,917.89,
"MESH, 3D LIGHT RIGHT LARGE/  0117321",69161000,CDM,278,RC,C1781,HCPCS,Outpatient,,,975.82,975.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.49,60,,468.39,percent of total billed charges,60% of total Billed charges for outpatient setting,828.28,84.88,,662.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.87,75,,585.5,percent of total billed charges,75% of total billed charges for outpatient setting,487.91,50,,390.33,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.66,80,,624.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,125.3,12.84,,100.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,975.82,65,,780.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.54,35,,273.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,585.49,60,,468.39,percent of total billed charges,60% of total billed charges for outpatient setting,125.3,975.82,
"MESH, CONVENTIONAL 8 X8   TEC2020",69160837,CDM,278,RC,,,Outpatient,,,720.87,720.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.52,60,,346.02,percent of total billed charges,60% of total Billed charges for outpatient setting,611.87,84.88,,489.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,360.44,50,,288.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,540.65,75,,432.52,percent of total billed charges,75% of total billed charges for outpatient setting,360.44,50,,288.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.56,12.84,,74.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.7,80,,461.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.56,12.84,,74.05,percent of total billed charges,12.84% of total billed charges,92.56,12.84,,74.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,720.87,65,,576.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.3,35,,201.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,432.52,60,,346.02,percent of total billed charges,60% of total billed charges for outpatient setting,92.56,720.87,
"MESH, PARIETEX 12 x 8    PCO3020",69160722,CDM,278,RC,C1781,HCPCS,Outpatient,,,3684.26,3684.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2210.56,60,,1768.45,percent of total billed charges,60% of total Billed charges for outpatient setting,3127.2,84.88,,2501.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2763.2,75,,2210.56,percent of total billed charges,75% of total billed charges for outpatient setting,1842.13,50,,1473.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.06,12.84,,378.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2947.41,80,,2357.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.06,12.84,,378.45,percent of total billed charges,12.84% of total billed charges,473.06,12.84,,378.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3868.47,105,,3094.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1289.49,35,,1031.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2210.56,60,,1768.45,percent of total billed charges,60% of total billed charges for outpatient setting,473.06,3868.47,
"MESH, PARIETEX 12 X12  TEC3030",69160838,CDM,278,RC,,,Outpatient,,,1272.57,1272.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.54,60,,610.83,percent of total billed charges,60% of total Billed charges for outpatient setting,1080.16,84.88,,864.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,636.29,50,,509.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,954.43,75,,763.54,percent of total billed charges,75% of total billed charges for outpatient setting,636.29,50,,509.03,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.4,12.84,,130.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.06,80,,814.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.4,12.84,,130.72,percent of total billed charges,12.84% of total billed charges,163.4,12.84,,130.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1272.57,65,,1018.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.4,35,,356.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,763.54,60,,610.83,percent of total billed charges,60% of total billed charges for outpatient setting,163.4,1272.57,
"MESH, PARIETEX 15X10CM  PCO1510X",69160983,CDM,278,RC,C1781,HCPCS,Outpatient,,,2045,2045,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1227,60,,981.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1735.8,84.88,,1388.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1533.75,75,,1227,percent of total billed charges,75% of total billed charges for outpatient setting,1022.5,50,,818,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,12.84,,210.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636,80,,1308.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,12.84,,210.06,percent of total billed charges,12.84% of total billed charges,262.58,12.84,,210.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2045,65,,1636,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.75,35,,572.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1227,60,,981.6,percent of total billed charges,60% of total billed charges for outpatient setting,262.58,2045,
"MESH, PARIETEX 3.6  ROUND   PCO9X",69160148,CDM,278,RC,C1781,HCPCS,Outpatient,,,1626.36,1626.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.82,60,,780.66,percent of total billed charges,60% of total Billed charges for outpatient setting,1380.45,84.88,,1104.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.77,75,,975.82,percent of total billed charges,75% of total billed charges for outpatient setting,813.18,50,,650.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.82,12.84,,167.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1301.09,80,,1040.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.82,12.84,,167.06,percent of total billed charges,12.84% of total billed charges,208.82,12.84,,167.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1626.36,65,,1301.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.23,35,,455.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,975.82,60,,780.66,percent of total billed charges,60% of total billed charges for outpatient setting,208.82,1626.36,
"MESH, PARIETEX 4.7  ROUND   PCO12X",69160226,CDM,278,RC,,,Outpatient,,,2015.53,2015.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.32,60,,967.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1710.78,84.88,,1368.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,1007.77,50,,806.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1511.65,75,,1209.32,percent of total billed charges,75% of total billed charges for outpatient setting,1007.77,50,,806.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.79,12.84,,207.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1612.42,80,,1289.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.79,12.84,,207.03,percent of total billed charges,12.84% of total billed charges,258.79,12.84,,207.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2015.53,65,,1612.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.44,35,,564.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1209.32,60,,967.46,percent of total billed charges,60% of total billed charges for outpatient setting,258.79,2015.53,
"MESH, PARIETEX 6  ROUND   PCO15X",69160147,CDM,278,RC,C1781,HCPCS,Outpatient,,,2638.09,2638.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1582.85,60,,1266.28,percent of total billed charges,60% of total Billed charges for outpatient setting,2239.21,84.88,,1791.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1978.57,75,,1582.86,percent of total billed charges,75% of total billed charges for outpatient setting,1319.05,50,,1055.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.73,12.84,,270.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2110.47,80,,1688.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.73,12.84,,270.98,percent of total billed charges,12.84% of total billed charges,338.73,12.84,,270.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2769.99,105,,2215.99,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,923.33,35,,738.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1582.85,60,,1266.28,percent of total billed charges,60% of total billed charges for outpatient setting,338.73,2769.99,
METAGLIP 5/500 : TAB,3303124,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
METANEPHRINES  24 HR URINE,220108,CDM,301,RC,83835,HCPCS,Outpatient,,,76.23,68.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,64.7,84.88,,51.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.17,75,,45.74,percent of total billed charges,75% of total billed charges for outpatient setting,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,80,,48.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,100,,,Fee Schedule,100% of Custom Fee Schedule,68.61,90,,54.89,percent of total billed charges,90% of total billed charges for outpatient setting,16.94,68.61,
METANEPHRINES  PLASMA,220113,CDM,301,RC,83835,HCPCS,Outpatient,,,76.23,68.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,64.7,84.88,,51.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.17,75,,45.74,percent of total billed charges,75% of total billed charges for outpatient setting,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,80,,48.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,100,,,Fee Schedule,100% of Custom Fee Schedule,68.61,90,,54.89,percent of total billed charges,90% of total billed charges for outpatient setting,16.94,68.61,
METAPROTENOL (ALUPENT) INH :650MG 14GM,3301492,CDM,259,RC,,,Outpatient,,,89.52,89.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.66,70,,50.13,percent of total billed charges,70% of total billed charges for outpatient setting,75.98,84.88,,60.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.76,50,,35.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.14,75,,53.71,percent of total billed charges,75% of total billed charges for outpatient setting,62.66,70,,50.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.49,12.84,,9.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.62,80,,57.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.49,12.84,,9.19,percent of total billed charges,12.84% of total billed charges,11.49,12.84,,9.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.19,65,,46.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.33,35,,25.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.57,90,,64.46,percent of total billed charges,90% of total billed charges for outpatient setting,11.49,80.57,
METAPROTERENOL (ALUPENT)0.4%: 2.5ML,3302960,CDM,636,RC,J7668,HCPCS,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.29,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,100,,,Fee Schedule,100% of Custom Fee Schedule,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.29,10.53,
METFORMIN  ER 500 MG TAB,3302880,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
METFORMIN (genericGLUCOPHAGE) 500 MG TAB,3301493,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METFORMIN (GLUCOPHAGE) TAB : 850 MG,3301494,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHADONE (DOLOPHINE) TAB : 10 MG,3301496,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METHADONE (DOLOPHINE) TAB : 5 MG,3301495,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METHAZOLAMIDE (NEPTAZANE) TAB : 50 MG,3301497,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHIMAZOLE (TAPAZOLE) TAB : 10 MG,3301498,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHOCARBAMOL (ROBAXIN) SDV 1000 MG,3301500,CDM,250,RC,,,Outpatient,,,85.22,85.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,72.33,84.88,,57.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.61,50,,34.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.92,75,,51.14,percent of total billed charges,75% of total billed charges for outpatient setting,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.18,80,,54.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.39,65,,44.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,35,,23.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.7,90,,61.36,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,76.7,
METHOCARBAMOL (ROBAXIN) TAB : 750 MG,3301499,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHOCARBAMOL 500MG TAB,3310093,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METHOHEXITAL (BREVITAL) INJ : 500 MG,3301502,CDM,250,RC,,,Outpatient,,,18.84,18.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,70,,10.55,percent of total billed charges,70% of total billed charges for outpatient setting,15.99,84.88,,12.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.42,50,,7.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.13,75,,11.3,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,70,,10.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,12.84,,1.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.07,80,,12.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.42,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.25,65,,9.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,35,,5.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.96,90,,13.57,percent of total billed charges,90% of total billed charges for outpatient setting,2.42,16.96,
METHOHEXITAL (BREVITAL) INJ : 500 MG,3301501,CDM,250,RC,,,Outpatient,,,87.4,87.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.18,70,,48.94,percent of total billed charges,70% of total billed charges for outpatient setting,74.19,84.88,,59.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.7,50,,34.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.55,75,,52.44,percent of total billed charges,75% of total billed charges for outpatient setting,61.18,70,,48.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,12.84,,8.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.92,80,,55.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,11.22,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.81,65,,45.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.59,35,,24.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.66,90,,62.93,percent of total billed charges,90% of total billed charges for outpatient setting,11.22,78.66,
METHOTREXATE (RHEUMATREX) TAB : 2.5MG UD,3301504,CDM,259,RC,,,Outpatient,,,7.95,7.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,84.88,,5.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.98,50,,3.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.96,75,,4.77,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.36,80,,5.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.17,65,,4.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,35,,2.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.16,90,,5.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,7.16,
METHOTREXATE 25MG/ML : INJ:,3301503,CDM,636,RC,J9250,HCPCS,Outpatient,,,32.19,32.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.53,70,,18.02,percent of total billed charges,70% of total billed charges for outpatient setting,27.32,84.88,,21.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.14,75,,19.31,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,70,,18.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.75,80,,20.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.92,65,,16.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.26,100,,,Fee Schedule,100% of Custom Fee Schedule,28.97,90,,23.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.26,28.97,
METHSCOPOLAMINE BROMIDE(PAMINE)2.5MG:TAB,3302975,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHYL (ANALGESIC BALM) OINT : 1 OZ,3301505,CDM,259,RC,,,Outpatient,,,4.32,4.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,84.88,,2.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.16,50,,1.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.24,75,,2.59,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,80,,2.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.81,65,,2.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,35,,1.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.89,90,,3.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.89,
METHYL SAL (BENGAY) OINT : 2 OZ,3301506,CDM,259,RC,,,Outpatient,,,11.8,11.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,70,,6.61,percent of total billed charges,70% of total billed charges for outpatient setting,10.02,84.88,,8.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.9,50,,4.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.85,75,,7.08,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,70,,6.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,80,,7.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.67,65,,6.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,35,,3.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.62,90,,8.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,10.62,
METHYLDOPA (ALDOMET) TAB : 250 MG,3301508,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METHYLDOPA (ALDOMET) TAB : 250MG UD,3301507,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METHYLENE BLUE 0.5% 10ML 5MG/ML VIAL/AMP,3308666,CDM,250,RC,,,Outpatient,,,547.71,547.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.4,70,,306.72,percent of total billed charges,70% of total billed charges for outpatient setting,464.9,84.88,,371.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,273.86,50,,219.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.78,75,,328.62,percent of total billed charges,75% of total billed charges for outpatient setting,383.4,70,,306.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.33,12.84,,56.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.17,80,,350.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.33,12.84,,56.26,percent of total billed charges,12.84% of total billed charges,70.33,12.84,,56.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,356.01,65,,284.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.7,35,,153.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,492.94,90,,394.35,percent of total billed charges,90% of total billed charges for outpatient setting,70.33,492.94,
METHYLENE BLUE VIAL 1% : 10ML,3308615,CDM,250,RC,,,Outpatient,,,484.17,484.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.92,70,,271.14,percent of total billed charges,70% of total billed charges for outpatient setting,410.96,84.88,,328.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,242.09,50,,193.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,363.13,75,,290.5,percent of total billed charges,75% of total billed charges for outpatient setting,338.92,70,,271.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.17,12.84,,49.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.34,80,,309.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.17,12.84,,49.74,percent of total billed charges,12.84% of total billed charges,62.17,12.84,,49.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,314.71,65,,251.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.46,35,,135.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,435.75,90,,348.6,percent of total billed charges,90% of total billed charges for outpatient setting,62.17,435.75,
METHYLENE BLUE VIAL 1% 1ML,3301509,CDM,250,RC,,,Outpatient,,,152.49,152.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.74,70,,85.39,percent of total billed charges,70% of total billed charges for outpatient setting,129.43,84.88,,103.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.25,50,,61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.37,75,,91.5,percent of total billed charges,75% of total billed charges for outpatient setting,106.74,70,,85.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,12.84,,15.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.99,80,,97.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,12.84,,15.66,percent of total billed charges,12.84% of total billed charges,19.58,12.84,,15.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.12,65,,79.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.37,35,,42.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.24,90,,109.79,percent of total billed charges,90% of total billed charges for outpatient setting,19.58,137.24,
METHYLERGONOVINE(METHERGINE)0.2MG/ML,3303296,CDM,250,RC,,,Outpatient,,,102.94,102.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.06,70,,57.65,percent of total billed charges,70% of total billed charges for outpatient setting,87.38,84.88,,69.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.47,50,,41.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.21,75,,61.77,percent of total billed charges,75% of total billed charges for outpatient setting,72.06,70,,57.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.35,80,,65.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,13.22,12.84,,10.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.91,65,,53.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.03,35,,28.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.65,90,,74.12,percent of total billed charges,90% of total billed charges for outpatient setting,13.22,92.65,
"METHYLMALONIC ACID,SERUM",220002,CDM,301,RC,83921,HCPCS,Outpatient,,,95.45,85.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.82,70,,53.46,percent of total billed charges,70% of total billed charges for outpatient setting,81.02,84.88,,64.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.59,75,,57.27,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,70,,53.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,80,,61.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.21,100,,,Fee Schedule,100% of Custom Fee Schedule,85.91,90,,68.73,percent of total billed charges,90% of total billed charges for outpatient setting,21.21,85.91,
METHYLNALTREXONE BROMIDE(RELISTOR):12MG,3304750,CDM,250,RC,,,Outpatient,,,186.9,186.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.83,70,,104.66,percent of total billed charges,70% of total billed charges for outpatient setting,158.64,84.88,,126.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,93.45,50,,74.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.18,75,,112.14,percent of total billed charges,75% of total billed charges for outpatient setting,130.83,70,,104.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,12.84,,19.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.52,80,,119.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,12.84,,19.2,percent of total billed charges,12.84% of total billed charges,24,12.84,,19.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,121.49,65,,97.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.42,35,,52.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,168.21,90,,134.57,percent of total billed charges,90% of total billed charges for outpatient setting,24,168.21,
METHYLPHENIDATE (RITALIN) TAB : 5 MG,3301510,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
METHYLPRED (A-METHAPRED) INJ : 125MG,3301516,CDM,250,RC,,,Outpatient,,,103.12,103.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,70,,57.74,percent of total billed charges,70% of total billed charges for outpatient setting,87.53,84.88,,70.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.56,50,,41.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.34,75,,61.87,percent of total billed charges,75% of total billed charges for outpatient setting,72.18,70,,57.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,12.84,,10.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.5,80,,66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,12.84,,10.59,percent of total billed charges,12.84% of total billed charges,13.24,12.84,,10.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.03,65,,53.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.09,35,,28.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.81,90,,74.25,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,92.81,
METHYLPRED (A-METHAPRED) INJ : 40MG,3301515,CDM,250,RC,,,Outpatient,,,76.65,76.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,65.06,84.88,,52.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.33,50,,30.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.49,75,,45.99,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.32,80,,49.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.82,65,,39.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.83,35,,21.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.99,90,,55.19,percent of total billed charges,90% of total billed charges for outpatient setting,9.84,68.99,
METHYLPRED (DEPO MEDROL) 80MG  1CC,3301513,CDM,636,RC,J1030,HCPCS,Outpatient,,,102.53,102.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.77,70,,57.42,percent of total billed charges,70% of total billed charges for outpatient setting,87.03,84.88,,69.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,76.9,75,,61.52,percent of total billed charges,75% of total billed charges for outpatient setting,71.77,70,,57.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,12.84,,10.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.02,80,,65.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,12.84,,10.53,percent of total billed charges,12.84% of total billed charges,13.16,12.84,,10.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.64,65,,53.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.6,100,,,Fee Schedule,100% of Custom Fee Schedule,92.28,90,,73.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,92.28,
METHYLPRED (DEPO MEDROL)INJ 40MG/ML:1ML,3301512,CDM,636,RC,J1020,HCPCS,Outpatient,,,44.69,44.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.28,70,,25.02,percent of total billed charges,70% of total billed charges for outpatient setting,37.93,84.88,,30.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,33.52,75,,26.82,percent of total billed charges,75% of total billed charges for outpatient setting,31.28,70,,25.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,12.84,,4.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.75,80,,28.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,12.84,,4.59,percent of total billed charges,12.84% of total billed charges,5.74,12.84,,4.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.05,65,,23.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,100,,,Fee Schedule,100% of Custom Fee Schedule,40.22,90,,32.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.51,40.22,
METHYLPRED (MEDROL) TAB : 4 MG UD,3301511,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METHYLPRED (SOLU MEDROL) INJ  1GM,3301517,CDM,250,RC,J2919,HCPCS,Outpatient,,,208.9,208.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.23,70,,116.98,percent of total billed charges,70% of total billed charges for outpatient setting,177.31,84.88,,141.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,104.45,50,,83.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.68,75,,125.34,percent of total billed charges,75% of total billed charges for outpatient setting,146.23,70,,116.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.82,12.84,,21.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.12,80,,133.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.82,12.84,,21.46,percent of total billed charges,12.84% of total billed charges,26.82,12.84,,21.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,135.79,65,,108.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,35,,58.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,188.01,90,,150.41,percent of total billed charges,90% of total billed charges for outpatient setting,26.82,188.01,
METHYLPRED (SOLU MEDROL) INJ : 125MG,3301514,CDM,250,RC,,,Outpatient,,,9.24,9.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,7.84,84.88,,6.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.62,50,,3.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.93,75,,5.54,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,70,,5.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.39,80,,5.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.01,65,,4.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,35,,2.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.32,90,,6.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.32,
METHYLPRED (SOLU MEDROL) INJ : 40MG,3301518,CDM,636,RC,J2920,HCPCS,Outpatient,,,76.65,76.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,65.06,84.88,,52.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.49,75,,45.99,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,70,,42.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.32,80,,49.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.82,65,,39.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of Custom Fee Schedule,68.99,90,,55.19,percent of total billed charges,90% of total billed charges for outpatient setting,4.68,68.99,
METHYLPRED (SOLU-MEDROL) INJ 125MG,3301519,CDM,636,RC,J2919,HCPCS,Outpatient,,,55.49,55.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.84,70,,31.07,percent of total billed charges,70% of total billed charges for outpatient setting,47.1,84.88,,37.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.75,50,,22.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.62,75,,33.3,percent of total billed charges,75% of total billed charges for outpatient setting,38.84,70,,31.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,12.84,,5.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.39,80,,35.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,7.12,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.07,65,,28.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,35,,15.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.94,90,,39.95,percent of total billed charges,90% of total billed charges for outpatient setting,7.12,49.94,
METHYLPREDNISOLONE 4MG DOSEPAK  21 TABS,3303054,CDM,259,RC,,,Outpatient,,,36.8,36.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.76,70,,20.61,percent of total billed charges,70% of total billed charges for outpatient setting,31.24,84.88,,24.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.4,50,,14.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.6,75,,22.08,percent of total billed charges,75% of total billed charges for outpatient setting,25.76,70,,20.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.44,80,,23.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.92,65,,19.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,35,,10.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.12,90,,26.5,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,33.12,
METOCLOPRAMIDE (genREGLAN) 10 MG TAB,3301520,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOCLOPRAMIDE (genREGLAN)inj 5MG/ML 2ML,3301525,CDM,636,RC,J2765,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOCLOPRAMIDE (REGLAN) INJ : 5MG/ML 2ML,3301524,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOCLOPRAMIDE (REGLAN) INJ : 5MG/ML 2ML,3301526,CDM,250,RC,,,Outpatient,,,6.34,6.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,70,,3.55,percent of total billed charges,70% of total billed charges for outpatient setting,5.38,84.88,,4.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.17,50,,2.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.76,75,,3.81,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,70,,3.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,80,,4.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.12,65,,3.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.22,35,,1.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.71,90,,4.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.81,5.71,
METOCLOPRAMIDE (REGLAN) SDV : 5MG/ML 2ML,3301522,CDM,250,RC,,,Outpatient,,,11.74,11.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,70,,6.58,percent of total billed charges,70% of total billed charges for outpatient setting,9.96,84.88,,7.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.87,50,,4.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.81,75,,7.05,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,70,,6.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,80,,7.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.63,65,,6.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,35,,3.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.57,90,,8.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.51,10.57,
METOCLOPRAMIDE (REGLAN) TAB : 10 MG,3301523,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOCLOPRAMIDE (REGLAN) TAB : 5 MG  UD,3301521,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
METOCLOPRAMIDE oral SOLN 1MG/ML  10ML,3303323,CDM,259,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
METOLAZONE (genZAROXOLYN) 2.5 MG TAB,3301527,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METOLAZONE (ZAROXOLYN):5 MG TAB,3302863,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
METOPROLOL (genericLOPRESSOR)  50 MG TAB,3302835,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOPROLOL (LOPRESSOR) 5MG/5 ML VIAL,3301534,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOPROLOL (LOPRESSOR) TAB : 100 MG  U/D,3301533,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOPROLOL (LOPRESSOR) TAB : 50 MG,3301530,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOPROLOL (LOPRESSOR) TAB : 50 MG,3301531,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOPROLOL (LOPRESSOR) TAB : 50 MG U/D,3301532,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METOPROLOL (TOPROL XL) TAB : 100 MG,3301529,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
METOPROLOL SUCC ER (genTOPROL XL) 25MG,3302698,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOPROLOL SUCC ER (genTOPROL XL) 50 MG,3301528,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METOPROLOL TART(genLOPRESSOR) 25MG TAB,3307662,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METRONIDAZOLE (FLAGYL) PREMIX : 500 MG,3301544,CDM,250,RC,,,Outpatient,,,21.17,21.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,17.97,84.88,,14.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.59,50,,8.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.88,75,,12.7,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,70,,11.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.94,80,,13.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.76,65,,11.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,35,,5.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.05,90,,15.24,percent of total billed charges,90% of total billed charges for outpatient setting,2.72,19.05,
METRONIDAZOLE (FLAGYL) TAB  250 MG U/D,3301537,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METRONIDAZOLE (FLAGYL) TAB : 50 MG,3301536,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METRONIDAZOLE (FLAGYL) TAB : 500 MG,3301535,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METRONIDAZOLE (FLAGYL) TAB : 500 MG,3301539,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METRONIDAZOLE (FLAGYL) TAB : 500 MG,3301540,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METRONIDAZOLE (FLAGYL) TAB : 500 MG U/D,3301538,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
METRONIDAZOLE (FLAGYL) TAB : 500 MG U/D,3303257,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
METRONIDAZOLE (genFLAGYL) PREMIX 500 MG,3301543,CDM,250,RC,J3490,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
METRONIDAZOLE (METROGEL) GEL: 30 GM,3301541,CDM,259,RC,,,Outpatient,,,98.92,98.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.24,70,,55.39,percent of total billed charges,70% of total billed charges for outpatient setting,83.96,84.88,,67.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.46,50,,39.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.19,75,,59.35,percent of total billed charges,75% of total billed charges for outpatient setting,69.24,70,,55.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.14,80,,63.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,12.7,12.84,,10.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.3,65,,51.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.62,35,,27.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.03,90,,71.22,percent of total billed charges,90% of total billed charges for outpatient setting,12.7,89.03,
METRONIDAZOLE (METROGEL-VAGL) GEL: 70 GM,3301542,CDM,259,RC,,,Outpatient,,,120.83,120.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.58,70,,67.66,percent of total billed charges,70% of total billed charges for outpatient setting,102.56,84.88,,82.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.42,50,,48.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.62,75,,72.5,percent of total billed charges,75% of total billed charges for outpatient setting,84.58,70,,67.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,12.84,,12.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.66,80,,77.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,12.84,,12.41,percent of total billed charges,12.84% of total billed charges,15.51,12.84,,12.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78.54,65,,62.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.29,35,,33.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108.75,90,,87,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,108.75,
MEXILETINE (MEXITIL) CAP : 150 MG,3301545,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
M-FERRITIN,221043,CDM,301,RC,82728,HCPCS,Outpatient,,,61.34,55.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,52.07,84.88,,41.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.01,75,,36.81,percent of total billed charges,75% of total billed charges for outpatient setting,42.94,70,,34.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.07,80,,39.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.84,100,,,Fee Schedule,100% of Custom Fee Schedule,55.21,90,,44.17,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,55.21,
M-FINGERSTICK GLUCOSE,221020,CDM,300,RC,82962,HCPCS,Outpatient,,,14.76,13.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,70,,8.26,percent of total billed charges,70% of total billed charges for outpatient setting,12.53,84.88,,10.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,11.07,75,,8.86,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,70,,8.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.81,80,,9.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.42,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.45,100,,,Fee Schedule,100% of Custom Fee Schedule,13.28,90,,10.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,13.28,
M-FLU A & B,221024,CDM,306,RC,87804,HCPCS,Outpatient,,,74.48,67.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.14,70,,41.71,percent of total billed charges,70% of total billed charges for outpatient setting,63.22,84.88,,50.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.86,75,,44.69,percent of total billed charges,75% of total billed charges for outpatient setting,52.14,70,,41.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.58,80,,47.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,67.03,90,,53.62,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,67.03,
M-FOLATE,221044,CDM,300,RC,82746,HCPCS,Outpatient,,,66.15,59.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.88,100,,,Fee Schedule,100% of Custom Fee Schedule,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,14.7,59.54,
"M-GFR,ESTIMATED",221035,CDM,300,RC,82565,HCPCS,Outpatient,,,23.04,20.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,84.88,,15.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.28,75,,13.82,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,70,,12.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,80,,14.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,100,,,Fee Schedule,100% of Custom Fee Schedule,20.74,90,,16.59,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,20.74,
M-H. PYLORI,221026,CDM,302,RC,86318,HCPCS,Outpatient,,,81.41,73.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.99,70,,45.59,percent of total billed charges,70% of total billed charges for outpatient setting,69.1,84.88,,55.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,61.06,75,,48.85,percent of total billed charges,75% of total billed charges for outpatient setting,56.99,70,,45.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.13,80,,52.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,73.27,90,,58.62,percent of total billed charges,90% of total billed charges for outpatient setting,15.55,73.27,
M-HCG URINE,221019,CDM,307,RC,81025,HCPCS,Outpatient,,,38.75,34.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,32.89,84.88,,26.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.06,75,,23.25,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,80,,24.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of Custom Fee Schedule,34.88,90,,27.9,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,34.88,
"M-HEMOCCULT, DIAGNOSTIC",221029,CDM,300,RC,82272,HCPCS,Outpatient,,,19.04,17.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,16.16,84.88,,12.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.28,75,,11.42,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,80,,12.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.14,90,,13.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,17.14,
"M-HEMOCCULT, SCREENING",221028,CDM,300,RC,82270,HCPCS,Outpatient,,,19.71,17.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,17.74,
M-HEMOGLOBIN A1C,221027,CDM,300,RC,83036,HCPCS,Outpatient,,,43.7,39.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,37.09,84.88,,29.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.78,75,,26.22,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,80,,27.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,100,,,Fee Schedule,100% of Custom Fee Schedule,39.33,90,,31.46,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,39.33,
MICAFUNGIN 100MG INJ,3314173,CDM,636,RC,J2248,HCPCS,Outpatient,,,140.1,140.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,118.92,84.88,,95.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,105.08,75,,84.06,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,70,,78.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.08,80,,89.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,17.99,12.84,,14.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.07,65,,72.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,100,,,Fee Schedule,100% of Custom Fee Schedule,126.09,90,,100.87,percent of total billed charges,90% of total billed charges for outpatient setting,0.89,126.09,
MICARDIS 40MG TAB,3303019,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
MICARDIS(TELMISARTAN) :80 MG,3303023,CDM,259,RC,,,Outpatient,,,12.32,12.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,70,,6.9,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,84.88,,8.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.16,50,,4.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.24,75,,7.39,percent of total billed charges,75% of total billed charges for outpatient setting,8.62,70,,6.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.58,12.84,,1.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,80,,7.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.58,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.58,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.01,65,,6.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,35,,3.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.09,90,,8.87,percent of total billed charges,90% of total billed charges for outpatient setting,1.58,11.09,
MICARDIS: 80/12.5 MG,3302988,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MICONAZOLE (MITRAZOLE) POWD 2% : 30GM,3301550,CDM,259,RC,,,Outpatient,,,21.43,21.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,70,,12,percent of total billed charges,70% of total billed charges for outpatient setting,18.19,84.88,,14.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.72,50,,8.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,15,70,,12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,2.75,12.84,,2.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.93,65,,11.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,35,,6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.29,90,,15.43,percent of total billed charges,90% of total billed charges for outpatient setting,2.75,19.29,
MICONAZOLE (MONISTAT 7) CRM 2% : 1.59OZ,3301547,CDM,259,RC,,,Outpatient,,,26.42,26.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,70,,14.79,percent of total billed charges,70% of total billed charges for outpatient setting,22.43,84.88,,17.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.21,50,,10.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.82,75,,15.86,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,70,,14.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.14,80,,16.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,65,,13.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,35,,7.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.78,90,,19.02,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.78,
MICONAZOLE (MONISTAT 7) SUPP :,3301548,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
MICONAZOLE (MONISTAT KIT) CRM : 30 GM,3301551,CDM,259,RC,,,Outpatient,,,5.26,5.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,4.46,84.88,,3.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.63,50,,2.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.95,75,,3.16,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,80,,3.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.42,65,,2.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.84,35,,1.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.73,90,,3.78,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.73,
MICONAZOLE (MONISTAT) 2% CRM :  45GM,3301552,CDM,259,RC,,,Outpatient,,,24.5,24.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,70,,13.72,percent of total billed charges,70% of total billed charges for outpatient setting,20.8,84.88,,16.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.25,50,,9.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.38,75,,14.7,percent of total billed charges,75% of total billed charges for outpatient setting,17.15,70,,13.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,12.84,,2.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,80,,15.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,12.84,,2.52,percent of total billed charges,12.84% of total billed charges,3.15,12.84,,2.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.93,65,,12.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,35,,6.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.05,90,,17.64,percent of total billed charges,90% of total billed charges for outpatient setting,3.15,22.05,
MICONAZOLE (MONISTAT) 2% KIT W/APPL CRM:,3301549,CDM,259,RC,,,Outpatient,,,36.25,36.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.38,70,,20.3,percent of total billed charges,70% of total billed charges for outpatient setting,30.77,84.88,,24.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.13,50,,14.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.19,75,,21.75,percent of total billed charges,75% of total billed charges for outpatient setting,25.38,70,,20.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,12.84,,3.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29,80,,23.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,12.84,,3.72,percent of total billed charges,12.84% of total billed charges,4.65,12.84,,3.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.56,65,,18.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,35,,10.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,90% of total billed charges for outpatient setting,4.65,32.63,
MICONAZOLE (MONISTAT) CRM : 45 GM,3301546,CDM,259,RC,,,Outpatient,,,21.97,21.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,18.65,84.88,,14.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.99,50,,8.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.48,75,,13.18,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,12.84,,2.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.58,80,,14.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,2.82,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.28,65,,11.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.69,35,,6.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.77,90,,15.82,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,19.77,
MICONAZOLE-7 NITRATE 2%: 45GM,3303119,CDM,259,RC,,,Outpatient,,,35.53,35.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.87,70,,19.9,percent of total billed charges,70% of total billed charges for outpatient setting,30.16,84.88,,24.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.77,50,,14.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.65,75,,21.32,percent of total billed charges,75% of total billed charges for outpatient setting,24.87,70,,19.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,12.84,,3.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.42,80,,22.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,12.84,,3.65,percent of total billed charges,12.84% of total billed charges,4.56,12.84,,3.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.09,65,,18.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,35,,9.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.98,90,,25.58,percent of total billed charges,90% of total billed charges for outpatient setting,4.56,31.98,
MICRO LINK ENDO COGENT,69159026,CDM,360,RC,,,Outpatient,,,809.91,809.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.94,70,,453.55,percent of total billed charges,70% of total billed charges for outpatient setting,687.45,84.88,,549.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,404.96,50,,323.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,607.43,75,,485.94,percent of total billed charges,75% of total billed charges for outpatient setting,566.94,70,,453.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,12.84,,83.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.93,80,,518.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,12.84,,83.19,percent of total billed charges,12.84% of total billed charges,103.99,12.84,,83.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.47,35,,226.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,728.92,90,,583.14,percent of total billed charges,90% of total billed charges for outpatient setting,103.99,728.92,
MICRO PULSE P3 / IRIDEX LASER /15522,69169261,CDM,272,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,891.24,84.88,,712.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,525,50,,420,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.5,75,,630,percent of total billed charges,75% of total billed charges for outpatient setting,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,80,,672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,682.5,65,,546,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,35,,294,percent of total billed charges,35% of total Billed charges for Outpatient Setting,945,90,,756,percent of total billed charges,90% of total billed charges for outpatient setting,134.82,945,
MICROALBUMIN 24 HR URINE,220801,CDM,301,RC,82043,HCPCS,Outpatient,,,26.01,23.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,22.08,84.88,,17.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.51,75,,15.61,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,80,,16.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,100,,,Fee Schedule,100% of Custom Fee Schedule,23.41,90,,18.73,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,23.41,
"MICROALBUMIN, RANDOM URINE W CREAT RATIO",220051,CDM,300,RC,82043,HCPCS,Outpatient,,,26.01,23.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,22.08,84.88,,17.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.51,75,,15.61,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,80,,16.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,100,,,Fee Schedule,100% of Custom Fee Schedule,23.41,90,,18.73,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,23.41,
MICROLARYNGEAL 4.0,7600860,CDM,272,RC,,,Outpatient,,,92.2,92.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.54,70,,51.63,percent of total billed charges,70% of total billed charges for outpatient setting,78.26,84.88,,62.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.1,50,,36.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.15,75,,55.32,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,70,,51.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,12.84,,9.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.76,80,,59.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,12.84,,9.47,percent of total billed charges,12.84% of total billed charges,11.84,12.84,,9.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.93,65,,47.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.27,35,,25.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.98,90,,66.38,percent of total billed charges,90% of total billed charges for outpatient setting,11.84,82.98,
MICROLARYNGEAL 5.0,7600850,CDM,272,RC,,,Outpatient,,,53.13,53.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.19,70,,29.75,percent of total billed charges,70% of total billed charges for outpatient setting,45.1,84.88,,36.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.57,50,,21.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.85,75,,31.88,percent of total billed charges,75% of total billed charges for outpatient setting,37.19,70,,29.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,12.84,,5.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.5,80,,34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,12.84,,5.46,percent of total billed charges,12.84% of total billed charges,6.82,12.84,,5.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.53,65,,27.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,35,,14.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.82,90,,38.26,percent of total billed charges,90% of total billed charges for outpatient setting,6.82,47.82,
MICROLARYNGEAL 6.0,7600855,CDM,272,RC,,,Outpatient,,,59.09,59.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.36,70,,33.09,percent of total billed charges,70% of total billed charges for outpatient setting,50.16,84.88,,40.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.55,50,,23.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.32,75,,35.46,percent of total billed charges,75% of total billed charges for outpatient setting,41.36,70,,33.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.27,80,,37.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.41,65,,30.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,35,,16.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.18,90,,42.54,percent of total billed charges,90% of total billed charges for outpatient setting,7.59,53.18,
MICROMATRIX 1MG / MM1000,69162675,CDM,278,RC,Q4118,HCPCS,Outpatient,,,4960,4960,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2976,60,,2380.8,percent of total billed charges,60% of total Billed charges for outpatient setting,4210.05,84.88,,3368.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3720,75,,2976,percent of total billed charges,75% of total billed charges for outpatient setting,2480,50,,1984,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.86,12.84,,509.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3968,80,,3174.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.86,12.84,,509.49,percent of total billed charges,12.84% of total billed charges,636.86,12.84,,509.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5208,105,,4166.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2976,60,,2380.8,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,5208,
MICROMATRIX PER 1MG / MM0500,69162521,CDM,278,RC,Q4118,HCPCS,Outpatient,,,2850.16,2850.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1710.1,60,,1368.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2419.22,84.88,,1935.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2137.62,75,,1710.1,percent of total billed charges,75% of total billed charges for outpatient setting,1425.08,50,,1140.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.96,12.84,,292.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2280.13,80,,1824.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.96,12.84,,292.77,percent of total billed charges,12.84% of total billed charges,365.96,12.84,,292.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2992.67,105,,2394.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1710.1,60,,1368.08,percent of total billed charges,60% of total billed charges for outpatient setting,3.56,2992.67,
MIDAS REX 4MM AM8 / 14MH40,70000498,CDM,272,RC,,,Outpatient,,,761.38,761.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.97,70,,426.38,percent of total billed charges,70% of total billed charges for outpatient setting,646.26,84.88,,517.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,380.69,50,,304.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,571.04,75,,456.83,percent of total billed charges,75% of total billed charges for outpatient setting,532.97,70,,426.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.76,12.84,,78.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.1,80,,487.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.76,12.84,,78.21,percent of total billed charges,12.84% of total billed charges,97.76,12.84,,78.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,494.9,65,,395.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.48,35,,213.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,685.24,90,,548.19,percent of total billed charges,90% of total billed charges for outpatient setting,97.76,685.24,
MIDAS REX CORNERSTONE BUR 5MM 874-455,69161772,CDM,272,RC,,,Outpatient,,,699.56,699.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.69,70,,391.75,percent of total billed charges,70% of total billed charges for outpatient setting,593.79,84.88,,475.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,349.78,50,,279.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,524.67,75,,419.74,percent of total billed charges,75% of total billed charges for outpatient setting,489.69,70,,391.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.82,12.84,,71.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.65,80,,447.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.82,12.84,,71.86,percent of total billed charges,12.84% of total billed charges,89.82,12.84,,71.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,454.71,65,,363.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.85,35,,195.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.6,90,,503.68,percent of total billed charges,90% of total billed charges for outpatient setting,89.82,629.6,
MIDAZOLAM (VERSED) AMP 1MG/ML:2ML,3301560,CDM,250,RC,,,Outpatient,,,9.1,9.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,7.72,84.88,,6.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.55,50,,3.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.83,75,,5.46,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,80,,5.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.92,65,,4.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,35,,2.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.19,90,,6.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.17,8.19,
MIDAZOLAM (VERSED) INJ : 1 MG/ML,3301562,CDM,250,RC,,,Outpatient,,,14.95,14.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,70,,8.38,percent of total billed charges,70% of total billed charges for outpatient setting,12.69,84.88,,10.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.48,50,,5.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,75,,8.97,percent of total billed charges,75% of total billed charges for outpatient setting,10.47,70,,8.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.92,12.84,,1.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,80,,9.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.92,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,1.92,12.84,,1.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.72,65,,7.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.23,35,,4.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.46,90,,10.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.92,13.46,
MIDAZOLAM (VERSED) INJ 1MG/ML  2ML,3301565,CDM,636,RC,J2250,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,2.92,
MIDAZOLAM (VERSED) INJ 1MG/ML : 2ML,3301554,CDM,250,RC,,,Outpatient,,,8.69,8.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.08,70,,4.86,percent of total billed charges,70% of total billed charges for outpatient setting,7.38,84.88,,5.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.35,50,,3.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.52,75,,5.22,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,70,,4.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,80,,5.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.65,65,,4.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,35,,2.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.82,90,,6.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.12,7.82,
MIDAZOLAM (VERSED) INJ 1MG/ML: 10ML,3301559,CDM,250,RC,,,Outpatient,,,4.85,4.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,84.88,,3.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.43,50,,1.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.64,75,,2.91,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,80,,3.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.15,65,,2.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,35,,1.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.37,90,,3.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.37,
MIDAZOLAM (VERSED) INJ 5MG/ML:2ML,3301557,CDM,250,RC,,,Outpatient,,,9.1,9.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,7.72,84.88,,6.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.55,50,,3.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.83,75,,5.46,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,70,,5.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,80,,5.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,1.17,12.84,,0.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.92,65,,4.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.19,35,,2.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.19,90,,6.55,percent of total billed charges,90% of total billed charges for outpatient setting,1.17,8.19,
MIDAZOLAM (VERSED) MDV 1MG/ML : 5ML,3301563,CDM,250,RC,,,Outpatient,,,34.58,34.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,29.35,84.88,,23.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.29,50,,13.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.94,75,,20.75,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,70,,19.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,80,,22.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,4.44,12.84,,3.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.48,65,,17.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,35,,9.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.12,90,,24.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.44,31.12,
MIDAZOLAM (VERSED) SDV 1MG/ML : 2ML,3301561,CDM,250,RC,,,Outpatient,,,15.77,15.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,70,,8.83,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,84.88,,10.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.89,50,,6.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.83,75,,9.46,percent of total billed charges,75% of total billed charges for outpatient setting,11.04,70,,8.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,80,,10.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.25,65,,8.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,35,,4.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.19,90,,11.35,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.19,
MIDAZOLAM (VERSED) SDV 1MG/ML : 5ML,3301558,CDM,250,RC,,,Outpatient,,,32.89,32.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.02,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,27.92,84.88,,22.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.45,50,,13.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.67,75,,19.74,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,12.84,,3.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.31,80,,21.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,4.22,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.38,65,,17.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.51,35,,9.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.6,90,,23.68,percent of total billed charges,90% of total billed charges for outpatient setting,4.22,29.6,
MIDAZOLAM (VERSED) SDV 5MG/ML : 1ML,3301564,CDM,250,RC,,,Outpatient,,,10.73,10.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.51,70,,6.01,percent of total billed charges,70% of total billed charges for outpatient setting,9.11,84.88,,7.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.37,50,,4.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.05,75,,6.44,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,70,,6.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,80,,6.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.97,65,,5.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,35,,3.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.66,90,,7.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.66,
MIDAZOLAM (VERSED)INJ 1MG/ML: 5ML,3301556,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MIDAZOLAM (VERSED)INJ 5MG/ML:1ML,3301555,CDM,636,RC,J2250,HCPCS,Outpatient,,,105.86,105.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.1,70,,59.28,percent of total billed charges,70% of total billed charges for outpatient setting,89.85,84.88,,71.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.4,75,,63.52,percent of total billed charges,75% of total billed charges for outpatient setting,74.1,70,,59.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.69,80,,67.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.81,65,,55.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,95.27,90,,76.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,95.27,
MIDAZOLAM SYRUP 10 MG/5 MLORAL UD,3302676,CDM,259,RC,,,Outpatient,,,35,35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,29.71,84.88,,23.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.5,50,,14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.25,75,,21,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,80,,22.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.75,65,,18.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,35,,9.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.5,
MIDODRINE (PROAMATINE) TAB : 5 MG,3301566,CDM,259,RC,,,Outpatient,,,5.73,5.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,70,,3.21,percent of total billed charges,70% of total billed charges for outpatient setting,4.86,84.88,,3.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.87,50,,2.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.3,75,,3.44,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,70,,3.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,80,,3.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.72,65,,2.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,35,,1.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.16,90,,4.13,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.16,
MIDRIN: CAPSULES,3302892,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MIDSTREAM CATH KIT RIGID,510048,CDM,270,RC,,,Outpatient,,,6.75,6.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,5.73,84.88,,4.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.38,50,,2.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.06,75,,4.05,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,70,,3.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,80,,4.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.39,65,,3.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,35,,1.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.08,90,,4.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.08,
MILK OF MAG (PHILLIPS):500 MG TABS,3303173,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MILK OF MAG LIQ W/CASCARA: 30ML,3301454,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MILK OF MAG LIQ: 30ML UD,3301456,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MILK OF MAG LIQ: 360ML,3301455,CDM,259,RC,,,Outpatient,,,5.66,5.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,84.88,,3.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.83,50,,2.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.25,75,,3.4,percent of total billed charges,75% of total billed charges for outpatient setting,3.96,70,,3.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,80,,3.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.73,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.68,65,,2.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,35,,1.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.09,90,,4.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.73,5.09,
MILK OF MAGNESIA CONCENTRATE 10 ML,3303255,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MILK OF MAGNESIA:118 ML BOTTLE,3302683,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MILOOP EXTRACTION LENS / 303071-9090-00,71000178,CDM,272,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390,65,,312,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540,90,,432,percent of total billed charges,90% of total billed charges for outpatient setting,77.04,540,
MINERAL OIL (CARRINGTON BAR) CRM : 3.5OZ,3301571,CDM,259,RC,,,Outpatient,,,19.27,19.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.49,70,,10.79,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,84.88,,13.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.64,50,,7.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.45,75,,11.56,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,70,,10.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,80,,12.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.53,65,,10.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,35,,5.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.34,90,,13.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,17.34,
MINERAL OIL (TEARS RENEWED) OINT : 3.5GM,3301570,CDM,259,RC,,,Outpatient,,,14.55,14.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,70,,8.15,percent of total billed charges,70% of total billed charges for outpatient setting,12.35,84.88,,9.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.28,50,,5.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.91,75,,8.73,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,70,,8.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,80,,9.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.46,65,,7.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,35,,4.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.1,90,,10.48,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,13.1,
MINERAL OIL : 30 ML  STRL LIGHT,3301569,CDM,259,RC,,,Outpatient,,,5.26,5.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,4.46,84.88,,3.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.63,50,,2.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.95,75,,3.16,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,80,,3.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.42,65,,2.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.84,35,,1.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.73,90,,3.78,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.73,
MINERAL OIL : 30 ML  U/D,3301568,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MINERAL OIL : 473ML,3301567,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MINERAL OIL TOPICAL LIGHT USP 10 ML,3302886,CDM,259,RC,,,Outpatient,,,65.04,65.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.53,70,,36.42,percent of total billed charges,70% of total billed charges for outpatient setting,55.21,84.88,,44.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.52,50,,26.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.78,75,,39.02,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,70,,36.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,12.84,,6.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.03,80,,41.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,12.84,,6.68,percent of total billed charges,12.84% of total billed charges,8.35,12.84,,6.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.28,65,,33.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.76,35,,18.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.54,90,,46.83,percent of total billed charges,90% of total billed charges for outpatient setting,8.35,58.54,
MINOCYCLINE (MINOCIN) CAP: 50 MG,3301572,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MINOXIDIL: 10 MG TAB,3302856,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MINOXIDIL: 2.5 MG TAB,3302991,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MIOCHOL-E(ACETYLCHOLINE) INTRAOCULAR,3307626,CDM,259,RC,,,Outpatient,,,283.88,283.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.72,70,,158.98,percent of total billed charges,70% of total billed charges for outpatient setting,240.96,84.88,,192.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,141.94,50,,113.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.91,75,,170.33,percent of total billed charges,75% of total billed charges for outpatient setting,198.72,70,,158.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,12.84,,29.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.1,80,,181.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,12.84,,29.16,percent of total billed charges,12.84% of total billed charges,36.45,12.84,,29.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,184.52,65,,147.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,35,,79.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,255.49,90,,204.39,percent of total billed charges,90% of total billed charges for outpatient setting,36.45,255.49,
MIOSTAT (CARBACHOL) 0.01% INTRAOCULAR,3303286,CDM,259,RC,,,Outpatient,,,208.7,208.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.09,70,,116.87,percent of total billed charges,70% of total billed charges for outpatient setting,177.14,84.88,,141.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,104.35,50,,83.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.53,75,,125.22,percent of total billed charges,75% of total billed charges for outpatient setting,146.09,70,,116.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.8,12.84,,21.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.96,80,,133.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.8,12.84,,21.44,percent of total billed charges,12.84% of total billed charges,26.8,12.84,,21.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,135.66,65,,108.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.05,35,,58.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,187.83,90,,150.26,percent of total billed charges,90% of total billed charges for outpatient setting,26.8,187.83,
MIRALAX 527 G BOTTLE,3302924,CDM,259,RC,,,Outpatient,,,190.37,190.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.26,70,,106.61,percent of total billed charges,70% of total billed charges for outpatient setting,161.59,84.88,,129.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,95.19,50,,76.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.78,75,,114.22,percent of total billed charges,75% of total billed charges for outpatient setting,133.26,70,,106.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,12.84,,19.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.3,80,,121.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,12.84,,19.55,percent of total billed charges,12.84% of total billed charges,24.44,12.84,,19.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.74,65,,98.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.63,35,,53.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171.33,90,,137.06,percent of total billed charges,90% of total billed charges for outpatient setting,24.44,171.33,
MIRALAX POWDER PACKET 17GMS,3302961,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
M-IRON,221045,CDM,300,RC,83540,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.17,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,26.21,
M-IRON W/TIBC,221046,CDM,300,RC,83550,HCPCS,Outpatient,,,39.33,35.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,84.88,,26.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.5,75,,23.6,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,70,,22.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,80,,25.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.58,100,,,Fee Schedule,100% of Custom Fee Schedule,35.4,90,,28.32,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,35.4,
MIRROR LENS SINGLE / K30-1015,69169690,CDM,272,RC,,,Outpatient,,,82.6,82.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.82,70,,46.26,percent of total billed charges,70% of total billed charges for outpatient setting,70.11,84.88,,56.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.3,50,,33.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.95,75,,49.56,percent of total billed charges,75% of total billed charges for outpatient setting,57.82,70,,46.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,80,,52.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.69,65,,42.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.91,35,,23.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,74.34,90,,59.47,percent of total billed charges,90% of total billed charges for outpatient setting,10.61,74.34,
MIRTAZAPINE (REMERON) TAB: 30 MG,3302860,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MIRTAZAPINE(REMERON SOLTAB): 30 MG,3302885,CDM,259,RC,,,Outpatient,,,29.18,29.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.43,70,,16.34,percent of total billed charges,70% of total billed charges for outpatient setting,24.77,84.88,,19.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.59,50,,11.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.89,75,,17.51,percent of total billed charges,75% of total billed charges for outpatient setting,20.43,70,,16.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.34,80,,18.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.97,65,,15.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,35,,8.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.26,90,,21.01,percent of total billed charges,90% of total billed charges for outpatient setting,3.75,26.26,
MIRTAZAPINE(REMERON SOLTAB):45 MG,3303150,CDM,259,RC,,,Outpatient,,,29.18,29.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.43,70,,16.34,percent of total billed charges,70% of total billed charges for outpatient setting,24.77,84.88,,19.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.59,50,,11.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.89,75,,17.51,percent of total billed charges,75% of total billed charges for outpatient setting,20.43,70,,16.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.34,80,,18.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,3.75,12.84,,3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.97,65,,15.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,35,,8.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.26,90,,21.01,percent of total billed charges,90% of total billed charges for outpatient setting,3.75,26.26,
MIRTAZAPINE(REMERON)15MG:TAB,3302868,CDM,259,RC,,,Outpatient,,,13.34,13.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.34,70,,7.47,percent of total billed charges,70% of total billed charges for outpatient setting,11.32,84.88,,9.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.67,50,,5.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.01,75,,8.01,percent of total billed charges,75% of total billed charges for outpatient setting,9.34,70,,7.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.67,80,,8.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.67,65,,6.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,35,,3.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.01,90,,9.61,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,12.01,
MISOPROSTOL (CYTOTEC) TAB 200 MCG,3302872,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MISOPROSTOL (CYTOTEC) TAB: 100 MCG,3301578,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MITOMYCIN 0.4mg/ml 0.8ml ophth,3313678,CDM,636,RC,J9280,HCPCS,Outpatient,,,315,315,,86.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,267.37,84.88,,213.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,236.25,75,,189,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,70,,176.4,percent of total billed charges,70% of total billed charges for outpatient setting,92.29,170,,,Fee Schedule,170% of Medicare OPPS rate,116.72,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,95,175,,,Fee Schedule,175% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,252,80,,201.6,percent of total billed charges,80% of total billed charges for outpatient setting,76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,67.86,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,204.75,65,,163.8,percent of total billed charges,65% of total billed charges for outpatient setting,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.03,100,,,Fee Schedule,100% of Custom Fee Schedule,283.5,90,,226.8,percent of total billed charges,90% of total billed charges for outpatient setting,28.03,283.5,
MITOMYCIN 20 MG INJ,3304698,CDM,636,RC,J9280,HCPCS,Outpatient,,,327.44,327.44,,86.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.21,70,,183.37,percent of total billed charges,70% of total billed charges for outpatient setting,277.93,84.88,,222.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,245.58,75,,196.46,percent of total billed charges,75% of total billed charges for outpatient setting,229.21,70,,183.37,percent of total billed charges,70% of total billed charges for outpatient setting,92.29,170,,,Fee Schedule,170% of Medicare OPPS rate,116.72,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.04,12.84,,33.632,percent of total billed charges,12.84% of total billed charges,95,175,,,Fee Schedule,175% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,261.95,80,,209.56,percent of total billed charges,80% of total billed charges for outpatient setting,76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,67.86,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.04,12.84,,33.63,percent of total billed charges,12.84% of total billed charges,42.04,12.84,,33.63,percent of total billed charges,12.84% of total billed charges,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,212.84,65,,170.27,percent of total billed charges,65% of total billed charges for outpatient setting,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.03,100,,,Fee Schedule,100% of Custom Fee Schedule,294.7,90,,235.76,percent of total billed charges,90% of total billed charges for outpatient setting,28.03,294.7,
MITOMYCIN 40MG INJ,3304494,CDM,636,RC,J9280,HCPCS,Outpatient,,,772.63,772.63,,86.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,540.84,70,,432.67,percent of total billed charges,70% of total billed charges for outpatient setting,655.81,84.88,,524.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,579.47,75,,463.58,percent of total billed charges,75% of total billed charges for outpatient setting,540.84,70,,432.67,percent of total billed charges,70% of total billed charges for outpatient setting,92.29,170,,,Fee Schedule,170% of Medicare OPPS rate,116.72,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,99.21,12.84,,79.368,percent of total billed charges,12.84% of total billed charges,95,175,,,Fee Schedule,175% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,618.1,80,,494.48,percent of total billed charges,80% of total billed charges for outpatient setting,76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,67.86,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,99.21,12.84,,79.37,percent of total billed charges,12.84% of total billed charges,99.21,12.84,,79.37,percent of total billed charges,12.84% of total billed charges,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,502.21,65,,401.77,percent of total billed charges,65% of total billed charges for outpatient setting,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.03,100,,,Fee Schedule,100% of Custom Fee Schedule,695.37,90,,556.3,percent of total billed charges,90% of total billed charges for outpatient setting,28.03,695.37,
MITOMYCIN 40MG/40MLS PREFILL SYRINGES,3312980,CDM,636,RC,J9280,HCPCS,Outpatient,,,1000,1000,,86.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,700,70,,560,percent of total billed charges,70% of total billed charges for outpatient setting,848.8,84.88,,679.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,750,75,,600,percent of total billed charges,75% of total billed charges for outpatient setting,700,70,,560,percent of total billed charges,70% of total billed charges for outpatient setting,92.29,170,,,Fee Schedule,170% of Medicare OPPS rate,116.72,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,128.4,12.84,,102.72,percent of total billed charges,12.84% of total billed charges,95,175,,,Fee Schedule,175% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,800,80,,640,percent of total billed charges,80% of total billed charges for outpatient setting,76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,67.86,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,128.4,12.84,,102.72,percent of total billed charges,12.84% of total billed charges,128.4,12.84,,102.72,percent of total billed charges,12.84% of total billed charges,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,650,65,,520,percent of total billed charges,65% of total billed charges for outpatient setting,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.03,100,,,Fee Schedule,100% of Custom Fee Schedule,900,90,,720,percent of total billed charges,90% of total billed charges for outpatient setting,28.03,900,
MITOMYCIN 5MG INJ:,3302665,CDM,636,RC,J9280,HCPCS,Outpatient,,,203.25,203.25,,86.86,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,142.28,70,,113.82,percent of total billed charges,70% of total billed charges for outpatient setting,172.52,84.88,,138.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,152.44,75,,121.95,percent of total billed charges,75% of total billed charges for outpatient setting,142.28,70,,113.82,percent of total billed charges,70% of total billed charges for outpatient setting,92.29,170,,,Fee Schedule,170% of Medicare OPPS rate,116.72,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,95,175,,,Fee Schedule,175% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,162.6,80,,130.08,percent of total billed charges,80% of total billed charges for outpatient setting,76,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,67.86,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,132.11,65,,105.69,percent of total billed charges,65% of total billed charges for outpatient setting,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,54.29,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.03,100,,,Fee Schedule,100% of Custom Fee Schedule,182.93,90,,146.34,percent of total billed charges,90% of total billed charges for outpatient setting,26.1,182.93,
MIVACURIUM (MIVACRON) INJ : 2 MG,3301580,CDM,250,RC,,,Outpatient,,,44.14,44.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.9,70,,24.72,percent of total billed charges,70% of total billed charges for outpatient setting,37.47,84.88,,29.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.07,50,,17.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.11,75,,26.49,percent of total billed charges,75% of total billed charges for outpatient setting,30.9,70,,24.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.31,80,,28.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.69,65,,22.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,35,,12.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.73,90,,31.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,39.73,
MIVACURIUM (MIVACRON) INJ : 2 MG,3301579,CDM,250,RC,,,Outpatient,,,48.99,48.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,84.88,,33.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.74,75,,29.39,percent of total billed charges,75% of total billed charges for outpatient setting,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.19,80,,31.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.84,65,,25.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.09,90,,35.27,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.09,
MIXER 3ML CEMENT AFFIRM / 658.969S,71000409,CDM,272,RC,,,Outpatient,,,1020,1020,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714,70,,571.2,percent of total billed charges,70% of total billed charges for outpatient setting,865.78,84.88,,692.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,510,50,,408,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765,75,,612,percent of total billed charges,75% of total billed charges for outpatient setting,714,70,,571.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.97,12.84,,104.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,816,80,,652.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.97,12.84,,104.78,percent of total billed charges,12.84% of total billed charges,130.97,12.84,,104.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663,65,,530.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357,35,,285.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,918,90,,734.4,percent of total billed charges,90% of total billed charges for outpatient setting,130.97,918,
M-LIPID PANEL,221002,CDM,300,RC,80061,HCPCS,Outpatient,,,60.26,54.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,84.88,,40.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.2,75,,36.16,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.21,80,,38.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.57,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.67,100,,,Fee Schedule,100% of Custom Fee Schedule,54.23,90,,43.38,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,54.23,
M-LIVER PROFILE,221012,CDM,300,RC,80076,HCPCS,Outpatient,,,36.77,33.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,31.21,84.88,,24.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.58,75,,22.06,percent of total billed charges,75% of total billed charges for outpatient setting,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,80,,23.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of Custom Fee Schedule,33.09,90,,26.47,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,33.09,
M-MAGNESIUM,221008,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
M-MONO,221023,CDM,306,RC,86308,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
MODAFINIL (PROVIGIL) 100MG: TAB,3303037,CDM,259,RC,,,Outpatient,,,24.07,24.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,70,,13.48,percent of total billed charges,70% of total billed charges for outpatient setting,20.43,84.88,,16.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.04,50,,9.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.05,75,,14.44,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,70,,13.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.26,80,,15.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.65,65,,12.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,35,,6.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.66,90,,17.33,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,21.66,
MODERNA 1ST DOSE COVID VACC ADMIN,5000011,CDM,771,RC,0011A,HCPCS,Outpatient,,,47.25,47.25,,56.15,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.08,70,,26.46,percent of total billed charges,70% of total billed charges for outpatient setting,40.11,84.88,,32.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.44,75,,28.35,percent of total billed charges,75% of total billed charges for outpatient setting,33.08,70,,26.46,percent of total billed charges,70% of total billed charges for outpatient setting,59.66,170,,,Fee Schedule,170% of Medicare OPPS rate,75.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.07,12.84,,4.856,percent of total billed charges,12.84% of total billed charges,61.41,175,,,Fee Schedule,175% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,37.8,80,,30.24,percent of total billed charges,80% of total billed charges for outpatient setting,49.13,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,43.87,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.71,65,,24.57,percent of total billed charges,65% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.3,100,,,Fee Schedule,100% of Custom Fee Schedule,42.53,90,,34.02,percent of total billed charges,90% of total billed charges for outpatient setting,6.07,75.45,
MODERNA 2ND DOSE COVID VACC ADMIN,5000012,CDM,771,RC,0012A,HCPCS,Outpatient,,,76.49,76.49,,56.15,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,53.54,70,,42.83,percent of total billed charges,70% of total billed charges for outpatient setting,64.92,84.88,,51.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,57.37,75,,45.9,percent of total billed charges,75% of total billed charges for outpatient setting,53.54,70,,42.83,percent of total billed charges,70% of total billed charges for outpatient setting,59.66,170,,,Fee Schedule,170% of Medicare OPPS rate,75.45,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,9.82,12.84,,7.856,percent of total billed charges,12.84% of total billed charges,61.41,175,,,Fee Schedule,175% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,61.19,80,,48.95,percent of total billed charges,80% of total billed charges for outpatient setting,49.13,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,43.87,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,9.82,12.84,,7.86,percent of total billed charges,12.84% of total billed charges,9.82,12.84,,7.86,percent of total billed charges,12.84% of total billed charges,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.72,65,,39.78,percent of total billed charges,65% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.09,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,27.32,100,,,Fee Schedule,100% of Custom Fee Schedule,68.84,90,,55.07,percent of total billed charges,90% of total billed charges for outpatient setting,9.82,75.45,
MODULE BLUE IO / 7700BIO,71000303,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE BLUE IV / 7700BIV,71000270,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE BLUE OXYGEN / 7700BAW,71000605,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MODULE GREEN IO / 7700GIO,71000794,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE GREEN IV / 7700GIV,71000271,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE GREEN OXYGEN / 7700GAW,71000027,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MODULE ORANGE IO / 7700OIO,71000251,CDM,271,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE ORANGE IV / 7700OIV,71000272,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE ORANGE OXYGEN / 7700OAW,71000410,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MODULE PURPLE IO / 7700PIO,71000793,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE PURPLE IV / 7700PIV,71000273,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE RED IO / 7700RIO,71000412,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE RED IV / 7700RIV,71000274,CDM,272,RC,,,Outpatient,,,212.5,212.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.75,70,,119,percent of total billed charges,70% of total billed charges for outpatient setting,180.37,84.88,,144.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,106.25,50,,85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.38,75,,127.5,percent of total billed charges,75% of total billed charges for outpatient setting,148.75,70,,119,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.29,12.84,,21.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170,80,,136,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.29,12.84,,21.83,percent of total billed charges,12.84% of total billed charges,27.29,12.84,,21.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,138.13,65,,110.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.38,35,,59.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,191.25,90,,153,percent of total billed charges,90% of total billed charges for outpatient setting,27.29,191.25,
MODULE RED OXYGEN / 7700RAW,71000411,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MODULE WHITE IO / 7700WIO,71000305,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE WHITE IV / 7700WIV,71000275,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE WHITE OXYGEN / 7700WAW,71000606,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MODULE YELLOW IO / 7700YIO,71000304,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,186.74,84.88,,149.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,110,50,,88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,75,,132,percent of total billed charges,75% of total billed charges for outpatient setting,154,70,,123.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176,80,,140.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,28.25,12.84,,22.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,65,,114.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,35,,61.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198,90,,158.4,percent of total billed charges,90% of total billed charges for outpatient setting,28.25,198,
MODULE YELLOW IV / 7700YIV,71000276,CDM,272,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,190.98,84.88,,152.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.5,50,,90,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,75,,135,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,70,,126,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,80,,144,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,28.89,12.84,,23.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.25,65,,117,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,35,,63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.5,90,,162,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,202.5,
MODULE YELLOW OXYGEN / 7700YAW,71000413,CDM,272,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,81.48,84.88,,65.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,48,50,,38.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,75,,57.6,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,70,,53.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,80,,61.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,12.33,12.84,,9.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.4,65,,49.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,35,,26.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,90% of total billed charges for outpatient setting,12.33,86.4,
MOEXIPRIL (UNIVASC) TAB : 15 MG,3301581,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
"MOL.DIAG.;NUCLEIC ACID PROBE,EACH",201029,CDM,300,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOL.DIAG.;SEPARATE-GEL ELECTROPHORESIS,201028,CDM,300,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOL.DX; AMP TARGET EA N/A SEQUENCE,201031,CDM,300,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOL.DX; INTERPRETATION AND REPORT,201032,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAAR DX,  ISOLATION OR EXTRACTION",200246,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DIAGNOSTIC,ISOLATION/EXTRACTIO",201026,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DIAGNOSTICS,ENZYME DIGEST",202580,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DIAGNOSTICS,ISOLATION OR EXTRA",201412,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DIAGNOSTICS,ISOLATION/EXTRACTI",202581,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOLECULAR DX SEP AND ID,200266,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX, INTERP AND REPORT",200251,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX, NUCLEIC ACID PROBE, EACH",200248,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,AMP TARGET MLTPLX BEYOND 2",200249,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,AMPL,MULTIPLX,1ST 2 SEQUENC",200253,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,AMPLIFICATION OF PT NUCLEIC",202583,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,AMPLIFICATION PT NUCLEIC AC",201253,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,AMPLIFICATION PT NUCLEIC AC",201414,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,INTERP AND REPORT",202584,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,INTERPRETATION/REPORT",201251,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,ISOLATION/EXTRACTION",201249,CDM,300,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,SEPARATION BY GEL ELECTROPH",202582,CDM,301,RC,81224,HCPCS,Outpatient,,,759.38,683.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.57,70,,425.26,percent of total billed charges,70% of total billed charges for outpatient setting,644.56,84.88,,515.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,569.54,75,,455.63,percent of total billed charges,75% of total billed charges for outpatient setting,531.57,70,,425.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.5,12.84,,78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,607.5,80,,486,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.5,12.84,,78,percent of total billed charges,12.84% of total billed charges,97.5,12.84,,78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.44,100,,,Fee Schedule,100% of Custom Fee Schedule,683.44,90,,546.75,percent of total billed charges,90% of total billed charges for outpatient setting,97.5,683.44,
"MOLECULAR DX,SEPARATION BY GEL ELECTROPH",201252,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"MOLECULAR DX,SEPARATION GEL ELECTROPHORE",201413,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOLECULAR DX/INTERP AND REPORT,201415,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOLECULAR ISOLATION,201509,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
MOMETASONE FUROATE (ASMANEX TWIST):INH,3303228,CDM,259,RC,,,Outpatient,,,356.23,356.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.36,70,,199.49,percent of total billed charges,70% of total billed charges for outpatient setting,302.37,84.88,,241.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.12,50,,142.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.17,75,,213.74,percent of total billed charges,75% of total billed charges for outpatient setting,249.36,70,,199.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.74,12.84,,36.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.98,80,,227.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.74,12.84,,36.59,percent of total billed charges,12.84% of total billed charges,45.74,12.84,,36.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,231.55,65,,185.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.68,35,,99.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.61,90,,256.49,percent of total billed charges,90% of total billed charges for outpatient setting,45.74,320.61,
MONO TEST,200240,CDM,306,RC,86308,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
MONODEK 48IN SZ 0 TAPR/CRV / M0068331371,70000147,CDM,278,RC,,,Outpatient,,,194.05,194.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.43,60,,93.14,percent of total billed charges,60% of total Billed charges for outpatient setting,164.71,84.88,,131.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,97.03,50,,77.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.54,75,,116.43,percent of total billed charges,75% of total billed charges for outpatient setting,97.03,50,,77.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.92,12.84,,19.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.24,80,,124.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.92,12.84,,19.94,percent of total billed charges,12.84% of total billed charges,24.92,12.84,,19.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,194.05,65,,155.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.92,35,,54.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.43,60,,93.14,percent of total billed charges,60% of total billed charges for outpatient setting,24.92,194.05,
MONOTUBE TRIAX 15X200MM / 5150-9-960,69162497,CDM,278,RC,,,Outpatient,,,2660.9,2660.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1596.54,60,,1277.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2258.57,84.88,,1806.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,1330.45,50,,1064.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1995.68,75,,1596.54,percent of total billed charges,75% of total billed charges for outpatient setting,1330.45,50,,1064.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.66,12.84,,273.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2128.72,80,,1702.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.66,12.84,,273.33,percent of total billed charges,12.84% of total billed charges,341.66,12.84,,273.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2793.95,105,,2235.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,931.32,35,,745.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1596.54,60,,1277.23,percent of total billed charges,60% of total billed charges for outpatient setting,341.66,2793.95,
MONSEL'S PASTE 8ML,3302686,CDM,259,RC,,,Outpatient,,,106.68,106.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.68,70,,59.74,percent of total billed charges,70% of total billed charges for outpatient setting,90.55,84.88,,72.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.34,50,,42.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.01,75,,64.01,percent of total billed charges,75% of total billed charges for outpatient setting,74.68,70,,59.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.7,12.84,,10.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.34,80,,68.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.7,12.84,,10.96,percent of total billed charges,12.84% of total billed charges,13.7,12.84,,10.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.34,65,,55.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.34,35,,29.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.01,90,,76.81,percent of total billed charges,90% of total billed charges for outpatient setting,13.7,96.01,
MONTELUKAST (SINGULAIR )10MG TAB,3303072,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MOPRHINE ORAL SOLN: 10 MG/5 ML,3303024,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MORCELLATOR 12MM CUTTER RED / 091112-01,69161450,CDM,272,RC,,,Outpatient,,,2122.17,2122.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1485.52,70,,1188.42,percent of total billed charges,70% of total billed charges for outpatient setting,1801.3,84.88,,1441.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,1061.09,50,,848.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1591.63,75,,1273.3,percent of total billed charges,75% of total billed charges for outpatient setting,1485.52,70,,1188.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.49,12.84,,217.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1697.74,80,,1358.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.49,12.84,,217.99,percent of total billed charges,12.84% of total billed charges,272.49,12.84,,217.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1379.41,65,,1103.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.76,35,,594.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1909.95,90,,1527.96,percent of total billed charges,90% of total billed charges for outpatient setting,272.49,1909.95,
MORCELLATOR 15mm CUTTER  Black 091115-01,69161451,CDM,272,RC,,,Outpatient,,,1856.89,1856.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1299.82,70,,1039.86,percent of total billed charges,70% of total billed charges for outpatient setting,1576.13,84.88,,1260.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,928.45,50,,742.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1392.67,75,,1114.14,percent of total billed charges,75% of total billed charges for outpatient setting,1299.82,70,,1039.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.42,12.84,,190.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1485.51,80,,1188.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.42,12.84,,190.74,percent of total billed charges,12.84% of total billed charges,238.42,12.84,,190.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1206.98,65,,965.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.91,35,,519.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1671.2,90,,1336.96,percent of total billed charges,90% of total billed charges for outpatient setting,238.42,1671.2,
MORETZ PEDI VENT TUBE SGL / 1056108,6151029,CDM,278,RC,L8699,HCPCS,Outpatient,,,165.2,165.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.12,60,,79.3,percent of total billed charges,60% of total Billed charges for outpatient setting,140.22,84.88,,112.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.6,50,,66.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.9,75,,99.12,percent of total billed charges,75% of total billed charges for outpatient setting,82.6,50,,66.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.21,12.84,,16.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.16,80,,105.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.21,12.84,,16.97,percent of total billed charges,12.84% of total billed charges,21.21,12.84,,16.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,165.2,65,,132.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.82,35,,46.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.12,60,,79.3,percent of total billed charges,60% of total billed charges for outpatient setting,21.21,165.2,
MORETZ TIT VENT TUBE DBL PK / 500-132,6152887,CDM,272,RC,L8699,HCPCS,Outpatient,,,205.35,205.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.75,70,,115,percent of total billed charges,70% of total billed charges for outpatient setting,174.3,84.88,,139.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.68,50,,82.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.01,75,,123.21,percent of total billed charges,75% of total billed charges for outpatient setting,143.75,70,,115,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,12.84,,21.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.28,80,,131.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,26.37,12.84,,21.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.48,65,,106.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.87,35,,57.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.82,90,,147.86,percent of total billed charges,90% of total billed charges for outpatient setting,26.37,184.82,
MORPHINE (DURAMORPH)0.5MG/ML 10ML EPID,3301602,CDM,636,RC,J2274,HCPCS,Outpatient,,,43.54,43.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.48,70,,24.38,percent of total billed charges,70% of total billed charges for outpatient setting,36.96,84.88,,29.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.66,75,,26.13,percent of total billed charges,75% of total billed charges for outpatient setting,30.48,70,,24.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.83,80,,27.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.3,65,,22.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of Custom Fee Schedule,39.19,90,,31.35,percent of total billed charges,90% of total billed charges for outpatient setting,5.59,39.19,
MORPHINE (MS CONTIN) TAB : 15 MG,3301586,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE (MS CONTIN) TAB : 15 MG,3301597,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE (MS CONTIN) TAB : 30 MG,3301592,CDM,259,RC,,,Outpatient,,,5.87,5.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,70,,3.29,percent of total billed charges,70% of total billed charges for outpatient setting,4.98,84.88,,3.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.94,50,,2.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.4,75,,3.52,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,70,,3.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,80,,3.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.82,65,,3.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,35,,1.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.28,90,,4.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.75,5.28,
MORPHINE SULF (ORAMORPH) TAB: 30 MG,3301587,CDM,259,RC,,,Outpatient,,,5.33,5.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,84.88,,3.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.67,50,,2.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4,75,,3.2,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,80,,3.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.46,65,,2.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,35,,1.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.8,90,,3.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.8,
MORPHINE SULF INJ 1MG/ML: 1ML,3301588,CDM,250,RC,,,Outpatient,,,50.55,50.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.39,70,,28.31,percent of total billed charges,70% of total billed charges for outpatient setting,42.91,84.88,,34.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.28,50,,20.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.91,75,,30.33,percent of total billed charges,75% of total billed charges for outpatient setting,35.39,70,,28.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.44,80,,32.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.86,65,,26.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.69,35,,14.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.5,90,,36.4,percent of total billed charges,90% of total billed charges for outpatient setting,6.49,45.5,
MORPHINE SULF MDV 15MG/ML : 20ML,3301585,CDM,250,RC,,,Outpatient,,,8.9,8.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,84.88,,6.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.45,50,,3.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.68,75,,5.34,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,70,,4.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,80,,5.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.79,65,,4.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.01,90,,6.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,8.01,
MORPHINE SULF MDV 15MG/ML : 20ML,3301598,CDM,250,RC,,,Outpatient,,,35.58,35.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.91,70,,19.93,percent of total billed charges,70% of total billed charges for outpatient setting,30.2,84.88,,24.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.79,50,,14.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.69,75,,21.35,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,70,,19.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,12.84,,3.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.46,80,,22.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.57,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.13,65,,18.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.45,35,,9.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.02,90,,25.62,percent of total billed charges,90% of total billed charges for outpatient setting,4.57,32.02,
MORPHINE SULF SDV  1MG/ML : 60ML,3301583,CDM,250,RC,,,Outpatient,,,15.97,15.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,13.56,84.88,,10.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.99,50,,6.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.98,75,,9.58,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.78,80,,10.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.38,65,,8.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,35,,4.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.37,90,,11.5,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.37,
MORPHINE SULF SDV 1MG/ML : 60ML,3301584,CDM,250,RC,,,Outpatient,,,9.7,9.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,70,,5.43,percent of total billed charges,70% of total billed charges for outpatient setting,8.23,84.88,,6.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.85,50,,3.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.28,75,,5.82,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,70,,5.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,80,,6.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.31,65,,5.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,35,,2.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.73,90,,6.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.25,8.73,
MORPHINE SULFATE (MORPH) AMP: 1 MG/ML,3301596,CDM,250,RC,,,Outpatient,,,41.38,41.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.97,70,,23.18,percent of total billed charges,70% of total billed charges for outpatient setting,35.12,84.88,,28.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.69,50,,16.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.04,75,,24.83,percent of total billed charges,75% of total billed charges for outpatient setting,28.97,70,,23.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.31,12.84,,4.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,80,,26.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.31,12.84,,4.25,percent of total billed charges,12.84% of total billed charges,5.31,12.84,,4.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.9,65,,21.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.48,35,,11.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.24,90,,29.79,percent of total billed charges,90% of total billed charges for outpatient setting,5.31,37.24,
MORPHINE SULFATE (MORPH) INJ 10 MG,3301590,CDM,636,RC,J2270,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,3.23,
MORPHINE SULFATE (MORPH) INJ: 4 MG,3301593,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE SULFATE (MORPH) INJ: 4 MG,3301594,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE SULFATE (MORPH) INJ: 4 MG/ML,3301589,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE SULFATE (MORPH) SDV: 15 MG,3301599,CDM,250,RC,,,Outpatient,,,59.48,59.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.64,70,,33.31,percent of total billed charges,70% of total billed charges for outpatient setting,50.49,84.88,,40.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.74,50,,23.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.61,75,,35.69,percent of total billed charges,75% of total billed charges for outpatient setting,41.64,70,,33.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,12.84,,6.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.58,80,,38.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.64,12.84,,6.11,percent of total billed charges,12.84% of total billed charges,7.64,12.84,,6.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.66,65,,30.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.82,35,,16.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.53,90,,42.82,percent of total billed charges,90% of total billed charges for outpatient setting,7.64,53.53,
MORPHINE SULFATE (PCA)1MG/ML 50ML,3301604,CDM,250,RC,,,Outpatient,,,154.34,154.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.04,70,,86.43,percent of total billed charges,70% of total billed charges for outpatient setting,131,84.88,,104.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.17,50,,61.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.76,75,,92.61,percent of total billed charges,75% of total billed charges for outpatient setting,108.04,70,,86.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.82,12.84,,15.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.47,80,,98.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.82,12.84,,15.86,percent of total billed charges,12.84% of total billed charges,19.82,12.84,,15.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.32,65,,80.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.02,35,,43.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.91,90,,111.13,percent of total billed charges,90% of total billed charges for outpatient setting,19.82,138.91,
MORPHINE SULFATE INJ  2 MG,3303112,CDM,636,RC,J2270,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,3.23,
MORPHINE SULFATE INJ 5MG/ML,3303357,CDM,636,RC,J2270,HCPCS,Outpatient,,,96.64,96.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.65,70,,54.12,percent of total billed charges,70% of total billed charges for outpatient setting,82.03,84.88,,65.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,72.48,75,,57.98,percent of total billed charges,75% of total billed charges for outpatient setting,67.65,70,,54.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,12.84,,9.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.31,80,,61.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,12.84,,9.93,percent of total billed charges,12.84% of total billed charges,12.41,12.84,,9.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.82,65,,50.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,100,,,Fee Schedule,100% of Custom Fee Schedule,86.98,90,,69.58,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,86.98,
MORPHINE SULFATE MDV 1MG/ML : 30ML,3301591,CDM,250,RC,,,Outpatient,,,50.55,50.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.39,70,,28.31,percent of total billed charges,70% of total billed charges for outpatient setting,42.91,84.88,,34.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.28,50,,20.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.91,75,,30.33,percent of total billed charges,75% of total billed charges for outpatient setting,35.39,70,,28.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.44,80,,32.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,6.49,12.84,,5.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.86,65,,26.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.69,35,,14.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.5,90,,36.4,percent of total billed charges,90% of total billed charges for outpatient setting,6.49,45.5,
MORPHINE SULFATE SDV: 10 MG    1 ML,3301600,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE SULFATE TAB: 15 MG,3301601,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
MORPHINE SULFATE TAB: 30 MG,3301595,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MORPHINE SULFATE: 1 MG,3301603,CDM,250,RC,,,Outpatient,,,50.82,50.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.57,70,,28.46,percent of total billed charges,70% of total billed charges for outpatient setting,43.14,84.88,,34.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.41,50,,20.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.12,75,,30.5,percent of total billed charges,75% of total billed charges for outpatient setting,35.57,70,,28.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,12.84,,5.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.66,80,,32.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,12.84,,5.22,percent of total billed charges,12.84% of total billed charges,6.53,12.84,,5.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.03,65,,26.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.79,35,,14.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.74,90,,36.59,percent of total billed charges,90% of total billed charges for outpatient setting,6.53,45.74,
MORPHOMETRIC ANALY ISHQUANT SEMIQ,900044,CDM,310,RC,88377,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,314.48,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,133.64,535.12,
MORPHOMETRIC ANALYSIS  IN SITU HYBRIDIZA,900137,CDM,310,RC,88368,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,1044.92,
MORPHOMETRIC ANALYSIS EA MULTIPLEX STAI,900138,CDM,310,RC,88374,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.45,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,133.64,535.12,
MORPHOMETRIC ANALYSIS TUMOR,900037,CDM,310,RC,88358,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,76.34,12.84,,61.072,percent of total billed charges,12.84% of total billed charges,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.12,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,73.12,535.12,
MORTEZ TI VENT TUBE(SGL PK)1056107,6150685,CDM,270,RC,,,Outpatient,,,116.11,116.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.28,70,,65.02,percent of total billed charges,70% of total billed charges for outpatient setting,98.55,84.88,,78.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.06,50,,46.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.08,75,,69.66,percent of total billed charges,75% of total billed charges for outpatient setting,81.28,70,,65.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,12.84,,11.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.89,80,,74.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,12.84,,11.93,percent of total billed charges,12.84% of total billed charges,14.91,12.84,,11.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.47,65,,60.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,35,,32.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.5,90,,83.6,percent of total billed charges,90% of total billed charges for outpatient setting,14.91,104.5,
MOTION FLUOROSCOPI EVAL OF SWALL FUNC,2400642,CDM,440,RC,92611,HCPCS,Outpatient,,,356.6,356.6,GN,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.62,70,,199.7,percent of total billed charges,70% of total billed charges for outpatient setting,302.68,84.88,,242.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.3,50,,142.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.45,75,,213.96,percent of total billed charges,75% of total billed charges for outpatient setting,249.62,70,,199.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.79,12.84,,36.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.28,80,,228.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.79,12.84,,36.63,percent of total billed charges,12.84% of total billed charges,45.79,12.84,,36.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.81,35,,99.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.94,90,,256.75,percent of total billed charges,90% of total billed charges for outpatient setting,45.79,320.94,
MOTRIN LIQ 100MG/5ML: 120ML,3302600,CDM,259,RC,,,Outpatient,,,20.57,20.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,70,,11.52,percent of total billed charges,70% of total billed charges for outpatient setting,17.46,84.88,,13.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.29,50,,8.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.43,75,,12.34,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,70,,11.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.64,12.84,,2.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,80,,13.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.64,12.84,,2.11,percent of total billed charges,12.84% of total billed charges,2.64,12.84,,2.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.37,65,,10.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,35,,5.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.51,90,,14.81,percent of total billed charges,90% of total billed charges for outpatient setting,2.64,18.51,
MOXIFLOXACIN  0.1% OPTH 0.8mg/0.8ml inj,3314172,CDM,259,RC,,,Outpatient,,,111,111,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.7,70,,62.16,percent of total billed charges,70% of total billed charges for outpatient setting,94.22,84.88,,75.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.5,50,,44.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.25,75,,66.6,percent of total billed charges,75% of total billed charges for outpatient setting,77.7,70,,62.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.25,12.84,,11.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.8,80,,71.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.25,12.84,,11.4,percent of total billed charges,12.84% of total billed charges,14.25,12.84,,11.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.15,65,,57.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.85,35,,31.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.9,90,,79.92,percent of total billed charges,90% of total billed charges for outpatient setting,14.25,99.9,
MOXIFLOXACIN  0.5% OPTH SOLN 3CC,3310391,CDM,259,RC,,,Outpatient,,,76.51,76.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.56,70,,42.85,percent of total billed charges,70% of total billed charges for outpatient setting,64.94,84.88,,51.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.26,50,,30.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,75,,45.9,percent of total billed charges,75% of total billed charges for outpatient setting,53.56,70,,42.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.82,12.84,,7.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.21,80,,48.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.82,12.84,,7.86,percent of total billed charges,12.84% of total billed charges,9.82,12.84,,7.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.73,65,,39.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.78,35,,21.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.86,90,,55.09,percent of total billed charges,90% of total billed charges for outpatient setting,9.82,68.86,
M-PHOSPHORUS,221007,CDM,300,RC,84100,HCPCS,Outpatient,,,21.33,19.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.93,70,,11.94,percent of total billed charges,70% of total billed charges for outpatient setting,18.1,84.88,,14.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16,75,,12.8,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,70,,11.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.06,80,,13.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.98,100,,,Fee Schedule,100% of Custom Fee Schedule,19.2,90,,15.36,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,19.2,
MPO PR3  ANCA  ANTIBODIES,201062,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
M-POTASSIUM - BLOOD,221013,CDM,300,RC,84132,HCPCS,Outpatient,,,21.42,19.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,18.18,84.88,,14.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,19.28,90,,15.42,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,19.28,
M-PSA DIAGNOSTIC,221009,CDM,300,RC,84153,HCPCS,Outpatient,,,82.76,74.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,70.25,84.88,,56.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.07,75,,49.66,percent of total billed charges,75% of total billed charges for outpatient setting,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,80,,52.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,74.48,90,,59.58,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,74.48,
M-PSA SCREENING,221010,CDM,300,RC,G0103,HCPCS,Outpatient,,,86.9,78.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,73.76,84.88,,59.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.18,75,,52.14,percent of total billed charges,75% of total billed charges for outpatient setting,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.52,80,,55.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,78.21,90,,62.57,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,78.21,
M-PT WITH INR,221021,CDM,305,RC,85610,HCPCS,Outpatient,,,19.31,17.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.52,70,,10.82,percent of total billed charges,70% of total billed charges for outpatient setting,16.39,84.88,,13.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.48,75,,11.58,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,70,,10.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,80,,12.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,100,,,Fee Schedule,100% of Custom Fee Schedule,17.38,90,,13.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.29,17.38,
M-PTT,221034,CDM,305,RC,85730,HCPCS,Outpatient,,,27.05,24.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,70,,15.15,percent of total billed charges,70% of total billed charges for outpatient setting,22.96,84.88,,18.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.29,75,,16.23,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,70,,15.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,80,,17.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.76,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,100,,,Fee Schedule,100% of Custom Fee Schedule,24.35,90,,19.48,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,24.35,
MRA CHEST W/WO CONTRAST,2100085,CDM,610,RC,71555,HCPCS,Outpatient,,,2860.2,2860.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.71,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRA HEAD W/O CONTRAST,2100025,CDM,610,RC,70544,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRA LOW EXT W/WO CONTRAST,2100220,CDM,610,RC,73725,HCPCS,Outpatient,,,2860.2,2860.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.88,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRA NECK W/O CONTRAST,2100040,CDM,610,RC,70547,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
M-RENAL FUNCTION PANEL W/ eGFR,221040,CDM,300,RC,80069,HCPCS,Outpatient,,,39.06,35.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,70,,21.87,percent of total billed charges,70% of total billed charges for outpatient setting,33.15,84.88,,26.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.91,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.3,75,,23.44,percent of total billed charges,75% of total billed charges for outpatient setting,27.34,70,,21.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.25,80,,25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,100% of Custom Fee Schedule,35.15,90,,28.12,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,35.15,
MRI 3D RENDERING,2100271,CDM,350,RC,76376,HCPCS,Outpatient,,,374.96,281.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.47,70,,209.98,percent of total billed charges,70% of total billed charges for outpatient setting,318.27,84.88,,254.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.22,75,,224.98,percent of total billed charges,75% of total billed charges for outpatient setting,262.47,70,,209.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.14,12.84,,38.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.97,80,,239.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.14,12.84,,38.51,percent of total billed charges,12.84% of total billed charges,48.14,12.84,,38.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.46,90,,269.97,percent of total billed charges,90% of total billed charges for outpatient setting,48.14,1550,
MRI ABD W/O CONTRAST,2100260,CDM,610,RC,74181,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI ABD W/WO CONTRAST,2100270,CDM,610,RC,74183,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI ANKLE LT W/CONTRAST,2100393,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ANKLE LT W/O CONTRAST,2100394,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ANKLE LT W/WO CONTRAST,2100395,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ANKLE RT W/CONTRAST,2100390,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ANKLE RT W/O CONTRAST,2100391,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ANKLE RT W/WO CONTRAST,2100392,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI BILAT ANKLE W/CONTRAST,2100396,CDM,610,RC,73722,HCPCS,Outpatient,,,4100.28,4100.28,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2870.2,70,,2296.16,percent of total billed charges,70% of total billed charges for outpatient setting,3480.32,84.88,,2784.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,2050.14,50,,1640.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3075.21,75,,2460.17,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.48,12.84,,421.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280.22,80,,2624.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.48,12.84,,421.18,percent of total billed charges,12.84% of total billed charges,526.48,12.84,,421.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435.1,35,,1148.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3690.25,90,,2952.2,percent of total billed charges,90% of total billed charges for outpatient setting,526.48,3690.25,
MRI BILAT ANKLE W/O CONTRAST,2100397,CDM,610,RC,73721,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT ANKLE W/WO CONTRAST,2100398,CDM,610,RC,73723,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT ELBOW  W/CONTRAST,2100315,CDM,610,RC,73222,HCPCS,Outpatient,,,2971.87,2971.87,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.31,70,,1664.25,percent of total billed charges,70% of total billed charges for outpatient setting,2522.52,84.88,,2018.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1485.94,50,,1188.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2228.9,75,,1783.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.5,80,,1902,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.15,35,,832.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.68,90,,2139.74,percent of total billed charges,90% of total billed charges for outpatient setting,381.59,2674.68,
MRI BILAT ELBOW W/O CONTRAST,2100316,CDM,610,RC,73221,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT ELBOW W/WO CONTRAST,2100317,CDM,610,RC,73223,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FEMUR W/CONTRAST,2100346,CDM,610,RC,73719,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FEMUR W/O CONTRAST,2100347,CDM,610,RC,73718,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FEMUR W/WO CONTRAST,2100348,CDM,610,RC,73720,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FINGER W/CONTRAST,2100282,CDM,610,RC,73219,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FINGER W/O CONTRAST,2100283,CDM,610,RC,73218,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FINGER W/WO CONTRAST,2100284,CDM,610,RC,73220,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOOT W/CONTRAST,2100356,CDM,610,RC,73719,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOOT W/O CONTRAST,2100357,CDM,610,RC,73718,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOOT W/WO CONTRAST,2100358,CDM,610,RC,73720,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOREARM  W/CONTRAST,2100239,CDM,610,RC,73219,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOREARM W/O CONTRAST,2100234,CDM,610,RC,73218,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT FOREARM W/WO CONTRAST,2100229,CDM,610,RC,73220,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HAND W/CONTRAST,2100257,CDM,610,RC,73219,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HAND W/O CONTRAST,2100258,CDM,610,RC,73218,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HAND W/WO CONTRAST,2100259,CDM,610,RC,73220,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HIP W/CONTRAST,2100386,CDM,610,RC,73722,HCPCS,Outpatient,,,2971.87,2971.87,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.31,70,,1664.25,percent of total billed charges,70% of total billed charges for outpatient setting,2522.52,84.88,,2018.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1485.94,50,,1188.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2228.9,75,,1783.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.5,80,,1902,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.15,35,,832.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.68,90,,2139.74,percent of total billed charges,90% of total billed charges for outpatient setting,381.59,2674.68,
MRI BILAT HIP W/O CONTRAST,2100387,CDM,610,RC,73721,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HIP W/WO CONTRAST,2100388,CDM,610,RC,73723,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HUMERUS  W/CONTRAST,2100297,CDM,610,RC,73219,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HUMERUS W/O CONTRAST,2100298,CDM,610,RC,73218,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT HUMERUS W/WO CONTRAST,2100299,CDM,610,RC,73220,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT KNEE W/CONTRAST,2100406,CDM,610,RC,73722,HCPCS,Outpatient,,,2971.87,2971.87,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.31,70,,1664.25,percent of total billed charges,70% of total billed charges for outpatient setting,2522.52,84.88,,2018.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1485.94,50,,1188.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2228.9,75,,1783.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.5,80,,1902,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.15,35,,832.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.68,90,,2139.74,percent of total billed charges,90% of total billed charges for outpatient setting,381.59,2674.68,
MRI BILAT KNEE W/O CONTRAST,2100407,CDM,610,RC,73721,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT KNEE W/WO CONTRAST,2100408,CDM,610,RC,73723,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT SHOULDER  W/CONTRAST,2100306,CDM,610,RC,73222,HCPCS,Outpatient,,,2971.87,2971.87,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.31,70,,1664.25,percent of total billed charges,70% of total billed charges for outpatient setting,2522.52,84.88,,2018.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1485.94,50,,1188.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2228.9,75,,1783.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.5,80,,1902,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.15,35,,832.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.68,90,,2139.74,percent of total billed charges,90% of total billed charges for outpatient setting,381.59,2674.68,
MRI BILAT SHOULDER W/O CONTRAST,2100307,CDM,610,RC,73221,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT SHOULDER W/WO CONTRAST,2100308,CDM,610,RC,73223,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT THUMB W/CONTRAST,2100267,CDM,610,RC,73219,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT THUMB W/O CONTRAST,2100268,CDM,610,RC,73218,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT THUMB W/WO CONTRAST,2100269,CDM,610,RC,73220,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TIB-FIB W/CONTRAST,2100376,CDM,610,RC,73719,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TIB-FIB W/O CONTRAST,2100377,CDM,610,RC,73718,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TIB-FIB W/WO CONTRAST,2100378,CDM,610,RC,73720,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TOE W/ CONTRAST,2100366,CDM,610,RC,73719,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TOE W/O CONTRAST,2100367,CDM,610,RC,73718,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT TOE W/WO CONTRAST,2100368,CDM,610,RC,73720,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT WRIST  W/CONTRAST,2100324,CDM,610,RC,73222,HCPCS,Outpatient,,,2971.87,2971.87,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.31,70,,1664.25,percent of total billed charges,70% of total billed charges for outpatient setting,2522.52,84.88,,2018.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1485.94,50,,1188.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2228.9,75,,1783.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.5,80,,1902,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,381.59,12.84,,305.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.15,35,,832.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.68,90,,2139.74,percent of total billed charges,90% of total billed charges for outpatient setting,381.59,2674.68,
MRI BILAT WRIST W/O CONTRAST,2100325,CDM,610,RC,73221,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BILAT WRIST W/WO CONTRAST,2100326,CDM,610,RC,73223,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI BRAIN W/O CONTRAST,2100075,CDM,610,RC,70551,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI BRAIN W/O CONTRAST DO NOT USE,2100055,CDM,610,RC,70551,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI BRAIN W/WO CONTRAST,2100065,CDM,610,RC,70553,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI BREAST W/WO CONTRAST,2100005,CDM,610,RC,C8908,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI CHEST W/O CONTRAST,2100070,CDM,610,RC,71550,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI C-SPINE W CONTRAST,2100091,CDM,612,RC,72142,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI C-SPINE W/O CONTRAST,2100090,CDM,612,RC,72141,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI C-SPINE W/WO CONTRAST,2105000,CDM,612,RC,72156,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI ELBOW LT W/CONTRAST,2100312,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ELBOW LT W/O CONTRAST,2100313,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ELBOW LT W/WO CONTRAST,2100314,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ELBOW RT W/CONTRAST,2100309,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ELBOW RT W/O CONTRAST,2100310,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI ELBOW RT W/WO CONTRAST,2100311,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR LT W/ CONTRAST,2100343,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR LT W/O CONTRAST,2100344,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR LT W/WO CONTRAST,2100345,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR RT W/ CONTRAST,2100340,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR RT W/O CONTRAST,2100341,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FEMUR RT W/WO CONTRAST,2100342,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER LT W/CONTRAST,2100279,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER LT W/O CONTRAST,2100280,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER LT W/WO CONTRAST,2100281,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER RT W/CONTRAST,2100276,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER RT W/O CONTRAST,2100277,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FINGER RT W/WO CONTRAST,2100278,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT LT W/ CONTRAST,2100353,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT LT W/O CONTRAST,2100354,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT LT W/WO CONTRAST,2100355,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT RT W/ CONTRAST,2100350,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT RT W/O CONTRAST,2100351,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOOT RT W/WO CONTRAST,2100352,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM LT W/CONTRAST,2100236,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM LT W/O CONTRAST,2100237,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM LT W/WO CONTRAST,2100238,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM RT W/CONTRAST,2100231,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM RT W/O CONTRAST,2100232,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI FOREARM RT W/WO CONTRAST,2100233,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND LT W/CONTRAST,2100254,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND LT W/O CONTRAST,2100255,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND LT W/WO CONTRAST,2100256,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND RT W/CONTRAST,2100251,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND RT W/O CONTRAST,2100252,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HAND RT W/WO CONTRAST,2100253,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP LT W/CONTRAST,2100383,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP LT W/O CONTRAST,2100384,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP LT W/WO CONTRAST,2100385,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP RT W/CONTRAST RT,2100380,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP RT W/O CONTRAST,2100381,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HIP RT W/WO CONTRAST,2100382,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS LT W/CONTRAST,2100294,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS LT W/O CONTRAST,2100295,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS LT W/WO CONTRAST,2100296,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS RT W/CONTRAST,2100291,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS RT W/O CONTRAST,2100292,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI HUMERUS RT W/WO CONTRAST,2100293,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE LT W/CONTRAST,2100403,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE LT W/O CONTRAST,2100404,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE LT W/WO CONTRAST,2100405,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE RT W/CONTRAST RT,2100400,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE RT W/O CONTRAST,2100401,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI KNEE RT W/WO CONTRAST,2100402,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/ CONTRAST - LEFT,2100330,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/ CONTRAST - RIGHT,2100331,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/CONTRAST BILAT,2100332,CDM,610,RC,73719,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI LOW EXT W/O CONTRAST - LEFT,2100190,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/O CONTRAST - RIGHT,2100191,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/O CONTRAST BILAT,2100192,CDM,610,RC,73718,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI LOW EXT W/WO CONTRAST - LEFT,2100333,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/WO CONTRAST - RIGHT,2100334,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW EXT W/WO CONTRAST BILAT,2100335,CDM,610,RC,73720,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI LOW EXT W/WO CONTRAST RT,2100200,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/CONTRAST BILAT,2100338,CDM,610,RC,73722,HCPCS,Outpatient,,,2972.08,2972.08,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.46,70,,1664.37,percent of total billed charges,70% of total billed charges for outpatient setting,2522.7,84.88,,2018.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,1486.04,50,,1188.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2229.06,75,,1783.25,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.62,12.84,,305.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.66,80,,1902.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.62,12.84,,305.3,percent of total billed charges,12.84% of total billed charges,381.62,12.84,,305.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040.23,35,,832.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2674.87,90,,2139.9,percent of total billed charges,90% of total billed charges for outpatient setting,381.62,2674.87,
MRI LOW JNT W/CONTRAST LT,2100337,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/CONTRAST RT,2100336,CDM,610,RC,73722,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/O CONTRAST BILATERAL,2100207,CDM,610,RC,73721,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI LOW JNT W/O CONTRAST LT,2100205,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/O CONTRAST RT,2100327,CDM,610,RC,73721,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/WO CONTRAST BILAT,2100329,CDM,610,RC,73723,HCPCS,Outpatient,,,4290.3,4290.3,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3003.21,70,,2402.57,percent of total billed charges,70% of total billed charges for outpatient setting,3641.61,84.88,,2913.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2145.15,50,,1716.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3217.73,75,,2574.18,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.24,80,,2745.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,550.87,12.84,,440.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.61,35,,1201.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3861.27,90,,3089.02,percent of total billed charges,90% of total billed charges for outpatient setting,550.87,3861.27,
MRI LOW JNT W/WO CONTRAST LT,2100328,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI LOW JNT W/WO CONTRAST RT,2100206,CDM,610,RC,73723,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI L-SPINE W/ CONTRAST,2100131,CDM,612,RC,72149,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI L-SPINE W/O CONTRAST,2100105,CDM,612,RC,72148,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI L-SPINE W/O CONTRAST,2100110,CDM,612,RC,72148,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI L-SPINE W/WO CONTRAST,2100130,CDM,612,RC,72158,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI ORB/FACE/NECK W/O CONTRAST,2100010,CDM,610,RC,70540,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI ORB/FACE/NECK W/WO CONTRAST,2100020,CDM,610,RC,70543,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI PATIENT PROFILE/SAFETY,210001,CDM,270,RC,,,Outpatient,,,5.15,5.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,70,,2.89,percent of total billed charges,70% of total billed charges for outpatient setting,4.37,84.88,,3.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.58,50,,2.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.86,75,,3.09,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,70,,2.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.12,80,,3.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.35,65,,2.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,35,,1.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.64,90,,3.71,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.64,
MRI PELVIS W/O CONTRAST,2100170,CDM,610,RC,72195,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI PELVIS W/WO CONTRAST,2100180,CDM,610,RC,72197,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI PELVIS/HIP W/CONTRAST,2100171,CDM,610,RC,72196,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI SHOULDER LT W/CONTRAST,2100303,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI SHOULDER LT W/O CONTRAST,2100304,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI SHOULDER LT W/WO CONTRAST,2100305,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI SHOULDER RT W/CONTRAST,2100300,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI SHOULDER RT W/O CONTRAST,2100301,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI SHOULDER RT W/WO CONTRAST,2100302,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TEMPOROMANDIBULAR JOINT W/O CONTRAST,2100021,CDM,610,RC,70336,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI THORACIC W/ CONTRAST,2100101,CDM,612,RC,72147,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI THORACIC W/O CONTRAST,2100100,CDM,612,RC,72146,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI THUMB LT W/CONTRAST,2100264,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI THUMB LT W/WO CONTRAST,2100266,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI THUMB LT WO CONTRAST,2100265,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI THUMB RT W/CONTRAST,2100261,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI THUMB RT W/WO CONTRAST,2100263,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI THUMB RT WO CONTRAST,2100262,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB LT W/ CONTRAST,2100373,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB LT W/O CONTRAST,2100374,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB LT W/WO CONTRAST,2100375,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB RT W/ CONTRAST,2100370,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB RT W/O CONTRAST,2100371,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TIB-FIB RT W/WO CONTRAST,2100372,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE LT W/ CONTRAST,2100363,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE LT W/O CONTRAST,2100364,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE LT W/WO CONTRAST,2100365,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE RT W/ CONTRAST,2100360,CDM,610,RC,73719,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE RT W/O CONTRAST,2100361,CDM,610,RC,73718,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI TOE RT W/WO CONTRAST,2100362,CDM,610,RC,73720,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI T-SPINE W/WO CONTRAST,2100125,CDM,612,RC,72157,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI UP EXT W/CONTRAST,2100230,CDM,610,RC,73219,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI UP EXT W/O CONTRAST,2100225,CDM,610,RC,73218,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI UP EXT W/WO CONTRAST,2100235,CDM,610,RC,73220,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI UP JNT W/ CONTRAST,2100241,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,507.34,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI UP JNT W/O CONTRAST,2100240,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,350.66,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2574.18,
MRI UP JNT W/WO CONTRAST,2100250,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,329.98,2574.18,
MRI W/O CONSTRAST MATERIALS FOLLOWED BY,2100215,CDM,610,RC,73723,HCPCS,Outpatient,,,2055.64,2055.64,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1438.95,70,,1151.16,percent of total billed charges,70% of total billed charges for outpatient setting,1744.83,84.88,,1395.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1541.73,75,,1233.38,percent of total billed charges,75% of total billed charges for outpatient setting,1438.95,70,,1151.16,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,263.94,12.84,,211.152,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1644.51,80,,1315.61,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,263.94,12.84,,211.15,percent of total billed charges,12.84% of total billed charges,263.94,12.84,,211.15,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1937,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,586.37,100,,,Fee Schedule,100% of Custom Fee Schedule,1850.08,90,,1480.06,percent of total billed charges,90% of total billed charges for outpatient setting,263.94,1937,
MRI WRIST LT W/CONTRAST,2100321,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI WRIST LT W/O CONTRAST,2100322,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI WRIST LT W/WO CONTRAST,2100323,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI WRIST RT W/CONTRAST,2100318,CDM,610,RC,73222,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI WRIST RT W/O CONTRAST,2100319,CDM,610,RC,73221,HCPCS,Outpatient,,,2860.2,2860.2,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
MRI WRIST RT W/WO CONTRAST,2100320,CDM,610,RC,73223,HCPCS,Outpatient,,,2860.2,2860.2,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.14,70,,1601.71,percent of total billed charges,70% of total billed charges for outpatient setting,2427.74,84.88,,1942.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1430.1,50,,1144.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145.15,75,,1716.12,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.16,80,,1830.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,367.25,12.84,,293.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1937,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.07,35,,800.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2574.18,90,,2059.34,percent of total billed charges,90% of total billed charges for outpatient setting,367.25,2574.18,
"MRSA SCREEN, PRE-SURGICAL",222012,CDM,300,RC,87149,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
M-RSV,221025,CDM,306,RC,87807,HCPCS,Outpatient,,,58.95,53.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.27,70,,33.02,percent of total billed charges,70% of total billed charges for outpatient setting,50.04,84.88,,40.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.21,75,,35.37,percent of total billed charges,75% of total billed charges for outpatient setting,41.27,70,,33.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.16,80,,37.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,53.06,90,,42.45,percent of total billed charges,90% of total billed charges for outpatient setting,13.1,53.06,
M-SED RATE,221031,CDM,305,RC,85652,HCPCS,Outpatient,,,12.15,10.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,10.31,84.88,,8.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,9.11,75,,7.29,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,80,,7.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,100,,,Fee Schedule,100% of Custom Fee Schedule,10.94,90,,8.75,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,10.94,
MSH-MAGNESIUM,200200,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
MSH-SED RATE,200290,CDM,305,RC,85652,HCPCS,Outpatient,,,12.15,10.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,10.31,84.88,,8.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,9.11,75,,7.29,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,70,,6.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,80,,7.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,100,,,Fee Schedule,100% of Custom Fee Schedule,10.94,90,,8.75,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,10.94,
MSH-VITAMIN B12,201729,CDM,301,RC,82607,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,15.08,61.07,
MSI ABD 3 OR MORE VIEWS,3100196,CDM,320,RC,74021,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.16,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,38.16,295.41,
MSI CT ABD & PELVIS W/ AND W/O CONTRAST,3200160,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT ABD & PELVIS W/ CONTRAST,3200159,CDM,352,RC,74177,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT ABD & PELVIS W/O CONTRAST,3200158,CDM,352,RC,74176,HCPCS,Outpatient,,,2290.05,1717.54,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,287.63,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,206.19,2061.05,
MSI CT ABD PELV  TRIPLE PHASE W/WO CONTR,3200319,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT ABD TRIPLE PHASE W/ WO CONTRAST,3200320,CDM,352,RC,74170,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT ABDOMEN W/ AND W/O CONTRAST,3200157,CDM,352,RC,74170,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT ABDOMEN W/ CONTRAST,3200156,CDM,352,RC,74160,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT ABDOMEN W/O CONTRAST,3200155,CDM,352,RC,74150,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT ANKLE LT W/O CONTRAST,3200104,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT ANKLE RT W/O CONTRAST,3200103,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT CHEST W/ AND W/O CONTRAST,3200132,CDM,352,RC,71270,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT CHEST W/ CONTRAST,3200131,CDM,352,RC,71260,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT CHEST W/O CONTRAST,3200130,CDM,352,RC,71250,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT C-SPINE W/CONTRAST,3200134,CDM,352,RC,72126,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT C-SPINE W/O CONTRAST,3200135,CDM,352,RC,72125,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT ELBOW LT W/O CONTRAST,3200187,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT ELBOW RT W/O CONTRAST,3200184,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FACIAL BONES W/O CONTRAST,3200120,CDM,351,RC,70486,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT FEMUR LT W/O CONTRAST,3200189,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FEMUR RT W/O CONTRAST,3200147,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FOOT LT W/O CONTRAST,3200151,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FOOT RT W/O CONTRAST,3200149,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FOREARM LT W/O CONTRAST,3200228,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT FOREARM RT W/O CONTRAST,3200225,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HAND LT W/O CONTRAST,3200201,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HAND RT W/O CONTRAST,3200203,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HEAD W/ AND W/O CONTRAST,3200001,CDM,351,RC,70470,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT HEAD W/ CONTRAST,3200003,CDM,351,RC,70460,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT HEAD W/O CONTRAST,3200000,CDM,351,RC,70450,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT HEMATURIA PROTOCOL,3200175,CDM,352,RC,74178,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HIP LT W/O CONTRAST,3200123,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HIP RT W/O CONTRAST,3200122,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HUMERUS LT W/O CONTRAST,3200181,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT HUMERUS RT W/O CONTRAST,3200178,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT KNEE LT W/O CONTRAST,3200102,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT KNEE RT W/O CONTRAST,3200101,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT LDCT FOR LUNG CANCER SCREENING,3200129,CDM,352,RC,71271,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT LOW EXT W/O CONTRAST,3200150,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT L-SPINE W/ CONTRAST,3200138,CDM,352,RC,72132,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT L-SPINE W/O CONTRAST,3200137,CDM,352,RC,72131,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT NECK W/ AND W/O CONTRAST,3200127,CDM,351,RC,70492,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT NECK W/ CONTRAST,3200126,CDM,351,RC,70491,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT NECK W/O CONTRAST,3200125,CDM,351,RC,70490,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT ORBITS W/O CONTRAST,3200010,CDM,351,RC,70480,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT PELVIS W/ AND W/O CONTRAST,3200142,CDM,352,RC,72194,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT PELVIS W/ CONTRAST,3200141,CDM,352,RC,72193,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT PELVIS W/O CONTRAST,3200140,CDM,352,RC,72192,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT SCANOGRAM GROWTH STUDY,3200165,CDM,359,RC,77073,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,68.22,2061.05,
MSI CT SHOULDER LT W/O CONTRAST,3201157,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT SHOULDER RT  W/O CONTRAST,3200153,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT SINUS W/O CONTRAST,3200115,CDM,351,RC,70486,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT TEMPORAL BONES W/ CONTRAST,3200006,CDM,351,RC,70481,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,296.21,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT TEMPORAL BONES W/O CONTRAST,3200005,CDM,351,RC,70480,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT TIB-FIB LT W/O CONTRAST,3200176,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT TIB-FIB RT W/O CONTRAST,3200169,CDM,359,RC,73700,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT T-SPINE W/O CONTRAST,3200136,CDM,352,RC,72128,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT UPPER EXT W/ AND W/O CONTRAST,3200146,CDM,359,RC,73202,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,333.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CT UPPER EXT W/O CONTRAST,3200145,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,150.45,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,97.56,2061.05,
MSI CT WRIST LT W/O CONTRAST,3200194,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CT WRIST RT W/O CONTRAST,3200191,CDM,359,RC,73200,HCPCS,Outpatient,,,2290.05,1717.54,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1145.03,50,,916.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1550,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.52,35,,641.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CTA CHEST,3200133,CDM,350,RC,71275,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CTA CHEST PE PROTOCOL W/ CONTRAST,3200345,CDM,350,RC,71275,HCPCS,Outpatient,,,2290.05,1717.54,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,347.31,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,160.06,2061.05,
MSI CTV HEAD,3200268,CDM,350,RC,74174,HCPCS,Outpatient,,,2290.05,1717.54,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,1943.79,84.88,,1555.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.54,75,,1374.03,percent of total billed charges,75% of total billed charges for outpatient setting,1603.04,70,,1282.43,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832.04,80,,1465.63,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061.05,90,,1648.84,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061.05,
MSI CTV NECK,3200269,CDM,350,RC,74174,HCPCS,Outpatient,,,2290,1717.5,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1603,70,,1282.4,percent of total billed charges,70% of total billed charges for outpatient setting,1943.75,84.88,,1555,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1717.5,75,,1374,percent of total billed charges,75% of total billed charges for outpatient setting,1603,70,,1282.4,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,294.04,12.84,,235.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1832,80,,1465.6,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,294.04,12.84,,235.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1550,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,464.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2061,90,,1648.8,percent of total billed charges,90% of total billed charges for outpatient setting,294.04,2061,
MSI ELBOW 3+ VWS BILATERAL,3100124,CDM,320,RC,73080,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI FOREARM 2 VIEWS BILATERAL,3100127,CDM,320,RC,73090,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI US ABD COMP,2500140,CDM,402,RC,76700,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ABD RUQ,2500145,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
"MSI US ABD, LIMITED",2500152,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ADB SOFT TISSUE,2500167,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US AORTA SCREENING FOR AAA,2500157,CDM,402,RC,76706,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.73,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ART DOPPLER BILAT LOWER EXT,2500055,CDM,921,RC,93925,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ART DOPPLER BILAT UPPER EXT,2500065,CDM,921,RC,93930,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ART DOPPLER UNI LOWER EXT,2500380,CDM,921,RC,93926,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US ART DOPPLER UNI UPPER EXT,2500070,CDM,921,RC,93931,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US AXILLA BILATERAL,2500159,CDM,402,RC,76882,HCPCS,Outpatient,,,954,954,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,809.76,84.88,,647.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,477,50,,381.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.5,75,,572.4,percent of total billed charges,75% of total billed charges for outpatient setting,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.2,80,,610.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.9,35,,267.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,858.6,90,,686.88,percent of total billed charges,90% of total billed charges for outpatient setting,122.49,858.6,
MSI US AXILLA UNILATERAL,2500158,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US BLADDER,2500166,CDM,402,RC,76857,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US CARD REFLUX VEN STUDY BILAT LOW,2500078,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US CAROTID DOPPLER,2500040,CDM,921,RC,93880,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US DUPLEX SCAN ABD/PELVIC/SCROTAL /R,2500044,CDM,921,RC,93975,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US GROIN  (VASCULAR) BILATERAL,2500264,CDM,921,RC,93925,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,642.14,
MSI US GROIN (NONVASCULAR),2500262,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
"MSI US GROIN (NONVASCULAR), BILATERAL",2500263,CDM,402,RC,76882,HCPCS,Outpatient,,,954,954,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,809.76,84.88,,647.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,477,50,,381.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.5,75,,572.4,percent of total billed charges,75% of total billed charges for outpatient setting,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.2,80,,610.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.9,35,,267.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,858.6,90,,686.88,percent of total billed charges,90% of total billed charges for outpatient setting,122.49,858.6,
MSI US GROIN (VASCULAR),2500260,CDM,921,RC,93926,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US HEMODIALYSIS ACCESS GRAFT,2600041,CDM,921,RC,93990,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PAROTID,2500129,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PELVIC,2500210,CDM,402,RC,76856,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PELVIC LTD,2500215,CDM,402,RC,76857,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PREG COMP,2500170,CDM,402,RC,76805,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PREG LTD,2500180,CDM,402,RC,76815,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US PROSTATE,2500225,CDM,402,RC,76872,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US RAD REFLUX VEN STUDY BILAT LOW,2500079,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US RENAL,2500150,CDM,402,RC,76770,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US RETROPERITONEAL (AORTA/KIDNEY) CO,2500151,CDM,402,RC,76770,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US SOFT TISSUE CHEST,2500238,CDM,402,RC,76604,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US SOFT TISSUE HEAD & NECK,2500237,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US SOFT TISSUE NON-VASC EXTREMITY,2500235,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US SPLEEN,2500146,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US TESTICULAR,2500220,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US THYROID,2500130,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US TRANS VAG,2500200,CDM,402,RC,76830,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US UPPER BACK LTD,2500218,CDM,402,RC,76604,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US VEN DOPPLER BILAT UPPER OR LOWER,2500075,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US VEN DOPPLER UNI UPPER OR LOWER E,2500080,CDM,921,RC,93971,HCPCS,Outpatient,,,561.52,561.52,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,393.06,70,,314.45,percent of total billed charges,70% of total billed charges for outpatient setting,476.62,84.88,,381.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,421.14,75,,336.91,percent of total billed charges,75% of total billed charges for outpatient setting,393.06,70,,314.45,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,449.22,80,,359.38,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,505.37,90,,404.3,percent of total billed charges,90% of total billed charges for outpatient setting,72.1,505.37,
MSI US VEN DOPPLER UNI UPPER OR LOWER EX,2500395,CDM,921,RC,93971,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI US VESSEL MAPPING FOR HEMODIALYSIS A,2500076,CDM,921,RC,93985,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256.31,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MSI XR AB FLAT AND ERECT,3100200,CDM,320,RC,74019,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.54,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,32.54,295.41,
MSI XR ANKLE 3+ VWS BILATERAL,3100179,CDM,320,RC,73610,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR ANKLE LT 2 VIEWS,3100176,CDM,320,RC,73600,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ANKLE LT 3 VIEWS,3100178,CDM,320,RC,73610,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ANKLE RT 2 VIEWS,3100175,CDM,320,RC,73600,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ANKLE RT 3 VIEWS,3100177,CDM,320,RC,73610,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR BILAT KNEE COMPLETE FOUR/+ VIEWS,3100168,CDM,320,RC,73564,HCPCS,Outpatient,,,492.35,369.26,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.65,70,,275.72,percent of total billed charges,70% of total billed charges for outpatient setting,417.91,84.88,,334.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,246.18,50,,196.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.26,75,,295.41,percent of total billed charges,75% of total billed charges for outpatient setting,344.65,70,,275.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.22,12.84,,50.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.88,80,,315.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.22,12.84,,50.58,percent of total billed charges,12.84% of total billed charges,63.22,12.84,,50.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.32,35,,137.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,443.12,90,,354.5,percent of total billed charges,90% of total billed charges for outpatient setting,63.22,443.12,
MSI XR BONE AGE HAND,3100205,CDM,320,RC,77072,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR BONE SURVEY COMPLETE,3100210,CDM,320,RC,77075,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR C SPINE 6 OR MORE VIEWS,3100063,CDM,320,RC,72052,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR CALCANEUS BILAT 2 VIEWS,3100187,CDM,320,RC,73650,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR CALCANEUS LT 2 VIEWS,3100186,CDM,320,RC,73650,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR CALCANEUS RT 2 VIEWS,3100185,CDM,320,RC,73650,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR CERVICAL SPINE 2 OR 3 VIEWS,3100061,CDM,320,RC,72040,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR CERVICAL SPINE 4 OR 5 VIEWS,3100062,CDM,320,RC,72050,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR CHEST 1 VIEWS,3100045,CDM,324,RC,71045,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,19.62,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,19.62,240.13,
MSI XR CHEST 2 VIEWS,3100050,CDM,324,RC,71046,HCPCS,Outpatient,,,266.81,200.11,,115.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.21,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,29.82,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,29.82,240.13,
MSI XR CLAVICLE LT,3100101,CDM,320,RC,73000,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR CLAVICLE RT,3100100,CDM,320,RC,73000,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ELBOW LT 2 VIEWS,3100121,CDM,320,RC,73070,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ELBOW LT 3 VIEWS,3100123,CDM,320,RC,73080,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ELBOW RT 2 VIEWS,3100120,CDM,320,RC,73070,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ELBOW RT 3 VIEWS,3100122,CDM,320,RC,73080,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
"MSI XR FACIAL BONES, COMPLETE 3+ VIEWS",3100010,CDM,320,RC,70150,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR FEMUR LT 1 VIEWS,3100156,CDM,320,RC,73551,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FEMUR LT 2 VIEWS,3100158,CDM,320,RC,73552,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FEMUR RT 1 VIEWS,3100155,CDM,320,RC,73551,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FEMUR RT 2 VIEWS,3100157,CDM,320,RC,73552,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FINGERS BILAT 2 VIEWS,3100142,CDM,320,RC,73140,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR FINGERS LT 2 VIEWS,3100141,CDM,320,RC,73140,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FINGERS RT 2 VIEWS,3100140,CDM,320,RC,73140,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOOT 3 VIEWS BILATERAL,3100184,CDM,320,RC,73630,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR FOOT LT 2 VIEWS,3100181,CDM,320,RC,73620,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOOT LT 3 VIEWS,3100183,CDM,320,RC,73630,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOOT RT 2 VIEWS,3100180,CDM,320,RC,73620,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOOT RT 3 VIEWS,3100182,CDM,320,RC,73630,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOREARM LT 2 VIEWS,3100126,CDM,320,RC,73090,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR FOREARM RT 2 VIEWS,3100125,CDM,320,RC,73090,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HAND LT 2 VIEWS,3100136,CDM,320,RC,73110,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HAND LT 3 VIEWS,3100138,CDM,320,RC,73130,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HAND RT 2 VIEWS,3100135,CDM,320,RC,73120,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR HAND RT 3 VIEWS,3100137,CDM,320,RC,73130,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HANDS 3 VIEWS BILATERAL,3100139,CDM,320,RC,73130,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR HIP LT 1 VIEW,3100146,CDM,320,RC,73501,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HIP LT 2-3 VIEW,3100148,CDM,320,RC,73502,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HIP RT 1 VIEW,3100145,CDM,320,RC,73501,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HIP RT 2-3 VIEW,3100147,CDM,320,RC,73502,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HIPS BIL 2-3 V W/WO PELVIS,3100151,CDM,320,RC,73502,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR HIPS BILAT 3-4 VIEWS,3100150,CDM,320,RC,73522,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,47.72,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR HIPS BILAT AP/LAT 2 VIEWS,3100149,CDM,320,RC,73521,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.61,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,38.61,295.41,
MSI XR HUMERUS 2 VIEWS BILATERAL,3100117,CDM,320,RC,73060,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR HUMERUS LT 2 VIEWS,3100116,CDM,320,RC,73060,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR HUMERUS RT 2 VIEWS,3100115,CDM,320,RC,73060,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR KNEE 1-2 VIEW BILATERAL,3100169,CDM,320,RC,73560,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR KNEE 3 VWS BILATERAL,3100167,CDM,320,RC,73562,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR KNEE BOTH AP,3100166,CDM,320,RC,73565,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR KNEE LT 1-2 VIEW,3100161,CDM,320,RC,73560,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR KNEE LT 3 VIEWS,3100163,CDM,320,RC,73562,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
"MSI XR KNEE LT 4 VWS(Stnd AP,Lat,RB,SNR)",3100165,CDM,320,RC,73564,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR KNEE RT 1-2 VIEW,3100160,CDM,320,RC,73560,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR KNEE RT 3 VIEWS,3100162,CDM,320,RC,73562,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
"MSI XR KNEE RT 4 VWS(Stnd AP,Lat,RB,SNR)",3100164,CDM,320,RC,73564,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR KUB,3100195,CDM,320,RC,74018,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.67,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,26.67,240.13,
MSI XR L SPINE 2-3 VIEWS,3100080,CDM,320,RC,72100,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR L SPINE 4 OR MORE VIEWS,3100081,CDM,320,RC,72120,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
"MSI XR MANDIBLE, PARTIAL <4 VIEWS",3100000,CDM,320,RC,70100,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
"MSI XR MASTOIDS, COMPLETE 3+ VIEWS",3100005,CDM,320,RC,70130,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
"MSI XR NASAL BONES, COMPLETE 3+ VIEWS",3100015,CDM,320,RC,70160,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR ORBITS LT 4+ VIEWS,3100021,CDM,320,RC,70200,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR ORBITS RT 4+ VIEWS,3100020,CDM,320,RC,70200,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR PELVIS 1-2 VIEWS,3100085,CDM,320,RC,72170,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR RIBS BILAT 3 VIEWS,3100057,CDM,320,RC,71110,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR RIBS LT 2 VIEWS,3100056,CDM,320,RC,71100,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR RIBS RT 2 VIEWS,3100055,CDM,320,RC,71100,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SACRUM/COCCYX 2 VIEWS,3100095,CDM,320,RC,72220,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SCAPULA LT,3100106,CDM,320,RC,73010,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR SCAPULA RT,3100105,CDM,320,RC,73010,HCPCS,Outpatient,,,328.23,246.17,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR SHOULDER 2 VWS BILATERAL,3100114,CDM,320,RC,73030,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR SHOULDER LT 1 VIEW,3100111,CDM,320,RC,73020,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SHOULDER LT 2 OR MORE,3100113,CDM,320,RC,73030,HCPCS,Outpatient,,,226.81,170.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.77,70,,127.02,percent of total billed charges,70% of total billed charges for outpatient setting,192.52,84.88,,154.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.41,50,,90.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.11,75,,136.09,percent of total billed charges,75% of total billed charges for outpatient setting,158.77,70,,127.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.12,12.84,,23.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.45,80,,145.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.12,12.84,,23.3,percent of total billed charges,12.84% of total billed charges,29.12,12.84,,23.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.38,35,,63.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.13,90,,163.3,percent of total billed charges,90% of total billed charges for outpatient setting,29.12,204.13,
MSI XR SHOULDER RT 1 VIEW,3100110,CDM,320,RC,73020,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SHOULDER RT 2 OR MORE,3100112,CDM,320,RC,73030,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SI JOINTS 3 OR MORE VIEWS,3100090,CDM,320,RC,72202,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR SINUSES <3 VIEWS,3100030,CDM,320,RC,70210,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SINUSES 3+ VIEWS,3100031,CDM,320,RC,70220,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SKULL 4+ VIEWS,3100035,CDM,320,RC,70260,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR SOFT TISSUE NECK,3100040,CDM,320,RC,70360,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR SPINE SCOLIOSIS EVALUATION,3100070,CDM,320,RC,72082,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,60.5,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR SPINE/SKULL (SCOL EVAL) 2 OR 3 VW,3100075,CDM,320,RC,72082,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,60.5,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR STERNUM,3100060,CDM,320,RC,71120,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR THORACIC SPINE 2 VIEWS,3100065,CDM,320,RC,72070,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
MSI XR TIB/FIB 2 VWS BIL,3100172,CDM,320,RC,73590,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR TIB/FIB LT 2 VIEWS,3100171,CDM,320,RC,73590,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR TIB/FIB RT 2 VIEWS,3100170,CDM,320,RC,73590,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR TOES LT 2 VIEWS,3100191,CDM,320,RC,73660,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR TOES RT 2 VIEWS,3100190,CDM,320,RC,73660,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR WRIST 3 VIEWS BILATERAL,3100134,CDM,320,RC,73110,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
MSI XR WRIST LT 2 VIEWS,3100131,CDM,320,RC,73100,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR WRIST LT 3 VIEWS,3100133,CDM,320,RC,73110,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR WRIST RT 2 VIEWS,3100130,CDM,320,RC,73100,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MSI XR WRIST RT 3 VIEWS,3100132,CDM,320,RC,73110,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
M-STREP A,221022,CDM,306,RC,87880,HCPCS,Outpatient,,,74.39,66.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.07,70,,41.66,percent of total billed charges,70% of total billed charges for outpatient setting,63.14,84.88,,50.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.79,75,,44.63,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,70,,41.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.51,80,,47.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,66.95,90,,53.56,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,66.95,
M-T3 UPTAKE,221005,CDM,301,RC,84479,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,26.21,
M-T4,221003,CDM,301,RC,84436,HCPCS,Outpatient,,,30.92,27.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,26.24,84.88,,20.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.19,75,,18.55,percent of total billed charges,75% of total billed charges for outpatient setting,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,80,,19.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,100,,,Fee Schedule,100% of Custom Fee Schedule,27.83,90,,22.26,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,27.83,
M-T4 FREE,221006,CDM,300,RC,84439,HCPCS,Outpatient,,,40.59,36.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,34.45,84.88,,27.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.44,75,,24.35,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.47,80,,25.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,100,,,Fee Schedule,100% of Custom Fee Schedule,36.53,90,,29.22,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,36.53,
MTHFR GENE,201263,CDM,301,RC,81291,HCPCS,Outpatient,,,294.03,264.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.82,70,,164.66,percent of total billed charges,70% of total billed charges for outpatient setting,249.57,84.88,,199.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,220.52,75,,176.42,percent of total billed charges,75% of total billed charges for outpatient setting,205.82,70,,164.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.22,80,,188.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.77,100,,,Fee Schedule,100% of Custom Fee Schedule,264.63,90,,211.7,percent of total billed charges,90% of total billed charges for outpatient setting,37.75,264.63,
"MTHFR GENE ANALYSIS, COMMON VARIANTS",220820,CDM,310,RC,81291,HCPCS,Outpatient,,,294.03,264.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.82,70,,164.66,percent of total billed charges,70% of total billed charges for outpatient setting,249.57,84.88,,199.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,220.52,75,,176.42,percent of total billed charges,75% of total billed charges for outpatient setting,205.82,70,,164.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.22,80,,188.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,37.75,12.84,,30.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.77,100,,,Fee Schedule,100% of Custom Fee Schedule,264.63,90,,211.7,percent of total billed charges,90% of total billed charges for outpatient setting,37.75,264.63,
M-TOTAL BILIRUBIN,221049,CDM,300,RC,82248,HCPCS,Outpatient,,,34.74,31.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,29.49,84.88,,23.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.06,75,,20.85,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,80,,22.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,31.27,90,,25.02,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,31.27,
M-TSH,221004,CDM,301,RC,84443,HCPCS,Outpatient,,,75.6,68.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.17,84.88,,51.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.7,75,,45.36,percent of total billed charges,75% of total billed charges for outpatient setting,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,80,,48.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,100,,,Fee Schedule,100% of Custom Fee Schedule,68.04,90,,54.43,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,68.04,
M-UA DIP,221018,CDM,307,RC,81003,HCPCS,Outpatient,,,10.13,9.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,8.6,84.88,,6.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,7.6,75,,6.08,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,80,,6.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of Custom Fee Schedule,9.12,90,,7.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,9.12,
MUCINEX (GUAFENESIN) ER 600MG: TAB,3303108,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MUCINEX DM(GUAIFENESIN/DEXTROM)600/30MG,3303107,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MUCOSAL ATOMIZATION DEVICE / MAD700,6151000,CDM,272,RC,,,Outpatient,,,71.68,71.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.18,70,,40.14,percent of total billed charges,70% of total billed charges for outpatient setting,60.84,84.88,,48.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.84,50,,28.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.76,75,,43.01,percent of total billed charges,75% of total billed charges for outpatient setting,50.18,70,,40.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.34,80,,45.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,9.2,12.84,,7.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.59,65,,37.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.09,35,,20.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.51,90,,51.61,percent of total billed charges,90% of total billed charges for outpatient setting,9.2,64.51,
MULTI VIT (THERAPEUTIC V/MIN) TAB:UD,3301612,CDM,259,RC,,,Outpatient,,,3.95,3.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,70,,2.22,percent of total billed charges,70% of total billed charges for outpatient setting,3.35,84.88,,2.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.98,50,,1.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.96,75,,2.37,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,70,,2.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.16,80,,2.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,0.51,12.84,,0.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.57,65,,2.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,35,,1.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.56,90,,2.85,percent of total billed charges,90% of total billed charges for outpatient setting,0.51,3.56,
MULTI-AD FLUID DISP SYST / 513506,69160861,CDM,272,RC,,,Outpatient,,,69.02,69.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.31,70,,38.65,percent of total billed charges,70% of total billed charges for outpatient setting,58.58,84.88,,46.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.51,50,,27.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.77,75,,41.42,percent of total billed charges,75% of total billed charges for outpatient setting,48.31,70,,38.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.86,12.84,,7.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.22,80,,44.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.86,12.84,,7.09,percent of total billed charges,12.84% of total billed charges,8.86,12.84,,7.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.86,65,,35.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.16,35,,19.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.12,90,,49.7,percent of total billed charges,90% of total billed charges for outpatient setting,8.86,62.12,
MULTIPLE PROCEDURES 10 OR MORE,6100060,CDM,360,RC,,,Outpatient,,,15015,15015,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10510.5,70,,8408.4,percent of total billed charges,70% of total billed charges for outpatient setting,12744.73,84.88,,10195.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7507.5,50,,6006,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11261.25,75,,9009,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.93,12.84,,1542.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12012,80,,9609.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.93,12.84,,1542.34,percent of total billed charges,12.84% of total billed charges,1927.93,12.84,,1542.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5255.25,35,,4204.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13513.5,90,,10810.8,percent of total billed charges,90% of total billed charges for outpatient setting,1927.93,13513.5,
MULTIPLE PROCEDURES 2 OR 3 PROCEDURES,6100050,CDM,360,RC,,,Outpatient,,,4200,4200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940,70,,2352,percent of total billed charges,70% of total billed charges for outpatient setting,3564.96,84.88,,2851.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,2100,50,,1680,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3150,75,,2520,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,12.84,,431.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3360,80,,2688,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,12.84,,431.42,percent of total billed charges,12.84% of total billed charges,539.28,12.84,,431.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470,35,,1176,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,90,,3024,percent of total billed charges,90% of total billed charges for outpatient setting,539.28,3780,
MULTIPLE PROCEDURES 4 OR 5,6100051,CDM,360,RC,,,Outpatient,,,6903.75,6903.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4832.63,70,,3866.1,percent of total billed charges,70% of total billed charges for outpatient setting,5859.9,84.88,,4687.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,3451.88,50,,2761.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5177.81,75,,4142.25,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.44,12.84,,709.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5523,80,,4418.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.44,12.84,,709.15,percent of total billed charges,12.84% of total billed charges,886.44,12.84,,709.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2416.31,35,,1933.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6213.38,90,,4970.7,percent of total billed charges,90% of total billed charges for outpatient setting,886.44,6213.38,
MULTIPLE PROCEDURES 6 OR 7,6100058,CDM,360,RC,,,Outpatient,,,9607.5,9607.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6725.25,70,,5380.2,percent of total billed charges,70% of total billed charges for outpatient setting,8154.85,84.88,,6523.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,4803.75,50,,3843,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7205.63,75,,5764.5,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1233.6,12.84,,986.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7686,80,,6148.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1233.6,12.84,,986.88,percent of total billed charges,12.84% of total billed charges,1233.6,12.84,,986.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3362.63,35,,2690.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8646.75,90,,6917.4,percent of total billed charges,90% of total billed charges for outpatient setting,1233.6,8646.75,
MULTIPLE PROCEDURES 8-9,6100059,CDM,360,RC,,,Outpatient,,,12311.25,12311.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8617.88,70,,6894.3,percent of total billed charges,70% of total billed charges for outpatient setting,10449.79,84.88,,8359.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,6155.63,50,,4924.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9233.44,75,,7386.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.76,12.84,,1264.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9849,80,,7879.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.76,12.84,,1264.61,percent of total billed charges,12.84% of total billed charges,1580.76,12.84,,1264.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4308.94,35,,3447.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11080.13,90,,8864.1,percent of total billed charges,90% of total billed charges for outpatient setting,1580.76,11080.13,
MULTIVIT M (THERA M ) TAB :  U/D,3301605,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MULTIVIT W/M (THERAPEUTIC VIT) TAB:30U,3301611,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MULTIVITAMIN (INFUVITE ) 2 SDV 10ML,3301607,CDM,250,RC,,,Outpatient,,,50.13,50.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,70,,28.07,percent of total billed charges,70% of total billed charges for outpatient setting,42.55,84.88,,34.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.07,50,,20.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.6,75,,30.08,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,70,,28.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,12.84,,5.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.1,80,,32.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,12.84,,5.15,percent of total billed charges,12.84% of total billed charges,6.44,12.84,,5.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.58,65,,26.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,35,,14.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.12,90,,36.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.44,45.12,
MULTIVITAMIN (MVI 12) MDV :5ML,3301609,CDM,250,RC,,,Outpatient,,,22.04,22.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.43,70,,12.34,percent of total billed charges,70% of total billed charges for outpatient setting,18.71,84.88,,14.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.02,50,,8.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.53,75,,13.22,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,70,,12.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,80,,14.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,2.83,12.84,,2.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.33,65,,11.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,35,,6.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.84,90,,15.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.83,19.84,
MULTIVITAMIN (THERAVITE) LIQ : 120ML,3301610,CDM,259,RC,,,Outpatient,,,16.17,16.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,70,,9.06,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,84.88,,10.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.09,50,,6.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.13,75,,9.7,percent of total billed charges,75% of total billed charges for outpatient setting,11.32,70,,9.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,80,,10.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.51,65,,8.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.66,35,,4.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.55,90,,11.64,percent of total billed charges,90% of total billed charges for outpatient setting,2.08,14.55,
MULTIVITAMIN CONC SDV : 5 ML,3301608,CDM,250,RC,,,Outpatient,,,17.73,17.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,70,,9.93,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,84.88,,12.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.87,50,,7.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,75,,10.64,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,70,,9.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,80,,11.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.52,65,,9.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,35,,4.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.96,90,,12.77,percent of total billed charges,90% of total billed charges for outpatient setting,2.28,15.96,
MULTIVITAMIN+BETACAROTENE TAB  U/D,3301606,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MUMPS AB IGG,201699,CDM,302,RC,86735,HCPCS,Outpatient,,,58.73,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,49.85,84.88,,39.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.05,75,,35.24,percent of total billed charges,75% of total billed charges for outpatient setting,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,80,,37.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,100% of Custom Fee Schedule,52.86,90,,42.29,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,52.86,
MUMPS AB IGG,220731,CDM,302,RC,86735,HCPCS,Outpatient,,,58.73,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,49.85,84.88,,39.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.05,75,,35.24,percent of total billed charges,75% of total billed charges for outpatient setting,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,80,,37.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,100% of Custom Fee Schedule,52.86,90,,42.29,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,52.86,
MUMPS AB IGM,201697,CDM,302,RC,86735,HCPCS,Outpatient,,,58.73,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,49.85,84.88,,39.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.05,75,,35.24,percent of total billed charges,75% of total billed charges for outpatient setting,41.11,70,,32.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,80,,37.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,100% of Custom Fee Schedule,52.86,90,,42.29,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,52.86,
MUPIROCIN OINT 1 GRAM UD CHARGE,3302680,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
MUPIROCIN(genericBACTROBAN) 2%OINT 22GM,3301614,CDM,259,RC,,,Outpatient,,,36.16,36.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,70,,20.25,percent of total billed charges,70% of total billed charges for outpatient setting,30.69,84.88,,24.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.08,50,,14.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.12,75,,21.7,percent of total billed charges,75% of total billed charges for outpatient setting,25.31,70,,20.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,80,,23.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,4.64,12.84,,3.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.5,65,,18.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,35,,10.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.54,90,,26.03,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,32.54,
MUSCLE BIOPSY,202046,CDM,310,RC,88305,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,178.52,
MUSCLE BX W/HISTOCHEMISTRY  REFERENCE,200399,CDM,314,RC,88305,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,178.52,
M-VITAMIN B12,221047,CDM,301,RC,82607,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,15.08,61.07,
M-VITAMIN D 25-HYDROXY,221048,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
MX ANKLE/BRACHIAL INDICES (ABI),2600352,CDM,921,RC,93922,HCPCS,Outpatient,,,636,636,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
MX COLOR FLOW,2600028,CDM,480,RC,93325,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
MX DIPYRIDAMOLE (PERSANTINE) TAB : 25 MG,3000508,CDM,259,RC,J1245,HCPCS,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,100,,,Fee Schedule,100% of Custom Fee Schedule,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
MX DOPPLER ECHO COMPLETE (ADD ON),2600026,CDM,480,RC,93320,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
MX DOPPLER ECHO FLW -UP/LIMITED (ADD ON),2600016,CDM,480,RC,93321,HCPCS,Outpatient,,,667.8,667.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,85.75,601.02,
MX ECHO COMPLETE W/DOPPLER & COLOR FLOW,2600017,CDM,483,RC,93306,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
MX ECHO FOLLOW UP OR LIMITED STUDY,2600023,CDM,483,RC,93308,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.19,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,642.14,
MX EVENT MONITORING HOOKUP,2600100,CDM,731,RC,93270,HCPCS,Outpatient,,,361.5,361.5,,53.38,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,56.72,170,,,Fee Schedule,170% of Medicare OPPS rate,71.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,58.39,175,,,Fee Schedule,175% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,46.71,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,41.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,33.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,33.36,325.35,
MX HOLTER MONITOR HOOKUP,2600119,CDM,731,RC,93225,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
MX NM ADENOSINE INJ:30 MG DIAGNOSTIC,3000509,CDM,636,RC,J0152,HCPCS,Outpatient,,,359.26,359.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.48,70,,201.18,percent of total billed charges,70% of total billed charges for outpatient setting,304.94,84.88,,243.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.63,50,,143.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.45,75,,215.56,percent of total billed charges,75% of total billed charges for outpatient setting,251.48,70,,201.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.13,12.84,,36.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.41,80,,229.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.13,12.84,,36.9,percent of total billed charges,12.84% of total billed charges,46.13,12.84,,36.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,233.52,65,,186.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.74,35,,100.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,323.33,90,,258.66,percent of total billed charges,90% of total billed charges for outpatient setting,46.13,323.33,
MX NM CARDIAC STRESS TEST,3000503,CDM,482,RC,93017,HCPCS,Outpatient,,,819.89,819.89,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,695.92,84.88,,556.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,614.92,75,,491.94,percent of total billed charges,75% of total billed charges for outpatient setting,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,105.27,12.84,,84.216,percent of total billed charges,12.84% of total billed charges,415.02,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,655.91,80,,524.73,percent of total billed charges,80% of total billed charges for outpatient setting,332.02,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,290.51,100,,,Fee Schedule,100% of Custom Fee Schedule,737.9,90,,590.32,percent of total billed charges,90% of total billed charges for outpatient setting,105.27,737.9,
MX NM EXERCISE STRESS NO IMAGES,3000517,CDM,482,RC,93017,HCPCS,Outpatient,,,819.89,819.89,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,695.92,84.88,,556.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,614.92,75,,491.94,percent of total billed charges,75% of total billed charges for outpatient setting,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,105.27,12.84,,84.216,percent of total billed charges,12.84% of total billed charges,415.02,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,655.91,80,,524.73,percent of total billed charges,80% of total billed charges for outpatient setting,332.02,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,290.51,100,,,Fee Schedule,100% of Custom Fee Schedule,737.9,90,,590.32,percent of total billed charges,90% of total billed charges for outpatient setting,105.27,737.9,
MX NM MUGA SCAN,3000191,CDM,341,RC,78472,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
MX NM MYOCARD PERF EF/WM MULTIPLE,3000501,CDM,341,RC,78452,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
MX NM MYOCARD PERF. EF/WM MULTI-SAMP,3000502,CDM,341,RC,78452,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
MX NM TC99 LABELED RBC'S/ UP TO 30mCi,3000736,CDM,343,RC,A9560,HCPCS,Outpatient,,,682.28,511.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.6,70,,382.08,percent of total billed charges,70% of total billed charges for outpatient setting,579.12,84.88,,463.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,511.71,75,,409.37,percent of total billed charges,75% of total billed charges for outpatient setting,477.6,70,,382.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.82,80,,436.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,443.48,65,,354.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.05,90,,491.24,percent of total billed charges,90% of total billed charges for outpatient setting,87.6,614.05,
MX NM TC99 MYOVIEW/ PER STUDY DOSE,3000506,CDM,636,RC,A9502,HCPCS,Outpatient,,,738.98,738.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.29,70,,413.83,percent of total billed charges,70% of total billed charges for outpatient setting,627.25,84.88,,501.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,554.24,75,,443.39,percent of total billed charges,75% of total billed charges for outpatient setting,517.29,70,,413.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.89,12.84,,75.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.18,80,,472.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.89,12.84,,75.91,percent of total billed charges,12.84% of total billed charges,94.89,12.84,,75.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480.34,65,,384.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.08,90,,532.06,percent of total billed charges,90% of total billed charges for outpatient setting,94.89,665.08,
MX NM TC99 SESTAMIBI/per study dose,3000504,CDM,636,RC,A9500,HCPCS,Outpatient,,,536.5,536.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.55,70,,300.44,percent of total billed charges,70% of total billed charges for outpatient setting,455.38,84.88,,364.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,402.38,75,,321.9,percent of total billed charges,75% of total billed charges for outpatient setting,375.55,70,,300.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,12.84,,55.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.2,80,,343.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,12.84,,55.11,percent of total billed charges,12.84% of total billed charges,68.89,12.84,,55.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.73,65,,278.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.85,90,,386.28,percent of total billed charges,90% of total billed charges for outpatient setting,68.89,482.85,
MX NM THALLIUM 201/mCi; PER mCi,3000507,CDM,636,RC,A9505,HCPCS,Outpatient,,,136.24,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.37,70,,76.3,percent of total billed charges,70% of total billed charges for outpatient setting,115.64,84.88,,92.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,102.18,75,,81.74,percent of total billed charges,75% of total billed charges for outpatient setting,95.37,70,,76.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,12.84,,13.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.99,80,,87.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,12.84,,13.99,percent of total billed charges,12.84% of total billed charges,17.49,12.84,,13.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.56,65,,70.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.62,90,,98.1,percent of total billed charges,90% of total billed charges for outpatient setting,17.49,173.75,
MX PATCH MONITOR 7-15 DAYS,2600096,CDM,731,RC,93246,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
MX PATCH MONITOR 72 HOUR,2600109,CDM,731,RC,93242,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
MX PATCH MONITOR 96+ HOUR,2600113,CDM,731,RC,93242,HCPCS,Outpatient,,,361.5,361.5,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,126.53,35,,101.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
MX PATCH MONITOR UP TO 48 HOUR,2600111,CDM,731,RC,93225,HCPCS,Outpatient,,,361.5,361.5,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,306.84,84.88,,245.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,271.13,75,,216.9,percent of total billed charges,75% of total billed charges for outpatient setting,253.05,70,,202.44,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.42,12.84,,37.136,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,289.2,80,,231.36,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,46.42,12.84,,37.14,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,83.48,100,,,Fee Schedule,100% of Custom Fee Schedule,325.35,90,,260.28,percent of total billed charges,90% of total billed charges for outpatient setting,46.42,325.35,
MX REGADENOSON (LEXISCAN):0.4MG/5ML,3000505,CDM,636,RC,J2785,HCPCS,Outpatient,,,797.35,797.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.15,70,,446.52,percent of total billed charges,70% of total billed charges for outpatient setting,676.79,84.88,,541.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,598.01,75,,478.41,percent of total billed charges,75% of total billed charges for outpatient setting,558.15,70,,446.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,12.84,,81.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.88,80,,510.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,12.84,,81.9,percent of total billed charges,12.84% of total billed charges,102.38,12.84,,81.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,518.28,65,,414.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of Custom Fee Schedule,717.62,90,,574.1,percent of total billed charges,90% of total billed charges for outpatient setting,62.24,717.62,
MX STRESS ECHO TEST,2600027,CDM,483,RC,93350,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
MX THORACOLUMBAR JUNCTION TWO VIEWS,2600090,CDM,320,RC,72080,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
MX TTE W/CONTRAST 2D & CF W/DOP ECHO,2600031,CDM,483,RC,C8929,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
MX TTE W/CONTRAST 2D LMT,2600032,CDM,483,RC,C8924,HCPCS,Outpatient,,,1141.31,1141.31,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,595.47,100,,,Fee Schedule,100% of Custom Fee Schedule,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,146.54,1027.18,
MX TTE W/CONTRAST 2D REST & W/STR,2600033,CDM,483,RC,C8930,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
MYCOPLASMA HOMINIS CULTURE,200137,CDM,310,RC,87109,HCPCS,Outpatient,,,69.26,62.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,70,,38.78,percent of total billed charges,70% of total billed charges for outpatient setting,58.79,84.88,,47.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.95,75,,41.56,percent of total billed charges,75% of total billed charges for outpatient setting,48.48,70,,38.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.41,80,,44.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,100,,,Fee Schedule,100% of Custom Fee Schedule,62.33,90,,49.86,percent of total billed charges,90% of total billed charges for outpatient setting,15.39,62.33,
MYCOPLASMA HOMINIS CULTURE,220064,CDM,310,RC,87109,HCPCS,Outpatient,,,69.26,62.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,70,,38.78,percent of total billed charges,70% of total billed charges for outpatient setting,58.79,84.88,,47.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.43,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.95,75,,41.56,percent of total billed charges,75% of total billed charges for outpatient setting,48.48,70,,38.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.41,80,,44.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,100,,,Fee Schedule,100% of Custom Fee Schedule,62.33,90,,49.86,percent of total billed charges,90% of total billed charges for outpatient setting,15.39,62.33,
MYCOPLASMA PNEUMONIA AB IGG,220426,CDM,302,RC,86738,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.12,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,53.62,
MYCOPLASMA PNEUMONIA AB IgG& IgM,220917,CDM,302,RC,86738,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.12,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,53.62,
MYCOPLASMA PNEUMONIA AB IGM,220424,CDM,302,RC,86738,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.12,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,53.62,
MYELIN BASIC PROTEIN,201068,CDM,301,RC,83873,HCPCS,Outpatient,,,77.4,69.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,70,,43.34,percent of total billed charges,70% of total billed charges for outpatient setting,65.7,84.88,,52.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.05,75,,46.44,percent of total billed charges,75% of total billed charges for outpatient setting,54.18,70,,43.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.92,80,,49.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.62,100,,,Fee Schedule,100% of Custom Fee Schedule,69.66,90,,55.73,percent of total billed charges,90% of total billed charges for outpatient setting,17.2,69.66,
MYELOGRAPHY CERVICAL,2400290,CDM,320,RC,72240,HCPCS,Outpatient,,,2274.82,1706.12,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1930.87,84.88,,1544.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1706.12,75,,1364.9,percent of total billed charges,75% of total billed charges for outpatient setting,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1089.87,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,292.09,12.84,,233.672,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1819.86,80,,1455.89,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,710.67,100,,,Fee Schedule,100% of Custom Fee Schedule,2047.34,90,,1637.87,percent of total billed charges,90% of total billed charges for outpatient setting,128,2047.34,
MYELOGRAPHY ENTIRE SPINAL CORD,2400455,CDM,320,RC,72270,HCPCS,Outpatient,,,2274.82,1706.12,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1930.87,84.88,,1544.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1706.12,75,,1364.9,percent of total billed charges,75% of total billed charges for outpatient setting,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1089.87,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,292.09,12.84,,233.672,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1819.86,80,,1455.89,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,710.67,100,,,Fee Schedule,100% of Custom Fee Schedule,2047.34,90,,1637.87,percent of total billed charges,90% of total billed charges for outpatient setting,128,2047.34,
MYELOGRAPHY LUMBOSACRAL,2400300,CDM,320,RC,72265,HCPCS,Outpatient,,,2274.82,1706.12,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1930.87,84.88,,1544.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1706.12,75,,1364.9,percent of total billed charges,75% of total billed charges for outpatient setting,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1089.87,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,292.09,12.84,,233.672,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1819.86,80,,1455.89,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,710.67,100,,,Fee Schedule,100% of Custom Fee Schedule,2047.34,90,,1637.87,percent of total billed charges,90% of total billed charges for outpatient setting,128,2047.34,
MYELOGRAPHY THORACIC,2400295,CDM,320,RC,72255,HCPCS,Outpatient,,,2274.82,1706.12,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1930.87,84.88,,1544.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1706.12,75,,1364.9,percent of total billed charges,75% of total billed charges for outpatient setting,1592.37,70,,1273.9,percent of total billed charges,70% of total billed charges for outpatient setting,1089.87,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,292.09,12.84,,233.672,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1819.86,80,,1455.89,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,292.09,12.84,,233.67,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,710.67,100,,,Fee Schedule,100% of Custom Fee Schedule,2047.34,90,,1637.87,percent of total billed charges,90% of total billed charges for outpatient setting,128,2047.34,
MYFORTIC 360 MG TAB,3303095,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
MYLANTA LIQ 200-20MG/5ML : 147ML,3302531,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MYLANTA TABLET :,3302541,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
MYLANTA TABLET DS CHEW 40-400MG:,3300715,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
MYLICON INFANT DROPS: SIMETHICONE 30MLS,3302785,CDM,259,RC,,,Outpatient,,,37.12,37.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,70,,20.78,percent of total billed charges,70% of total billed charges for outpatient setting,31.51,84.88,,25.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.56,50,,14.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.84,75,,22.27,percent of total billed charges,75% of total billed charges for outpatient setting,25.98,70,,20.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,12.84,,3.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,80,,23.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,12.84,,3.82,percent of total billed charges,12.84% of total billed charges,4.77,12.84,,3.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.13,65,,19.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.99,35,,10.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.41,90,,26.73,percent of total billed charges,90% of total billed charges for outpatient setting,4.77,33.41,
MYOGLOBIN,200840,CDM,300,RC,83874,HCPCS,Outpatient,,,58.14,52.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.7,70,,32.56,percent of total billed charges,70% of total billed charges for outpatient setting,49.35,84.88,,39.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.18,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.61,75,,34.89,percent of total billed charges,75% of total billed charges for outpatient setting,40.7,70,,32.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.51,80,,37.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.86,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.49,100,,,Fee Schedule,100% of Custom Fee Schedule,52.33,90,,41.86,percent of total billed charges,90% of total billed charges for outpatient setting,12.29,52.33,
MYOSURE REACH EXT TISSUE RMVL /10-401FC,69162359,CDM,272,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,70,,1400,percent of total billed charges,70% of total billed charges for outpatient setting,2122,84.88,,1697.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,1250,50,,1000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1875,75,,1500,percent of total billed charges,75% of total billed charges for outpatient setting,1750,70,,1400,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,80,,1600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,321,12.84,,256.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1625,65,,1300,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875,35,,700,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2250,90,,1800,percent of total billed charges,90% of total billed charges for outpatient setting,321,2250,
NA,200590,CDM,300,RC,84295,HCPCS,Outpatient,,,21.65,19.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,18.38,84.88,,14.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.24,75,,12.99,percent of total billed charges,75% of total billed charges for outpatient setting,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,80,,13.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,100,,,Fee Schedule,100% of Custom Fee Schedule,19.49,90,,15.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,19.49,
NA BIPHOS (NEUTRA-PHOS) PKG FRUIT:UD,3301616,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NA PHOSPHATE 3 MM/ML : 15 ML,3302761,CDM,250,RC,,,Outpatient,,,96.88,96.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.82,70,,54.26,percent of total billed charges,70% of total billed charges for outpatient setting,82.23,84.88,,65.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.44,50,,38.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.66,75,,58.13,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,70,,54.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,12.84,,9.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.5,80,,62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,12.84,,9.95,percent of total billed charges,12.84% of total billed charges,12.44,12.84,,9.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.97,65,,50.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.91,35,,27.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.19,90,,69.75,percent of total billed charges,90% of total billed charges for outpatient setting,12.44,87.19,
NABUMETONE (RELAFEN) 500MG:TAB,3303056,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NABUMETONE (RELAFEN) 750MG:TAB,3303279,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NADOLOL (CORGARD) TAB : 20 MG  U/D,3301617,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NADOLOL (CORGARD) TAB : 40 MG   U/D,3301618,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NAFCILLIN (NAFCIL) INJ : 1 GM,3301619,CDM,250,RC,,,Outpatient,,,6.14,6.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,70,,3.44,percent of total billed charges,70% of total billed charges for outpatient setting,5.21,84.88,,4.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.07,50,,2.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.61,75,,3.69,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,70,,3.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.79,12.84,,0.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,80,,3.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.79,12.84,,0.63,percent of total billed charges,12.84% of total billed charges,0.79,12.84,,0.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.99,65,,3.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,35,,1.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.53,90,,4.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.79,5.53,
NAFCILLIN (NAFCIL) INJ : 10 GM,3301621,CDM,250,RC,,,Outpatient,,,38.22,38.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.75,70,,21.4,percent of total billed charges,70% of total billed charges for outpatient setting,32.44,84.88,,25.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.11,50,,15.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.67,75,,22.94,percent of total billed charges,75% of total billed charges for outpatient setting,26.75,70,,21.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,12.84,,3.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.58,80,,24.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,12.84,,3.93,percent of total billed charges,12.84% of total billed charges,4.91,12.84,,3.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.84,65,,19.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.38,35,,10.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.4,90,,27.52,percent of total billed charges,90% of total billed charges for outpatient setting,4.91,34.4,
NAFCILLIN (NAFCIL) INJ : 2 GM,3301620,CDM,250,RC,,,Outpatient,,,11.87,11.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,10.08,84.88,,8.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.94,50,,4.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.9,75,,7.12,percent of total billed charges,75% of total billed charges for outpatient setting,8.31,70,,6.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,80,,7.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.72,65,,6.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,35,,3.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.68,90,,8.54,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,10.68,
NAIL 1.5IN HEADED / 6541-4-515,71000569,CDM,278,RC,C1713,HCPCS,Outpatient,,,348,348,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,60,,167.04,percent of total billed charges,60% of total Billed charges for outpatient setting,295.38,84.88,,236.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261,75,,208.8,percent of total billed charges,75% of total billed charges for outpatient setting,174,50,,139.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,12.84,,35.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.4,80,,222.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,12.84,,35.74,percent of total billed charges,12.84% of total billed charges,44.68,12.84,,35.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348,65,,278.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.8,35,,97.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,208.8,60,,167.04,percent of total billed charges,60% of total billed charges for outpatient setting,44.68,348,
NAIL 10X330MM TIBIAL CANN / 04.004.446S,668738,CDM,278,RC,C1776,HCPCS,Outpatient,,,3335.92,3335.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2001.55,60,,1601.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2831.53,84.88,,2265.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2501.94,75,,2001.55,percent of total billed charges,75% of total billed charges for outpatient setting,1667.96,50,,1334.37,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.33,12.84,,342.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2668.74,80,,2134.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.33,12.84,,342.66,percent of total billed charges,12.84% of total billed charges,428.33,12.84,,342.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3502.72,105,,2802.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.57,35,,934.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2001.55,60,,1601.24,percent of total billed charges,60% of total billed charges for outpatient setting,428.33,3502.72,
NAIL 2.25X300MM FLEXIBLE / 0194-2250S,69169204,CDM,278,RC,C1713,HCPCS,Outpatient,,,892.11,892.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.27,60,,428.22,percent of total billed charges,60% of total Billed charges for outpatient setting,757.22,84.88,,605.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.08,75,,535.26,percent of total billed charges,75% of total billed charges for outpatient setting,446.06,50,,356.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.55,12.84,,91.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.69,80,,570.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.55,12.84,,91.64,percent of total billed charges,12.84% of total billed charges,114.55,12.84,,91.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,892.11,65,,713.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.24,35,,249.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,535.27,60,,428.22,percent of total billed charges,60% of total billed charges for outpatient setting,114.55,892.11,
NAIL 3.0X130MM FIB LT / AR-8973L-30-130,71000507,CDM,278,RC,C1713,HCPCS,Outpatient,,,6289.5,6289.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3773.7,60,,3018.96,percent of total billed charges,60% of total Billed charges for outpatient setting,5338.53,84.88,,4270.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4717.13,75,,3773.7,percent of total billed charges,75% of total billed charges for outpatient setting,3144.75,50,,2515.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.57,12.84,,646.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5031.6,80,,4025.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.57,12.84,,646.06,percent of total billed charges,12.84% of total billed charges,807.57,12.84,,646.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6603.98,105,,5283.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2201.33,35,,1761.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3773.7,60,,3018.96,percent of total billed charges,60% of total billed charges for outpatient setting,807.57,6603.98,
NAIL 8X150MM HUMERAL / 1832-1035S,216940,CDM,278,RC,C1776,HCPCS,Outpatient,,,3173.52,3173.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1904.11,60,,1523.29,percent of total billed charges,60% of total Billed charges for outpatient setting,2693.68,84.88,,2154.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2380.14,75,,1904.11,percent of total billed charges,75% of total billed charges for outpatient setting,1586.76,50,,1269.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.48,12.84,,325.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2538.82,80,,2031.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.48,12.84,,325.98,percent of total billed charges,12.84% of total billed charges,407.48,12.84,,325.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3332.2,105,,2665.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1110.73,35,,888.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1904.11,60,,1523.29,percent of total billed charges,60% of total billed charges for outpatient setting,407.48,3332.2,
NAIL FLEXIBLE 1.75X300MM / 0194-1750S,69169205,CDM,278,RC,,,Outpatient,,,833.96,833.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.38,60,,400.3,percent of total billed charges,60% of total Billed charges for outpatient setting,707.87,84.88,,566.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,416.98,50,,333.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,625.47,75,,500.38,percent of total billed charges,75% of total billed charges for outpatient setting,416.98,50,,333.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.08,12.84,,85.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.17,80,,533.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.08,12.84,,85.66,percent of total billed charges,12.84% of total billed charges,107.08,12.84,,85.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,833.96,65,,667.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.89,35,,233.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,500.38,60,,400.3,percent of total billed charges,60% of total billed charges for outpatient setting,107.08,833.96,
NAIL TI ELASTIC 2.0X440MM / 475.920,69162485,CDM,278,RC,,,Outpatient,,,1168.45,1168.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.07,60,,560.86,percent of total billed charges,60% of total Billed charges for outpatient setting,991.78,84.88,,793.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,584.23,50,,467.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,876.34,75,,701.07,percent of total billed charges,75% of total billed charges for outpatient setting,584.23,50,,467.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.03,12.84,,120.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.76,80,,747.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.03,12.84,,120.02,percent of total billed charges,12.84% of total billed charges,150.03,12.84,,120.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1168.45,65,,934.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.96,35,,327.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,701.07,60,,560.86,percent of total billed charges,60% of total billed charges for outpatient setting,150.03,1168.45,
NALBUPHINE (NUBAIN) AMP : 10 MG/ML,3301622,CDM,250,RC,,,Outpatient,,,17.25,17.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.08,70,,9.66,percent of total billed charges,70% of total billed charges for outpatient setting,14.64,84.88,,11.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.63,50,,6.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.94,75,,10.35,percent of total billed charges,75% of total billed charges for outpatient setting,12.08,70,,9.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,80,,11.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.21,65,,8.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,35,,4.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,90% of total billed charges for outpatient setting,2.21,15.53,
NALBUPHINE (NUBAIN) AMP 10 MG/ML:1 ML,3301625,CDM,250,RC,,,Outpatient,,,4.12,4.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,70,,2.3,percent of total billed charges,70% of total billed charges for outpatient setting,3.5,84.88,,2.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.06,50,,1.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.09,75,,2.47,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,70,,2.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,80,,2.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.68,65,,2.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,35,,1.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.71,90,,2.97,percent of total billed charges,90% of total billed charges for outpatient setting,0.53,3.71,
NALBUPHINE (NUBAIN) AMP 20MG/ML: 1ML,3301623,CDM,636,RC,J2300,HCPCS,Outpatient,,,23.82,23.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,20.22,84.88,,16.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.87,75,,14.3,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,70,,13.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.06,80,,15.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,3.06,12.84,,2.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.48,65,,12.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,100,,,Fee Schedule,100% of Custom Fee Schedule,21.44,90,,17.15,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,21.44,
NALBUPHINE (NUBAIN) PF AMP 20MG/ML: 1ML,3301624,CDM,250,RC,,,Outpatient,,,6.21,6.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,84.88,,4.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,50,,2.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.66,75,,3.73,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,80,,3.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.04,65,,3.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.59,90,,4.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.59,
NALBUPHINE (NUBAIN)10MG/ML: INJ.,3303122,CDM,250,RC,,,Outpatient,,,68.84,68.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.19,70,,38.55,percent of total billed charges,70% of total billed charges for outpatient setting,58.43,84.88,,46.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.42,50,,27.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.63,75,,41.3,percent of total billed charges,75% of total billed charges for outpatient setting,48.19,70,,38.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,12.84,,7.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.07,80,,44.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,12.84,,7.07,percent of total billed charges,12.84% of total billed charges,8.84,12.84,,7.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.75,65,,35.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.09,35,,19.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,61.96,90,,49.57,percent of total billed charges,90% of total billed charges for outpatient setting,8.84,61.96,
NALEX A: TAB,3303126,CDM,259,RC,,,Outpatient,,,11.51,11.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,9.77,84.88,,7.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.76,50,,4.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.63,75,,6.9,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,70,,6.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.21,80,,7.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.48,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.48,65,,5.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,35,,3.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.36,90,,8.29,percent of total billed charges,90% of total billed charges for outpatient setting,1.48,10.36,
NALOXONE (genNARCAN) AMP 0.4MG/ML 1ML,3301626,CDM,250,RC,J2310,HCPCS,Outpatient,,,27.6,27.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.32,70,,15.46,percent of total billed charges,70% of total billed charges for outpatient setting,23.43,84.88,,18.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.7,75,,16.56,percent of total billed charges,75% of total billed charges for outpatient setting,19.32,70,,15.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,80,,17.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,65,,14.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,100,,,Fee Schedule,100% of Custom Fee Schedule,24.84,90,,19.87,percent of total billed charges,90% of total billed charges for outpatient setting,3.54,24.84,
NALOXONE (NARACN) AMP 1MG/ML: 1ML,3301628,CDM,636,RC,J2310,HCPCS,Outpatient,,,14.09,14.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,70,,7.89,percent of total billed charges,70% of total billed charges for outpatient setting,11.96,84.88,,9.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.57,75,,8.46,percent of total billed charges,75% of total billed charges for outpatient setting,9.86,70,,7.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,80,,9.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.16,65,,7.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,100,,,Fee Schedule,100% of Custom Fee Schedule,12.68,90,,10.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,13.94,
NALOXONE (NARCAN) AMP : 0.4 MG/ML,3301627,CDM,250,RC,,,Outpatient,,,8.77,8.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,84.88,,5.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.39,50,,3.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.58,75,,5.26,percent of total billed charges,75% of total billed charges for outpatient setting,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,80,,5.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.7,65,,4.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,35,,2.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.89,90,,6.31,percent of total billed charges,90% of total billed charges for outpatient setting,1.13,7.89,
NALOXONE (NARCAN) SYRINGE : 1 MG/ML,3301630,CDM,250,RC,,,Outpatient,,,60.8,60.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.56,70,,34.05,percent of total billed charges,70% of total billed charges for outpatient setting,51.61,84.88,,41.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.4,50,,24.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.6,75,,36.48,percent of total billed charges,75% of total billed charges for outpatient setting,42.56,70,,34.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,12.84,,6.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,80,,38.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,12.84,,6.25,percent of total billed charges,12.84% of total billed charges,7.81,12.84,,6.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.52,65,,31.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.28,35,,17.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.72,90,,43.78,percent of total billed charges,90% of total billed charges for outpatient setting,7.81,54.72,
NALOXONE (NARCAN) SYRINGE 0.4MG:1 ML,3301629,CDM,250,RC,,,Outpatient,,,54.32,54.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,70,,30.42,percent of total billed charges,70% of total billed charges for outpatient setting,46.11,84.88,,36.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.16,50,,21.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.74,75,,32.59,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,70,,30.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,12.84,,5.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.46,80,,34.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,12.84,,5.58,percent of total billed charges,12.84% of total billed charges,6.97,12.84,,5.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.31,65,,28.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,35,,15.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.89,90,,39.11,percent of total billed charges,90% of total billed charges for outpatient setting,6.97,48.89,
NAMENDA: 10 MG TAB,3303046,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NANOSCOPE HANDPIECE / AR-3210-0040,69169827,CDM,272,RC,,,Outpatient,,,2306.5,2306.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1614.55,70,,1291.64,percent of total billed charges,70% of total billed charges for outpatient setting,1957.76,84.88,,1566.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,1153.25,50,,922.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729.88,75,,1383.9,percent of total billed charges,75% of total billed charges for outpatient setting,1614.55,70,,1291.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.15,12.84,,236.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1845.2,80,,1476.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.15,12.84,,236.92,percent of total billed charges,12.84% of total billed charges,296.15,12.84,,236.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1499.23,65,,1199.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.28,35,,645.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2075.85,90,,1660.68,percent of total billed charges,90% of total billed charges for outpatient setting,296.15,2075.85,
NAPHAZOLINE (VASOCON A) OPTH SOL : 15ML,3301631,CDM,259,RC,,,Outpatient,,,17.08,17.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,70,,9.57,percent of total billed charges,70% of total billed charges for outpatient setting,14.5,84.88,,11.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.54,50,,6.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.81,75,,10.25,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,70,,9.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,80,,10.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,2.19,12.84,,1.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.1,65,,8.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.98,35,,4.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.37,90,,12.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.19,15.37,
NAPROXEN (ALEVE) TAB : 220 MG,3301634,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NAPROXEN (ANAPROX): 275 MG TAB,3302809,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NAPROXEN (NAPROSYN) TAB 250 MG,3301632,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NAPROXEN (NAPROSYN) TAB: 500 MG,3301633,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NARCAN AMP 0.4 MG/ML:  1ML,3302601,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NASAL BONES,2400060,CDM,320,RC,70160,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
NASAL CAN O2,7601005,CDM,270,RC,,,Outpatient,,,38.18,38.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.73,70,,21.38,percent of total billed charges,70% of total billed charges for outpatient setting,32.41,84.88,,25.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.09,50,,15.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.64,75,,22.91,percent of total billed charges,75% of total billed charges for outpatient setting,26.73,70,,21.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,80,,24.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.82,65,,19.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.36,35,,10.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.36,90,,27.49,percent of total billed charges,90% of total billed charges for outpatient setting,4.9,34.36,
NASAL OXY CANNULA W ETC 02 MON/001590,5150182,CDM,270,RC,,,Outpatient,,,44.25,44.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,70,,24.78,percent of total billed charges,70% of total billed charges for outpatient setting,37.56,84.88,,30.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.13,50,,17.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.19,75,,26.55,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,70,,24.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,80,,28.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.76,65,,23.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.49,35,,12.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,39.83,
NASAL RAE  7.0 CUFFED / DYNJAANC70,5050081,CDM,272,RC,,,Outpatient,,,36.34,36.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.44,70,,20.35,percent of total billed charges,70% of total billed charges for outpatient setting,30.85,84.88,,24.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.17,50,,14.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.26,75,,21.81,percent of total billed charges,75% of total billed charges for outpatient setting,25.44,70,,20.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.07,80,,23.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,4.67,12.84,,3.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.62,65,,18.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,35,,10.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.71,90,,26.17,percent of total billed charges,90% of total billed charges for outpatient setting,4.67,32.71,
NASAL RAE  UNCUF 3.0MM,5050072,CDM,272,RC,,,Outpatient,,,18.95,18.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,16.08,84.88,,12.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.48,50,,7.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.21,75,,11.37,percent of total billed charges,75% of total billed charges for outpatient setting,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,80,,12.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.32,65,,9.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.63,35,,5.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.06,90,,13.65,percent of total billed charges,90% of total billed charges for outpatient setting,2.43,17.06,
NASAL RAE 6.0 CUFFED / DYNJAANC60,5050079,CDM,272,RC,,,Outpatient,,,28.81,28.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,84.88,,19.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.41,50,,11.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.61,75,,17.29,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.05,80,,18.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.73,65,,14.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,35,,8.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.93,90,,20.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.93,
NASAL RAE 6.5 CUFFED,5050080,CDM,272,RC,,,Outpatient,,,43.04,43.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.13,70,,24.1,percent of total billed charges,70% of total billed charges for outpatient setting,36.53,84.88,,29.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.52,50,,17.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.28,75,,25.82,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,70,,24.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.53,12.84,,4.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.43,80,,27.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.53,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,5.53,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.98,65,,22.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.06,35,,12.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.74,90,,30.99,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,38.74,
NASAL RAE 7.5 CUFFED / DYNJAANC75,5050082,CDM,272,RC,,,Outpatient,,,28.81,28.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,84.88,,19.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.41,50,,11.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.61,75,,17.29,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.05,80,,18.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.73,65,,14.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,35,,8.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.93,90,,20.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.93,
NASAL RAE CUFF 8.0,5050083,CDM,272,RC,,,Outpatient,,,31.78,31.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,26.97,84.88,,21.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.89,50,,12.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.84,75,,19.07,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.42,80,,20.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.66,65,,16.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.12,35,,8.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.6,90,,22.88,percent of total billed charges,90% of total billed charges for outpatient setting,4.08,28.6,
NASAL RAE UNCUF 3.5MM,5050073,CDM,272,RC,,,Outpatient,,,18.95,18.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,16.08,84.88,,12.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.48,50,,7.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.21,75,,11.37,percent of total billed charges,75% of total billed charges for outpatient setting,13.27,70,,10.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,80,,12.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.32,65,,9.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.63,35,,5.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.06,90,,13.65,percent of total billed charges,90% of total billed charges for outpatient setting,2.43,17.06,
NASAL RAE UNCUF 4.0,7650230,CDM,272,RC,,,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,22.39,84.88,,17.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.19,50,,10.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.79,75,,15.83,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,80,,16.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.15,65,,13.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,35,,7.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.74,90,,18.99,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.74,
NASAL RAE UNCUF 4.5,7650235,CDM,272,RC,,,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,22.39,84.88,,17.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.19,50,,10.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.79,75,,15.83,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,80,,16.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.15,65,,13.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,35,,7.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.74,90,,18.99,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.74,
NASAL RAE UNCUF 5.0,7650240,CDM,272,RC,,,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,22.39,84.88,,17.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.19,50,,10.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.79,75,,15.83,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,80,,16.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.15,65,,13.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,35,,7.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.74,90,,18.99,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.74,
NASAL RAE UNCUF 5.5 / 7650245,7650245,CDM,272,RC,,,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,22.39,84.88,,17.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.19,50,,10.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.79,75,,15.83,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,70,,14.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.1,80,,16.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.15,65,,13.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,35,,7.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.74,90,,18.99,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.74,
NASAL RAE UNCUF 6.0,7650250,CDM,272,RC,,,Outpatient,,,30.41,30.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,84.88,,20.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.21,50,,12.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,75,,18.25,percent of total billed charges,75% of total billed charges for outpatient setting,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.77,65,,15.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.37,90,,21.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.37,
NASAL RAE UNCUF 6.0,7650255,CDM,272,RC,,,Outpatient,,,30.41,30.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,84.88,,20.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.21,50,,12.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,75,,18.25,percent of total billed charges,75% of total billed charges for outpatient setting,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.77,65,,15.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.37,90,,21.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.37,
NASONEX NASAL: 17GM,3302914,CDM,259,RC,,,Outpatient,,,238.64,238.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.05,70,,133.64,percent of total billed charges,70% of total billed charges for outpatient setting,202.56,84.88,,162.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.32,50,,95.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.98,75,,143.18,percent of total billed charges,75% of total billed charges for outpatient setting,167.05,70,,133.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.91,80,,152.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.12,65,,124.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.52,35,,66.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.78,90,,171.82,percent of total billed charges,90% of total billed charges for outpatient setting,30.64,214.78,
NATALIZUMAB (TYSABRI) 20MG/ML 15ML VIAL,3313005,CDM,636,RC,J2323,HCPCS,Outpatient,,,14183.36,14183.36,,38.44,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,9928.35,70,,7942.68,percent of total billed charges,70% of total billed charges for outpatient setting,12038.84,84.88,,9631.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,10637.52,75,,8510.02,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,40.85,170,,,Fee Schedule,170% of Medicare OPPS rate,51.66,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,1821.14,12.84,,1456.912,percent of total billed charges,12.84% of total billed charges,42.05,175,,,Fee Schedule,175% of Medicare OPPS rate,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,11346.69,80,,9077.35,percent of total billed charges,80% of total billed charges for outpatient setting,33.64,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,30.03,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,1821.14,12.84,,1456.91,percent of total billed charges,12.84% of total billed charges,1821.14,12.84,,1456.91,percent of total billed charges,12.84% of total billed charges,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,9219.18,65,,7375.34,percent of total billed charges,65% of total billed charges for outpatient setting,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,24.03,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.64,100,,,Fee Schedule,100% of Custom Fee Schedule,12765.02,90,,10212.02,percent of total billed charges,90% of total billed charges for outpatient setting,16.64,12765.02,
NDL CONTIPLEX TUOHY 18G X 2IN / 331673,70000640,CDM,272,RC,,,Outpatient,,,192.93,192.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.05,70,,108.04,percent of total billed charges,70% of total billed charges for outpatient setting,163.76,84.88,,131.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,96.47,50,,77.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.7,75,,115.76,percent of total billed charges,75% of total billed charges for outpatient setting,135.05,70,,108.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.77,12.84,,19.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.34,80,,123.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.77,12.84,,19.82,percent of total billed charges,12.84% of total billed charges,24.77,12.84,,19.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,125.4,65,,100.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.53,35,,54.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.64,90,,138.91,percent of total billed charges,90% of total billed charges for outpatient setting,24.77,173.64,
NDL CONTIPLEX TUOHY 18G X 4IN / 331693,70000153,CDM,272,RC,,,Outpatient,,,178.08,178.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.66,70,,99.73,percent of total billed charges,70% of total billed charges for outpatient setting,151.15,84.88,,120.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.04,50,,71.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.56,75,,106.85,percent of total billed charges,75% of total billed charges for outpatient setting,124.66,70,,99.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.87,12.84,,18.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.46,80,,113.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.87,12.84,,18.3,percent of total billed charges,12.84% of total billed charges,22.87,12.84,,18.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.75,65,,92.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,35,,49.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.27,90,,128.22,percent of total billed charges,90% of total billed charges for outpatient setting,22.87,160.27,
NDL CTR 20 CNT DBL MAGNET SMALL / NC30MB,6150123,CDM,272,RC,,,Outpatient,,,7.02,7.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,70,,3.93,percent of total billed charges,70% of total billed charges for outpatient setting,5.96,84.88,,4.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.51,50,,2.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.27,75,,4.22,percent of total billed charges,75% of total billed charges for outpatient setting,4.91,70,,3.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.62,80,,4.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.56,65,,3.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,35,,1.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.32,90,,5.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.9,6.32,
NDL CTR 60 CTR DBL MAGNET (large),6150124,CDM,272,RC,,,Outpatient,,,165.47,165.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.83,70,,92.66,percent of total billed charges,70% of total billed charges for outpatient setting,140.45,84.88,,112.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.74,50,,66.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.1,75,,99.28,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,70,,92.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.25,12.84,,17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.38,80,,105.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.25,12.84,,17,percent of total billed charges,12.84% of total billed charges,21.25,12.84,,17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,107.56,65,,86.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.91,35,,46.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,148.92,90,,119.14,percent of total billed charges,90% of total billed charges for outpatient setting,21.25,148.92,
NEBCIN (TOBRAMYCIN)INJ 40MG/ML :2ML,3302566,CDM,250,RC,,,Outpatient,,,39.76,39.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.83,70,,22.26,percent of total billed charges,70% of total billed charges for outpatient setting,33.75,84.88,,27,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.88,50,,15.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.82,75,,23.86,percent of total billed charges,75% of total billed charges for outpatient setting,27.83,70,,22.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,12.84,,4.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,80,,25.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,12.84,,4.09,percent of total billed charges,12.84% of total billed charges,5.11,12.84,,4.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.84,65,,20.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.92,35,,11.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.78,90,,28.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.11,35.78,
NEBULIZER AVA NEB W/TEE & MO,6050132,CDM,272,RC,,,Outpatient,,,28.98,28.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.29,70,,16.23,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,84.88,,19.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.49,50,,11.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.74,75,,17.39,percent of total billed charges,75% of total billed charges for outpatient setting,20.29,70,,16.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,12.84,,2.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,80,,18.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,3.72,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.84,65,,15.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.14,35,,8.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.08,90,,20.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.72,26.08,
NEBULIZER KIT W/ STERILE H2O   CK0010,69162105,CDM,271,RC,,,Outpatient,,,28.55,28.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,70,,15.99,percent of total billed charges,70% of total billed charges for outpatient setting,24.23,84.88,,19.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.28,50,,11.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.41,75,,17.13,percent of total billed charges,75% of total billed charges for outpatient setting,19.99,70,,15.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,80,,18.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.56,65,,14.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,35,,7.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.7,90,,20.56,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,25.7,
NEBULIZER MASK W/ TUBING / RHS885U,364738,CDM,272,RC,,,Outpatient,,,6.66,6.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,70,,3.73,percent of total billed charges,70% of total billed charges for outpatient setting,5.65,84.88,,4.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.33,50,,2.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5,75,,4,percent of total billed charges,75% of total billed charges for outpatient setting,4.66,70,,3.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,80,,4.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.33,65,,3.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,35,,1.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.99,90,,4.79,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,5.99,
NEBULIZER MISTY ANG W/T7'TB,5050007,CDM,270,RC,,,Outpatient,,,6.24,6.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,70,,3.5,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,84.88,,4.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.12,50,,2.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.68,75,,3.74,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,70,,3.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.99,80,,3.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.06,65,,3.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.62,90,,4.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.62,
NEBULIZER TX -INITIAL,1300110,CDM,410,RC,94640,HCPCS,Outpatient,,,332.86,332.86,,269.5,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,282.53,84.88,,226.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,249.65,75,,199.72,percent of total billed charges,75% of total billed charges for outpatient setting,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,286.34,170,,,Fee Schedule,170% of Medicare OPPS rate,362.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.74,12.84,,34.192,percent of total billed charges,12.84% of total billed charges,294.76,175,,,Fee Schedule,175% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.29,80,,213.03,percent of total billed charges,80% of total billed charges for outpatient setting,235.81,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,210.54,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,181,100,,,Case rate,pays based on fixed rate ,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,168.43,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,93.01,100,,,Fee Schedule,100% of Custom Fee Schedule,299.57,90,,239.66,percent of total billed charges,90% of total billed charges for outpatient setting,42.74,362.14,
NEBULIZER/002438,5100508,CDM,270,RC,,,Outpatient,,,8.55,8.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,7.26,84.88,,5.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.28,50,,3.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.41,75,,5.13,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,80,,5.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.56,65,,4.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,35,,2.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.7,90,,6.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.7,
NEBULIZER-TX SUBSEQUENT,1300115,CDM,410,RC,94640,HCPCS,Outpatient,,,332.86,332.86,76,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,282.53,84.88,,226.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,166.43,50,,133.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.65,75,,199.72,percent of total billed charges,75% of total billed charges for outpatient setting,233,70,,186.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.74,12.84,,34.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.29,80,,213.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,42.74,12.84,,34.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,181,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.5,35,,93.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.57,90,,239.66,percent of total billed charges,90% of total billed charges for outpatient setting,42.74,299.57,
NEBULIZIER AIRLIFE / 002002,5150276,CDM,270,RC,,,Outpatient,,,12.48,12.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,70,,6.99,percent of total billed charges,70% of total billed charges for outpatient setting,10.59,84.88,,8.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.36,75,,7.49,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,70,,6.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,35,,3.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.23,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.23,
NECK SOFT TISSUE,2400120,CDM,320,RC,70360,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
NEEDLE 18G 6IN SPINAL TUOHY / 332160,3750054,CDM,272,RC,,,Outpatient,,,45.64,45.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.95,70,,25.56,percent of total billed charges,70% of total billed charges for outpatient setting,38.74,84.88,,30.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.82,50,,18.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.23,75,,27.38,percent of total billed charges,75% of total billed charges for outpatient setting,31.95,70,,25.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,12.84,,4.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.51,80,,29.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,12.84,,4.69,percent of total billed charges,12.84% of total billed charges,5.86,12.84,,4.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.67,65,,23.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.97,35,,12.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.08,90,,32.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,41.08,
NEEDLE 20G 1IN POWER PORT / 0652010,69169043,CDM,272,RC,,,Outpatient,,,42.07,42.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.45,70,,23.56,percent of total billed charges,70% of total billed charges for outpatient setting,35.71,84.88,,28.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.04,50,,16.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.55,75,,25.24,percent of total billed charges,75% of total billed charges for outpatient setting,29.45,70,,23.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.66,80,,26.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,5.4,12.84,,4.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.35,65,,21.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.72,35,,11.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.86,90,,30.29,percent of total billed charges,90% of total billed charges for outpatient setting,5.4,37.86,
NEEDLE 20G 4IN STIMUPLEX / 333648,70000639,CDM,272,RC,,,Outpatient,,,85.12,85.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.58,70,,47.66,percent of total billed charges,70% of total billed charges for outpatient setting,72.25,84.88,,57.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.56,50,,34.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.84,75,,51.07,percent of total billed charges,75% of total billed charges for outpatient setting,59.58,70,,47.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.93,12.84,,8.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,80,,54.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.93,12.84,,8.74,percent of total billed charges,12.84% of total billed charges,10.93,12.84,,8.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.33,65,,44.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.79,35,,23.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.61,90,,61.29,percent of total billed charges,90% of total billed charges for outpatient setting,10.93,76.61,
NEEDLE 20G 5CM KOPANS BREAST / G02586,70000703,CDM,278,RC,C1819,HCPCS,Outpatient,,,148.2,148.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.92,60,,71.14,percent of total billed charges,60% of total Billed charges for outpatient setting,125.79,84.88,,100.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,75,,88.92,percent of total billed charges,75% of total billed charges for outpatient setting,74.1,50,,59.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,80,,94.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.2,65,,118.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.87,35,,41.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.92,60,,71.14,percent of total billed charges,60% of total billed charges for outpatient setting,19.03,148.2,
NEEDLE 20G 6IN STIMUPLEX / 333646,1897503,CDM,272,RC,,,Outpatient,,,94.64,94.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.25,70,,53,percent of total billed charges,70% of total billed charges for outpatient setting,80.33,84.88,,64.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.32,50,,37.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.98,75,,56.78,percent of total billed charges,75% of total billed charges for outpatient setting,66.25,70,,53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,80,,60.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,12.15,12.84,,9.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.52,65,,49.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,35,,26.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.18,90,,68.14,percent of total billed charges,90% of total billed charges for outpatient setting,12.15,85.18,
NEEDLE 20G 7CM KOPANS BREAST / G02601,70000658,CDM,278,RC,C1819,HCPCS,Outpatient,,,148.2,148.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.92,60,,71.14,percent of total billed charges,60% of total Billed charges for outpatient setting,125.79,84.88,,100.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,75,,88.92,percent of total billed charges,75% of total billed charges for outpatient setting,74.1,50,,59.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,80,,94.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.2,65,,118.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.87,35,,41.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.92,60,,71.14,percent of total billed charges,60% of total billed charges for outpatient setting,19.03,148.2,
NEEDLE 20G 9CM KOPANS BREAST / G02587,70000704,CDM,278,RC,C1819,HCPCS,Outpatient,,,148.2,148.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.92,60,,71.14,percent of total billed charges,60% of total Billed charges for outpatient setting,125.79,84.88,,100.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,75,,88.92,percent of total billed charges,75% of total billed charges for outpatient setting,74.1,50,,59.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,80,,94.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,19.03,12.84,,15.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.2,65,,118.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.87,35,,41.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.92,60,,71.14,percent of total billed charges,60% of total billed charges for outpatient setting,19.03,148.2,
NEEDLE 20G ENDOSCOPIC / MRN-420,69162548,CDM,272,RC,,,Outpatient,,,205,205,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,174,84.88,,139.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.5,50,,82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,75,,123,percent of total billed charges,75% of total billed charges for outpatient setting,143.5,70,,114.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,80,,131.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,26.32,12.84,,21.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.25,65,,106.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.75,35,,57.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.5,90,,147.6,percent of total billed charges,90% of total billed charges for outpatient setting,26.32,184.5,
NEEDLE 22G 2IN STIMUPLEX / 333642,70000638,CDM,272,RC,,,Outpatient,,,86.17,86.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.32,70,,48.26,percent of total billed charges,70% of total billed charges for outpatient setting,73.14,84.88,,58.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.09,50,,34.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.63,75,,51.7,percent of total billed charges,75% of total billed charges for outpatient setting,60.32,70,,48.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,12.84,,8.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,80,,55.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,12.84,,8.85,percent of total billed charges,12.84% of total billed charges,11.06,12.84,,8.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.01,65,,44.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,35,,24.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,77.55,90,,62.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.06,77.55,
NEEDLE 22GX1.5IN SPINAL QUINCKE/ 405161,70000228,CDM,272,RC,,,Outpatient,,,17.82,17.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,70,,9.98,percent of total billed charges,70% of total billed charges for outpatient setting,15.13,84.88,,12.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.91,50,,7.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.37,75,,10.7,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,70,,9.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.26,80,,11.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.58,65,,9.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,35,,4.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.04,90,,12.83,percent of total billed charges,90% of total billed charges for outpatient setting,2.29,16.04,
NEEDLE 25G 2.3MM INTERJECT / M00518361,105687,CDM,272,RC,,,Outpatient,,,244.2,244.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.94,70,,136.75,percent of total billed charges,70% of total billed charges for outpatient setting,207.28,84.88,,165.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,122.1,50,,97.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.15,75,,146.52,percent of total billed charges,75% of total billed charges for outpatient setting,170.94,70,,136.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.36,12.84,,25.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.36,80,,156.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.36,12.84,,25.09,percent of total billed charges,12.84% of total billed charges,31.36,12.84,,25.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,158.73,65,,126.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.47,35,,68.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,219.78,90,,175.82,percent of total billed charges,90% of total billed charges for outpatient setting,31.36,219.78,
NEEDLE 25G 38MM RETROBULBAR / 8065420920,69162941,CDM,272,RC,,,Outpatient,,,69.16,69.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.41,70,,38.73,percent of total billed charges,70% of total billed charges for outpatient setting,58.7,84.88,,46.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.58,50,,27.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.87,75,,41.5,percent of total billed charges,75% of total billed charges for outpatient setting,48.41,70,,38.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,12.84,,7.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.33,80,,44.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,12.84,,7.1,percent of total billed charges,12.84% of total billed charges,8.88,12.84,,7.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.95,65,,35.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,35,,19.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.24,90,,49.79,percent of total billed charges,90% of total billed charges for outpatient setting,8.88,62.24,
NEEDLE 25G 4.68IN SPNL QUINCKIE / 405234,69162950,CDM,272,RC,,,Outpatient,,,35.2,35.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.64,70,,19.71,percent of total billed charges,70% of total billed charges for outpatient setting,29.88,84.88,,23.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.6,50,,14.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.4,75,,21.12,percent of total billed charges,75% of total billed charges for outpatient setting,24.64,70,,19.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.16,80,,22.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.88,65,,18.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.32,35,,9.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.68,90,,25.34,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,31.68,
NEEDLE 25G 5IN SPINAL / 333875,69169619,CDM,272,RC,,,Outpatient,,,39.52,39.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,70,,22.13,percent of total billed charges,70% of total billed charges for outpatient setting,33.54,84.88,,26.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.76,50,,15.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.64,75,,23.71,percent of total billed charges,75% of total billed charges for outpatient setting,27.66,70,,22.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.62,80,,25.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.69,65,,20.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.83,35,,11.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.57,90,,28.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.07,35.57,
NEEDLE ALARA NEURO BEVEL / AA-11-NSW,71000043,CDM,272,RC,,,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,845,65,,676,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1170,90,,936,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1170,
NEEDLE ALARA NEURO DIAMOND / AAN-09-NSW,71000028,CDM,272,RC,,,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,845,65,,676,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1170,90,,936,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1170,
NEEDLE BIOPSY ULTRA / 658.114S,69162848,CDM,272,RC,,,Outpatient,,,584.01,584.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.81,70,,327.05,percent of total billed charges,70% of total billed charges for outpatient setting,495.71,84.88,,396.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,292.01,50,,233.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.01,75,,350.41,percent of total billed charges,75% of total billed charges for outpatient setting,408.81,70,,327.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.99,12.84,,59.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.21,80,,373.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.99,12.84,,59.99,percent of total billed charges,12.84% of total billed charges,74.99,12.84,,59.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,379.61,65,,303.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.4,35,,163.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,525.61,90,,420.49,percent of total billed charges,90% of total billed charges for outpatient setting,74.99,525.61,
NEEDLE BONE ACCESS 11G BEVEL / 685.031S,69162440,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
NEEDLE BONE ACCESS 11G TROCAR/ 685.031S,69162441,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
NEEDLE BONE ACCS  8G BEVEL / 685.028S,69162446,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
NEEDLE BONE ACCS  8G TROCAR / 685.027S,69162461,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
NEEDLE BONE ACCS 11G TROCAR 685.030S,69162444,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
NEEDLE BONE MARROW 15G / DIN1515X,69161432,CDM,272,RC,,,Outpatient,,,88.49,88.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.94,70,,49.55,percent of total billed charges,70% of total billed charges for outpatient setting,75.11,84.88,,60.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.25,50,,35.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.37,75,,53.1,percent of total billed charges,75% of total billed charges for outpatient setting,61.94,70,,49.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,12.84,,9.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.79,80,,56.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,12.84,,9.09,percent of total billed charges,12.84% of total billed charges,11.36,12.84,,9.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.52,65,,46.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.97,35,,24.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.64,90,,63.71,percent of total billed charges,90% of total billed charges for outpatient setting,11.36,79.64,
NEEDLE BONE MARROW ASP / 74295-01M,69169395,CDM,272,RC,,,Outpatient,,,1018.08,1018.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.66,70,,570.13,percent of total billed charges,70% of total billed charges for outpatient setting,864.15,84.88,,691.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,509.04,50,,407.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,763.56,75,,610.85,percent of total billed charges,75% of total billed charges for outpatient setting,712.66,70,,570.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.72,12.84,,104.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.46,80,,651.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.72,12.84,,104.58,percent of total billed charges,12.84% of total billed charges,130.72,12.84,,104.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,661.75,65,,529.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.33,35,,285.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,916.27,90,,733.02,percent of total billed charges,90% of total billed charges for outpatient setting,130.72,916.27,
NEEDLE BONE MARROW ASPIR KIT/ 2604-90021,69169149,CDM,272,RC,,,Outpatient,,,1048.62,1048.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.03,70,,587.22,percent of total billed charges,70% of total billed charges for outpatient setting,890.07,84.88,,712.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,524.31,50,,419.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,786.47,75,,629.18,percent of total billed charges,75% of total billed charges for outpatient setting,734.03,70,,587.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.64,12.84,,107.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.9,80,,671.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.64,12.84,,107.71,percent of total billed charges,12.84% of total billed charges,134.64,12.84,,107.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,681.6,65,,545.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.02,35,,293.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,943.76,90,,755.01,percent of total billed charges,90% of total billed charges for outpatient setting,134.64,943.76,
NEEDLE BREAST 20G X 1.5IN // 409409,2750004,CDM,272,RC,,,Outpatient,,,85.63,85.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.94,70,,47.95,percent of total billed charges,70% of total billed charges for outpatient setting,72.68,84.88,,58.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.82,50,,34.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,75,,51.38,percent of total billed charges,75% of total billed charges for outpatient setting,59.94,70,,47.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.99,12.84,,8.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.5,80,,54.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.99,12.84,,8.79,percent of total billed charges,12.84% of total billed charges,10.99,12.84,,8.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.66,65,,44.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,35,,23.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,77.07,90,,61.66,percent of total billed charges,90% of total billed charges for outpatient setting,10.99,77.07,
NEEDLE BREAST LOCAL 20G X 3.5 / BF409407,2450092,CDM,272,RC,,,Outpatient,,,88.27,88.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.79,70,,49.43,percent of total billed charges,70% of total billed charges for outpatient setting,74.92,84.88,,59.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.14,50,,35.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.2,75,,52.96,percent of total billed charges,75% of total billed charges for outpatient setting,61.79,70,,49.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.33,12.84,,9.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.62,80,,56.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.33,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,11.33,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.38,65,,45.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,35,,24.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.44,90,,63.55,percent of total billed charges,90% of total billed charges for outpatient setting,11.33,79.44,
NEEDLE BREAST LOCAL 20GX2.5 / 409408,2450093,CDM,272,RC,,,Outpatient,,,155.49,155.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.84,70,,87.07,percent of total billed charges,70% of total billed charges for outpatient setting,131.98,84.88,,105.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.75,50,,62.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.62,75,,93.3,percent of total billed charges,75% of total billed charges for outpatient setting,108.84,70,,87.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.96,12.84,,15.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.39,80,,99.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.96,12.84,,15.97,percent of total billed charges,12.84% of total billed charges,19.96,12.84,,15.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.07,65,,80.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.42,35,,43.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.94,90,,111.95,percent of total billed charges,90% of total billed charges for outpatient setting,19.96,139.94,
NEEDLE COAXIAL 13GX10 / C1810A,70000120,CDM,270,RC,,,Outpatient,,,110.31,110.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,93.63,84.88,,74.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.16,50,,44.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.73,75,,66.18,percent of total billed charges,75% of total billed charges for outpatient setting,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.25,80,,70.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.7,65,,57.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.61,35,,30.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.28,90,,79.42,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,99.28,
NEEDLE COAXIAL 13GX13 / C1820A,70000121,CDM,270,RC,,,Outpatient,,,110.31,110.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,93.63,84.88,,74.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.16,50,,44.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.73,75,,66.18,percent of total billed charges,75% of total billed charges for outpatient setting,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.25,80,,70.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.7,65,,57.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.61,35,,30.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.28,90,,79.42,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,99.28,
NEEDLE COAXIAL 15X13.8 / C1616A,70000824,CDM,270,RC,,,Outpatient,,,101.52,101.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.06,70,,56.85,percent of total billed charges,70% of total billed charges for outpatient setting,86.17,84.88,,68.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.76,50,,40.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.14,75,,60.91,percent of total billed charges,75% of total billed charges for outpatient setting,71.06,70,,56.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.04,12.84,,10.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.22,80,,64.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.04,12.84,,10.43,percent of total billed charges,12.84% of total billed charges,13.04,12.84,,10.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.99,65,,52.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.53,35,,28.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.37,90,,73.1,percent of total billed charges,90% of total billed charges for outpatient setting,13.04,91.37,
NEEDLE COAXIAL 17X13.8 / C1816A,70000047,CDM,270,RC,,,Outpatient,,,104.79,104.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,70,,58.68,percent of total billed charges,70% of total billed charges for outpatient setting,88.95,84.88,,71.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.4,50,,41.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.59,75,,62.87,percent of total billed charges,75% of total billed charges for outpatient setting,73.35,70,,58.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,12.84,,10.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.83,80,,67.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.46,12.84,,10.77,percent of total billed charges,12.84% of total billed charges,13.46,12.84,,10.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.11,65,,54.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.68,35,,29.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.31,90,,75.45,percent of total billed charges,90% of total billed charges for outpatient setting,13.46,94.31,
NEEDLE COAXIAL 19GX7.8 / C2010A,70000812,CDM,270,RC,,,Outpatient,,,110.31,110.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,93.63,84.88,,74.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.16,50,,44.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.73,75,,66.18,percent of total billed charges,75% of total billed charges for outpatient setting,77.22,70,,61.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.25,80,,70.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,14.16,12.84,,11.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.7,65,,57.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.61,35,,30.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.28,90,,79.42,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,99.28,
NEEDLE DELIVERY 8G X 10CM / DLS-7083-01S,69169315,CDM,272,RC,,,Outpatient,,,321.3,321.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.91,70,,179.93,percent of total billed charges,70% of total billed charges for outpatient setting,272.72,84.88,,218.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.65,50,,128.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.98,75,,192.78,percent of total billed charges,75% of total billed charges for outpatient setting,224.91,70,,179.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.25,12.84,,33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.04,80,,205.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.25,12.84,,33,percent of total billed charges,12.84% of total billed charges,41.25,12.84,,33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208.85,65,,167.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,35,,89.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.17,90,,231.34,percent of total billed charges,90% of total billed charges for outpatient setting,41.25,289.17,
NEEDLE ECHOBRIGHT 22X50MM / EBL22050SGC,70000221,CDM,272,RC,,,Outpatient,,,105.99,105.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.19,70,,59.35,percent of total billed charges,70% of total billed charges for outpatient setting,89.96,84.88,,71.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,53,50,,42.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.49,75,,63.59,percent of total billed charges,75% of total billed charges for outpatient setting,74.19,70,,59.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.79,80,,67.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.89,65,,55.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,35,,29.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.39,90,,76.31,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,95.39,
NEEDLE ELECTROMYAGRAPHY STUDIES,5100090,CDM,922,RC,51785,HCPCS,Outpatient,,,743.44,743.44,,381.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,520.41,70,,416.33,percent of total billed charges,70% of total billed charges for outpatient setting,631.03,84.88,,504.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,319.23,50,,255.38,percent of total billed charges,50% of total Billed charges for outpatient setting,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.58,75,,446.06,percent of total billed charges,75% of total billed charges for outpatient setting,520.41,70,,416.33,percent of total billed charges,70% of total billed charges for outpatient setting,405.36,170,,,Fee Schedule,170% of Medicare OPPS rate,512.66,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,95.46,12.84,,76.368,percent of total billed charges,12.84% of total billed charges,417.29,175,,,Fee Schedule,175% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,594.75,80,,475.8,percent of total billed charges,80% of total billed charges for outpatient setting,333.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,298.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,95.46,12.84,,76.37,percent of total billed charges,12.84% of total billed charges,95.46,12.84,,76.37,percent of total billed charges,12.84% of total billed charges,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,238.45,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,251.12,100,,,Fee Schedule,100% of Custom Fee Schedule,669.1,90,,535.28,percent of total billed charges,90% of total billed charges for outpatient setting,95.46,669.1,
NEEDLE EMG 1 EXTREMITY,6000619,CDM,922,RC,95860,HCPCS,Outpatient,,,425.32,425.32,,161.66,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,361.01,84.88,,288.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,318.99,75,,255.19,percent of total billed charges,75% of total billed charges for outpatient setting,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,171.77,170,,,Fee Schedule,170% of Medicare OPPS rate,217.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,54.61,12.84,,43.688,percent of total billed charges,12.84% of total billed charges,176.82,175,,,Fee Schedule,175% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,340.26,80,,272.21,percent of total billed charges,80% of total billed charges for outpatient setting,141.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,126.3,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.04,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,59.84,100,,,Fee Schedule,100% of Custom Fee Schedule,382.79,90,,306.23,percent of total billed charges,90% of total billed charges for outpatient setting,54.61,382.79,
NEEDLE EMG 1 EXTREMITY NON LIMB UNI BILA,6000621,CDM,922,RC,95870,HCPCS,Outpatient,,,182.35,182.35,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.65,70,,102.12,percent of total billed charges,70% of total billed charges for outpatient setting,154.78,84.88,,123.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.18,50,,72.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.76,75,,109.41,percent of total billed charges,75% of total billed charges for outpatient setting,127.65,70,,102.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.41,12.84,,18.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.88,80,,116.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.41,12.84,,18.73,percent of total billed charges,12.84% of total billed charges,23.41,12.84,,18.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.82,35,,51.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,164.12,90,,131.3,percent of total billed charges,90% of total billed charges for outpatient setting,23.41,323,
NEEDLE EMG 2 LIMBS W 5 OR MORE MUSCLES,6000620,CDM,922,RC,95861,HCPCS,Outpatient,,,425.32,425.32,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,361.01,84.88,,288.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.66,50,,170.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.99,75,,255.19,percent of total billed charges,75% of total billed charges for outpatient setting,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.61,12.84,,43.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.26,80,,272.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.86,35,,119.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,382.79,90,,306.23,percent of total billed charges,90% of total billed charges for outpatient setting,54.61,382.79,
NEEDLE EMG 4 EXTR / 5 OR MORE MUSCLES,6000655,CDM,922,RC,95864,HCPCS,Outpatient,,,425.32,425.32,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,361.01,84.88,,288.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,318.99,75,,255.19,percent of total billed charges,75% of total billed charges for outpatient setting,297.72,70,,238.18,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,54.61,12.84,,43.688,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,340.26,80,,272.21,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,54.61,12.84,,43.69,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,382.79,90,,306.23,percent of total billed charges,90% of total billed charges for outpatient setting,54.61,382.79,
NEEDLE EMG EA EXTREM W/NERVE CONDUCTION,6000622,CDM,922,RC,95885,HCPCS,Outpatient,,,300,300,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,70,,168,percent of total billed charges,70% of total billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,210,70,,168,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,270,90,,216,percent of total billed charges,90% of total billed charges for outpatient setting,38.52,323,
NEEDLE FORAMEN 12.5CM INTERSTIM /041829,69162845,CDM,272,RC,,,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,70,,121.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,65,,112.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,90,,155.74,percent of total billed charges,90% of total billed charges for outpatient setting,27.77,194.67,
NEEDLE FORAMEN 18.5GX5 IN /041839,69169614,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
NEEDLE GUIDE REPLACEMENT / 610-608,70000053,CDM,320,RC,,,Outpatient,,,106.74,80.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.72,70,,59.78,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,84.88,,72.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.37,50,,42.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.06,75,,64.05,percent of total billed charges,75% of total billed charges for outpatient setting,74.72,70,,59.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,12.84,,10.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.39,80,,68.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,12.84,,10.97,percent of total billed charges,12.84% of total billed charges,13.71,12.84,,10.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.36,35,,29.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.07,90,,76.86,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,128,
NEEDLE GUIDE STERILE ENDOCAVITY W/ COVER,69162232,CDM,272,RC,,,Outpatient,,,101.7,101.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.19,70,,56.95,percent of total billed charges,70% of total billed charges for outpatient setting,86.32,84.88,,69.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.85,50,,40.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.28,75,,61.02,percent of total billed charges,75% of total billed charges for outpatient setting,71.19,70,,56.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,12.84,,10.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.36,80,,65.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,12.84,,10.45,percent of total billed charges,12.84% of total billed charges,13.06,12.84,,10.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.11,65,,52.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.6,35,,28.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.53,90,,73.22,percent of total billed charges,90% of total billed charges for outpatient setting,13.06,91.53,
NEEDLE HUBER 19GA / 4447002-02,5150203,CDM,272,RC,,,Outpatient,,,66.37,66.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.46,70,,37.17,percent of total billed charges,70% of total billed charges for outpatient setting,56.33,84.88,,45.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.19,50,,26.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.78,75,,39.82,percent of total billed charges,75% of total billed charges for outpatient setting,46.46,70,,37.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.52,12.84,,6.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,80,,42.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.52,12.84,,6.82,percent of total billed charges,12.84% of total billed charges,8.52,12.84,,6.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.14,65,,34.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.23,35,,18.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.73,90,,47.78,percent of total billed charges,90% of total billed charges for outpatient setting,8.52,59.73,
NEEDLE HUBER WINGED EXT SET/MH2301,5050204,CDM,272,RC,,,Outpatient,,,27.59,27.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,70,,15.45,percent of total billed charges,70% of total billed charges for outpatient setting,23.42,84.88,,18.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.8,50,,11.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.69,75,,16.55,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,70,,15.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,80,,17.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.93,65,,14.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.66,35,,7.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.83,90,,19.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.54,24.83,
NEEDLE INJETAK 23G CYSTO  / 96009,69162725,CDM,272,RC,,,Outpatient,,,258,258,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.6,70,,144.48,percent of total billed charges,70% of total billed charges for outpatient setting,218.99,84.88,,175.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,129,50,,103.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.5,75,,154.8,percent of total billed charges,75% of total billed charges for outpatient setting,180.6,70,,144.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.13,12.84,,26.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.4,80,,165.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.13,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.13,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.7,65,,134.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.3,35,,72.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.2,90,,185.76,percent of total billed charges,90% of total billed charges for outpatient setting,33.13,232.2,
NEEDLE JAMSHIDI   685.022S,69162403,CDM,272,RC,,,Outpatient,,,406.64,406.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.65,70,,227.72,percent of total billed charges,70% of total billed charges for outpatient setting,345.16,84.88,,276.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.32,50,,162.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.98,75,,243.98,percent of total billed charges,75% of total billed charges for outpatient setting,284.65,70,,227.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.21,12.84,,41.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.31,80,,260.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.21,12.84,,41.77,percent of total billed charges,12.84% of total billed charges,52.21,12.84,,41.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.32,65,,211.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.32,35,,113.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.98,90,,292.78,percent of total billed charges,90% of total billed charges for outpatient setting,52.21,365.98,
NEEDLE NO.1 CNLTED PEDIGUARD P2ND1001,69162316,CDM,272,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.19,65,,224.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.55,389.34,
NEEDLE SCLEROTHERAPY / LDVI-25-240,6050142,CDM,272,RC,,,Outpatient,,,185,185,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.5,70,,103.6,percent of total billed charges,70% of total billed charges for outpatient setting,157.03,84.88,,125.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.5,50,,74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.75,75,,111,percent of total billed charges,75% of total billed charges for outpatient setting,129.5,70,,103.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148,80,,118.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,23.75,12.84,,19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.25,65,,96.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.75,35,,51.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,166.5,90,,133.2,percent of total billed charges,90% of total billed charges for outpatient setting,23.75,166.5,
NEEDLE SCORPION KNEE / AR-12990N,71000620,CDM,272,RC,,,Outpatient,,,819,819,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,695.17,84.88,,556.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,409.5,50,,327.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.25,75,,491.4,percent of total billed charges,75% of total billed charges for outpatient setting,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,80,,524.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,532.35,65,,425.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,35,,229.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,737.1,90,,589.68,percent of total billed charges,90% of total billed charges for outpatient setting,105.16,737.1,
NEEDLE SPINAL 17G x3.5IN TUOHY /PAIN8001,69169618,CDM,272,RC,,,Outpatient,,,64.42,64.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.09,70,,36.07,percent of total billed charges,70% of total billed charges for outpatient setting,54.68,84.88,,43.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.21,50,,25.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.32,75,,38.66,percent of total billed charges,75% of total billed charges for outpatient setting,45.09,70,,36.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.27,12.84,,6.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.54,80,,41.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.27,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,8.27,12.84,,6.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.87,65,,33.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.55,35,,18.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.98,90,,46.38,percent of total billed charges,90% of total billed charges for outpatient setting,8.27,57.98,
NEEDLE SPINAL 18G 3.5IN / 405184,6150390,CDM,272,RC,,,Outpatient,,,16.29,16.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,13.83,84.88,,11.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,50,,6.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.22,75,,9.78,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,80,,10.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.59,65,,8.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,35,,4.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.66,90,,11.73,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.66,
NEEDLE SPINAL 22G 3.5IN QUINCKE/ 405181,6152258,CDM,272,RC,,,Outpatient,,,16.29,16.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,13.83,84.88,,11.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,50,,6.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.22,75,,9.78,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,80,,10.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.59,65,,8.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,35,,4.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.66,90,,11.73,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.66,
NEEDLE SPINAL 22G 7IN QUINCKE / 405170,70000574,CDM,272,RC,,,Outpatient,,,44.97,44.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.48,70,,25.18,percent of total billed charges,70% of total billed charges for outpatient setting,38.17,84.88,,30.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.49,50,,17.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.73,75,,26.98,percent of total billed charges,75% of total billed charges for outpatient setting,31.48,70,,25.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,12.84,,4.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.98,80,,28.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,12.84,,4.62,percent of total billed charges,12.84% of total billed charges,5.77,12.84,,4.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.23,65,,23.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.74,35,,12.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.47,90,,32.38,percent of total billed charges,90% of total billed charges for outpatient setting,5.77,40.47,
NEEDLE SPINAL 22G X10IN / CHE22G101,69161990,CDM,272,RC,,,Outpatient,,,42.91,42.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,36.42,84.88,,29.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.46,50,,17.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.18,75,,25.74,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,70,,24.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,80,,27.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,5.51,12.84,,4.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.89,65,,22.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.02,35,,12.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.62,90,,30.9,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,38.62,
NEEDLE SPINAL 22GX5IN QUINCKIE / 405148,3750055,CDM,272,RC,,,Outpatient,,,35.2,35.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.64,70,,19.71,percent of total billed charges,70% of total billed charges for outpatient setting,29.88,84.88,,23.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.6,50,,14.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.4,75,,21.12,percent of total billed charges,75% of total billed charges for outpatient setting,24.64,70,,19.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.16,80,,22.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,4.52,12.84,,3.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.88,65,,18.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.32,35,,9.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.68,90,,25.34,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,31.68,
NEEDLE SPINAL 25GX3.5 WHITACRE / 405138,69162138,CDM,272,RC,,,Outpatient,,,42.98,42.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,70,,24.07,percent of total billed charges,70% of total billed charges for outpatient setting,36.48,84.88,,29.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.49,50,,17.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.24,75,,25.79,percent of total billed charges,75% of total billed charges for outpatient setting,30.09,70,,24.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,12.84,,4.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.38,80,,27.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,5.52,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.94,65,,22.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,35,,12.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.68,90,,30.94,percent of total billed charges,90% of total billed charges for outpatient setting,5.52,38.68,
NEEDLE SPINAL 25GX3IN QUINCKE / 405170,70000276,CDM,272,RC,,,Outpatient,,,10.11,10.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.08,70,,5.66,percent of total billed charges,70% of total billed charges for outpatient setting,8.58,84.88,,6.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.06,50,,4.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.58,75,,6.06,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,70,,5.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,80,,6.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,1.3,12.84,,1.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.57,65,,5.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,35,,2.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.1,90,,7.28,percent of total billed charges,90% of total billed charges for outpatient setting,1.3,9.1,
NEEDLE SPNL 22G 4.75IN SPROTTE/03115130C,70000289,CDM,272,RC,,,Outpatient,,,98,98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.6,70,,54.88,percent of total billed charges,70% of total billed charges for outpatient setting,83.18,84.88,,66.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,49,50,,39.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,75,,58.8,percent of total billed charges,75% of total billed charges for outpatient setting,68.6,70,,54.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,12.84,,10.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.4,80,,62.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,12.84,,10.06,percent of total billed charges,12.84% of total billed charges,12.58,12.84,,10.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.7,65,,50.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,35,,27.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.2,90,,70.56,percent of total billed charges,90% of total billed charges for outpatient setting,12.58,88.2,
NEEDLE SPNL 22GX3.5IN SPROTTE /32115130C,70000288,CDM,272,RC,,,Outpatient,,,81.13,81.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.79,70,,45.43,percent of total billed charges,70% of total billed charges for outpatient setting,68.86,84.88,,55.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.57,50,,32.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.85,75,,48.68,percent of total billed charges,75% of total billed charges for outpatient setting,56.79,70,,45.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,12.84,,8.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.9,80,,51.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,10.42,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.73,65,,42.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.4,35,,22.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.02,90,,58.42,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,73.02,
NEEDLE SPNL 25GX3.5IN SPROTTE /02115129A,70000290,CDM,272,RC,,,Outpatient,,,81.48,81.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.04,70,,45.63,percent of total billed charges,70% of total billed charges for outpatient setting,69.16,84.88,,55.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.74,50,,32.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.11,75,,48.89,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,70,,45.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.46,12.84,,8.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.18,80,,52.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.46,12.84,,8.37,percent of total billed charges,12.84% of total billed charges,10.46,12.84,,8.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.96,65,,42.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.52,35,,22.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.33,90,,58.66,percent of total billed charges,90% of total billed charges for outpatient setting,10.46,73.33,
NEEDLE SUTURE LASSO / AR-4560,71000621,CDM,272,RC,,,Outpatient,,,152.25,152.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.58,70,,85.26,percent of total billed charges,70% of total billed charges for outpatient setting,129.23,84.88,,103.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.13,50,,60.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.19,75,,91.35,percent of total billed charges,75% of total billed charges for outpatient setting,106.58,70,,85.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.55,12.84,,15.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.8,80,,97.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.55,12.84,,15.64,percent of total billed charges,12.84% of total billed charges,19.55,12.84,,15.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.96,65,,79.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.29,35,,42.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.03,90,,109.62,percent of total billed charges,90% of total billed charges for outpatient setting,19.55,137.03,
NEEDLE THYROID BX/20GX1 1/2/DON'T USE,2650005,CDM,272,RC,,,Outpatient,,,80.3,80.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.21,70,,44.97,percent of total billed charges,70% of total billed charges for outpatient setting,68.16,84.88,,54.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.15,50,,32.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.23,75,,48.18,percent of total billed charges,75% of total billed charges for outpatient setting,56.21,70,,44.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,12.84,,8.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.24,80,,51.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,12.84,,8.25,percent of total billed charges,12.84% of total billed charges,10.31,12.84,,8.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.2,65,,41.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.11,35,,22.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.27,90,,57.82,percent of total billed charges,90% of total billed charges for outpatient setting,10.31,72.27,
NEEDLE TRU-CUT 14GAX6IN / 2N2704X,6150111,CDM,272,RC,,,Outpatient,,,171.31,171.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.92,70,,95.94,percent of total billed charges,70% of total billed charges for outpatient setting,145.41,84.88,,116.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.66,50,,68.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.48,75,,102.78,percent of total billed charges,75% of total billed charges for outpatient setting,119.92,70,,95.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,12.84,,17.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.05,80,,109.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,12.84,,17.6,percent of total billed charges,12.84% of total billed charges,22,12.84,,17.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,111.35,65,,89.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.96,35,,47.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.18,90,,123.34,percent of total billed charges,90% of total billed charges for outpatient setting,22,154.18,
NEEDLE WANG,6050135,CDM,272,RC,,,Outpatient,,,394.34,394.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.04,70,,220.83,percent of total billed charges,70% of total billed charges for outpatient setting,334.72,84.88,,267.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,197.17,50,,157.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.76,75,,236.61,percent of total billed charges,75% of total billed charges for outpatient setting,276.04,70,,220.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,12.84,,40.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.47,80,,252.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,12.84,,40.5,percent of total billed charges,12.84% of total billed charges,50.63,12.84,,40.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,256.32,65,,205.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.02,35,,110.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,354.91,90,,283.93,percent of total billed charges,90% of total billed charges for outpatient setting,50.63,354.91,
NEEDLE Y 200 LITE / YN-200,69162663,CDM,272,RC,,,Outpatient,,,1452,1452,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1016.4,70,,813.12,percent of total billed charges,70% of total billed charges for outpatient setting,1232.46,84.88,,985.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,726,50,,580.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1089,75,,871.2,percent of total billed charges,75% of total billed charges for outpatient setting,1016.4,70,,813.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.44,12.84,,149.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161.6,80,,929.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.44,12.84,,149.15,percent of total billed charges,12.84% of total billed charges,186.44,12.84,,149.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,943.8,65,,755.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.2,35,,406.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1306.8,90,,1045.44,percent of total billed charges,90% of total billed charges for outpatient setting,186.44,1306.8,
NEEDLE Y 400  / 48850400,69169100,CDM,272,RC,,,Outpatient,,,3004.31,3004.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2103.02,70,,1682.42,percent of total billed charges,70% of total billed charges for outpatient setting,2550.06,84.88,,2040.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1502.16,50,,1201.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2253.23,75,,1802.58,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.75,12.84,,308.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2403.45,80,,1922.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.75,12.84,,308.6,percent of total billed charges,12.84% of total billed charges,385.75,12.84,,308.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1952.8,65,,1562.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1051.51,35,,841.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2703.88,90,,2163.1,percent of total billed charges,90% of total billed charges for outpatient setting,385.75,2703.88,
NEEDLE YUEH 5FR 19G / G09489,70000641,CDM,272,RC,,,Outpatient,,,144.9,144.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.43,70,,81.14,percent of total billed charges,70% of total billed charges for outpatient setting,122.99,84.88,,98.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.45,50,,57.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.68,75,,86.94,percent of total billed charges,75% of total billed charges for outpatient setting,101.43,70,,81.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.61,12.84,,14.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,80,,92.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.61,12.84,,14.89,percent of total billed charges,12.84% of total billed charges,18.61,12.84,,14.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.19,65,,75.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.72,35,,40.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.41,90,,104.33,percent of total billed charges,90% of total billed charges for outpatient setting,18.61,130.41,
NEEDLES RFA GENRT / SL:RFA,69169289,CDM,272,RC,,,Outpatient,,,88.2,88.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,74.86,84.88,,59.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.1,50,,35.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.15,75,,52.92,percent of total billed charges,75% of total billed charges for outpatient setting,61.74,70,,49.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,80,,56.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,11.32,12.84,,9.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.33,65,,45.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.87,35,,24.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.38,90,,63.5,percent of total billed charges,90% of total billed charges for outpatient setting,11.32,79.38,
NEFAZODONE (SERZONE) TAB : 100 MG,3301635,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NEFAZODONE (SERZONE) TAB : 100 MG,3301636,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
"NEISSERIA GONORRHOEAE,AMP PROBE TECH",201418,CDM,300,RC,87591,HCPCS,Outpatient,,,157.91,142.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,134.03,84.88,,107.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,118.43,75,,94.74,percent of total billed charges,75% of total billed charges for outpatient setting,110.54,70,,88.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.33,80,,101.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,51.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.54,100,,,Fee Schedule,100% of Custom Fee Schedule,142.12,90,,113.7,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,142.12,
NELFINAVIR (VIRACEPT) TAB : 250 MG,3301637,CDM,259,RC,,,Outpatient,,,6.69,6.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,70,,3.74,percent of total billed charges,70% of total billed charges for outpatient setting,5.68,84.88,,4.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.35,50,,2.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.02,75,,4.02,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,70,,3.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,80,,4.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,0.86,12.84,,0.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.35,65,,3.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.34,35,,1.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.02,90,,4.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,6.02,
NEOMEDIC ANCHORSURE FIXATION / A-SURE,69169523,CDM,278,RC,C2631,HCPCS,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071,60,,856.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1785,65,,1428,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1071,60,,856.8,percent of total billed charges,60% of total billed charges for outpatient setting,229.19,1785,
NEOMY SULF (NEOMYCIN) DROP : 10 ML,3301640,CDM,259,RC,,,Outpatient,,,61.14,61.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.8,70,,34.24,percent of total billed charges,70% of total billed charges for outpatient setting,51.9,84.88,,41.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.57,50,,24.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.86,75,,36.69,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,70,,34.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.91,80,,39.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,7.85,12.84,,6.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.74,65,,31.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.4,35,,17.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.03,90,,44.02,percent of total billed charges,90% of total billed charges for outpatient setting,7.85,55.03,
NEOMY SULF (NEOSPORIN PLUS) CRM : 0.5OZ,3301641,CDM,259,RC,,,Outpatient,,,9.98,9.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,70,,5.59,percent of total billed charges,70% of total billed charges for outpatient setting,8.47,84.88,,6.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.99,50,,3.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.49,75,,5.99,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,70,,5.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.98,80,,6.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.49,65,,5.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,35,,2.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.98,90,,7.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.28,8.98,
NEOMY SULF (POLYMYXIN B TRIPLE) OINT:30G,3301639,CDM,259,RC,,,Outpatient,,,13.62,13.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,84.88,,9.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.81,50,,5.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.22,75,,8.18,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,80,,8.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.85,65,,7.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,35,,3.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.26,90,,9.81,percent of total billed charges,90% of total billed charges for outpatient setting,1.75,12.26,
NEOMYC/POLYMIX/DEXAMETH OPHTH OINT:3.5GM,3310294,CDM,259,RC,,,Outpatient,,,110.68,110.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.48,70,,61.98,percent of total billed charges,70% of total billed charges for outpatient setting,93.95,84.88,,75.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.34,50,,44.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.01,75,,66.41,percent of total billed charges,75% of total billed charges for outpatient setting,77.48,70,,61.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.21,12.84,,11.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.54,80,,70.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.21,12.84,,11.37,percent of total billed charges,12.84% of total billed charges,14.21,12.84,,11.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.94,65,,57.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.74,35,,30.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.61,90,,79.69,percent of total billed charges,90% of total billed charges for outpatient setting,14.21,99.61,
NEOMYCIN (AK-SPORE HC) OPHT OINT :3.5 GM,3301644,CDM,259,RC,,,Outpatient,,,16.99,16.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.89,70,,9.51,percent of total billed charges,70% of total billed charges for outpatient setting,14.42,84.88,,11.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.5,50,,6.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.74,75,,10.19,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,70,,9.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,80,,10.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.04,65,,8.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,35,,4.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.29,90,,12.23,percent of total billed charges,90% of total billed charges for outpatient setting,2.18,15.29,
NEOMYCIN (ANTIBIOTIC) OTIC SUSP: 10 ML,3301651,CDM,259,RC,,,Outpatient,,,94.35,94.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,84.88,,64.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.18,50,,37.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.76,75,,56.61,percent of total billed charges,75% of total billed charges for outpatient setting,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,80,,60.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.33,65,,49.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,35,,26.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.92,90,,67.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,84.92,
NEOMYCIN (CORTISPORIN) TOP : 15 GM,3301645,CDM,259,RC,,,Outpatient,,,148.65,148.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.06,70,,83.25,percent of total billed charges,70% of total billed charges for outpatient setting,126.17,84.88,,100.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.33,50,,59.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.49,75,,89.19,percent of total billed charges,75% of total billed charges for outpatient setting,104.06,70,,83.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.09,12.84,,15.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.92,80,,95.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.09,12.84,,15.27,percent of total billed charges,12.84% of total billed charges,19.09,12.84,,15.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.62,65,,77.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.03,35,,41.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.79,90,,107.03,percent of total billed charges,90% of total billed charges for outpatient setting,19.09,133.79,
NEOMYCIN (NEOMYCIN POLY B DEX) DROP: 5ML,3301646,CDM,259,RC,,,Outpatient,,,21.57,21.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.1,70,,12.08,percent of total billed charges,70% of total billed charges for outpatient setting,18.31,84.88,,14.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.79,50,,8.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.18,75,,12.94,percent of total billed charges,75% of total billed charges for outpatient setting,15.1,70,,12.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.26,80,,13.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.02,65,,11.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,35,,6.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.41,90,,15.53,percent of total billed charges,90% of total billed charges for outpatient setting,2.77,19.41,
NEOMYCIN (NEOMYCIN POLY B GRM) DROP:10ML,3301647,CDM,259,RC,,,Outpatient,,,66.73,66.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.71,70,,37.37,percent of total billed charges,70% of total billed charges for outpatient setting,56.64,84.88,,45.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.37,50,,26.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.05,75,,40.04,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,70,,37.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,12.84,,6.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.38,80,,42.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,8.57,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.37,65,,34.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.36,35,,18.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.06,90,,48.05,percent of total billed charges,90% of total billed charges for outpatient setting,8.57,60.06,
NEOMYCIN (POLY B HC) OTIC SUSP 10 ML,3301648,CDM,259,RC,,,Outpatient,,,215.7,215.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.99,70,,120.79,percent of total billed charges,70% of total billed charges for outpatient setting,183.09,84.88,,146.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.85,50,,86.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.78,75,,129.42,percent of total billed charges,75% of total billed charges for outpatient setting,150.99,70,,120.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.56,80,,138.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,27.7,12.84,,22.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.21,65,,112.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,35,,60.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.13,90,,155.3,percent of total billed charges,90% of total billed charges for outpatient setting,27.7,194.13,
NEOMYCIN (POLYMYXIN-B/HC) OPTH : 5 ML,3301649,CDM,259,RC,,,Outpatient,,,71.84,71.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.29,70,,40.23,percent of total billed charges,70% of total billed charges for outpatient setting,60.98,84.88,,48.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.92,50,,28.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.88,75,,43.1,percent of total billed charges,75% of total billed charges for outpatient setting,50.29,70,,40.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,12.84,,7.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.47,80,,45.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,12.84,,7.38,percent of total billed charges,12.84% of total billed charges,9.22,12.84,,7.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.7,65,,37.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,35,,20.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.66,90,,51.73,percent of total billed charges,90% of total billed charges for outpatient setting,9.22,64.66,
NEOMYCIN (TRIPLE ANTIB) OPHT OINT:3.75GM,3301643,CDM,259,RC,,,Outpatient,,,15.66,15.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,70,,8.77,percent of total billed charges,70% of total billed charges for outpatient setting,13.29,84.88,,10.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.83,50,,6.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.75,75,,9.4,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,70,,8.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.53,80,,10.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,2.01,12.84,,1.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.18,65,,8.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,,4.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.09,90,,11.27,percent of total billed charges,90% of total billed charges for outpatient setting,2.01,14.09,
NEOMYCIN SULF TAB: 500 MG,3301642,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NEOSPORIN GU IRRIGANT 40-200000 MG/ML,3302596,CDM,250,RC,,,Outpatient,,,48.68,48.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.08,70,,27.26,percent of total billed charges,70% of total billed charges for outpatient setting,41.32,84.88,,33.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.34,50,,19.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.51,75,,29.21,percent of total billed charges,75% of total billed charges for outpatient setting,34.08,70,,27.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,12.84,,5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.94,80,,31.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,12.84,,5,percent of total billed charges,12.84% of total billed charges,6.25,12.84,,5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.64,65,,25.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,35,,13.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.81,90,,35.05,percent of total billed charges,90% of total billed charges for outpatient setting,6.25,43.81,
NEOSTIGMINE (PROSTIGMIN) TAB : 15 MG,3301652,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NEOSTIGMINE (PROSTIGMN) MDV : 1 MG  10ML,3301653,CDM,250,RC,,,Outpatient,,,13.47,13.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.43,70,,7.54,percent of total billed charges,70% of total billed charges for outpatient setting,11.43,84.88,,9.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.74,50,,5.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.1,75,,8.08,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,70,,7.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,80,,8.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.76,65,,7.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,35,,3.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.12,90,,9.7,percent of total billed charges,90% of total billed charges for outpatient setting,1.73,12.12,
NEOSTIGMINE 1MG/ML 10ML vial,3307354,CDM,250,RC,J2710,HCPCS,Outpatient,,,39.42,39.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.59,70,,22.07,percent of total billed charges,70% of total billed charges for outpatient setting,33.46,84.88,,26.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.57,75,,23.66,percent of total billed charges,75% of total billed charges for outpatient setting,27.59,70,,22.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.54,80,,25.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.62,65,,20.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.48,90,,28.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,35.48,
NEOSTIGMINE 1MG/ML 5ML SYRINGE,3301654,CDM,250,RC,J2710,HCPCS,Outpatient,,,96.9,96.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.83,70,,54.26,percent of total billed charges,70% of total billed charges for outpatient setting,82.25,84.88,,65.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.94,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,72.68,75,,58.14,percent of total billed charges,75% of total billed charges for outpatient setting,67.83,70,,54.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,12.84,,9.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,80,,62.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,12.84,,9.95,percent of total billed charges,12.84% of total billed charges,12.44,12.84,,9.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.99,65,,50.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.21,90,,69.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,87.21,
NEOSYNEPHRINE SPRAY MILD: 15CC,3302837,CDM,259,RC,,,Outpatient,,,17.61,17.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,70,,9.86,percent of total billed charges,70% of total billed charges for outpatient setting,14.95,84.88,,11.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.81,50,,7.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.21,75,,10.57,percent of total billed charges,75% of total billed charges for outpatient setting,12.33,70,,9.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.09,80,,11.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.45,65,,9.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,35,,4.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.85,90,,12.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.26,15.85,
"NEPHELOMETRY, EA ANYLYTE",200279,CDM,301,RC,83883,HCPCS,Outpatient,,,61.2,55.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,70,,34.27,percent of total billed charges,70% of total billed charges for outpatient setting,51.95,84.88,,41.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.9,75,,36.72,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,70,,34.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,80,,39.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,55.08,90,,44.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,55.08,
NEPHRO-VITE RX TABS,3303348,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
NEPTUNE MANIFOLD 1 PORT / 702-25-000,69169128,CDM,270,RC,,,Outpatient,,,61.81,61.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.27,70,,34.62,percent of total billed charges,70% of total billed charges for outpatient setting,52.46,84.88,,41.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.91,50,,24.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.36,75,,37.09,percent of total billed charges,75% of total billed charges for outpatient setting,43.27,70,,34.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,12.84,,6.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.45,80,,39.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,12.84,,6.35,percent of total billed charges,12.84% of total billed charges,7.94,12.84,,6.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.18,65,,32.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,35,,17.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.63,90,,44.5,percent of total billed charges,90% of total billed charges for outpatient setting,7.94,55.63,
NEPTUNE MANIFOLD 4 PORT  / 702-020-000,69169132,CDM,270,RC,,,Outpatient,,,97.2,97.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.04,70,,54.43,percent of total billed charges,70% of total billed charges for outpatient setting,82.5,84.88,,66,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.6,50,,38.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,75,,58.32,percent of total billed charges,75% of total billed charges for outpatient setting,68.04,70,,54.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,12.84,,9.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,80,,62.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,12.84,,9.98,percent of total billed charges,12.84% of total billed charges,12.48,12.84,,9.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.18,65,,50.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.02,35,,27.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.48,90,,69.98,percent of total billed charges,90% of total billed charges for outpatient setting,12.48,87.48,
NEPTUNE MFOLD SPECIMN 4 PORT 702-020-001,6150561,CDM,270,RC,,,Outpatient,,,146.78,146.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.75,70,,82.2,percent of total billed charges,70% of total billed charges for outpatient setting,124.59,84.88,,99.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.39,50,,58.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.09,75,,88.07,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,70,,82.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.85,12.84,,15.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.42,80,,93.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.85,12.84,,15.08,percent of total billed charges,12.84% of total billed charges,18.85,12.84,,15.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.41,65,,76.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.37,35,,41.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.1,90,,105.68,percent of total billed charges,90% of total billed charges for outpatient setting,18.85,132.1,
NERVE BLOCK PACK (P&S) / DYNJRA0747A,69161962,CDM,272,RC,,,Outpatient,,,98.96,98.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.27,70,,55.42,percent of total billed charges,70% of total billed charges for outpatient setting,84,84.88,,67.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.48,50,,39.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.22,75,,59.38,percent of total billed charges,75% of total billed charges for outpatient setting,69.27,70,,55.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.71,12.84,,10.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.17,80,,63.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.71,12.84,,10.17,percent of total billed charges,12.84% of total billed charges,12.71,12.84,,10.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.32,65,,51.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.64,35,,27.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.06,90,,71.25,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,89.06,
NERVE STIMULATOR LOCATOR // 8562010,70000018,CDM,272,RC,,,Outpatient,,,465.8,465.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.06,70,,260.85,percent of total billed charges,70% of total billed charges for outpatient setting,395.37,84.88,,316.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,232.9,50,,186.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,349.35,75,,279.48,percent of total billed charges,75% of total billed charges for outpatient setting,326.06,70,,260.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.81,12.84,,47.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.64,80,,298.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.81,12.84,,47.85,percent of total billed charges,12.84% of total billed charges,59.81,12.84,,47.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.77,65,,242.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.03,35,,130.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,419.22,90,,335.38,percent of total billed charges,90% of total billed charges for outpatient setting,59.81,419.22,
NERVE STIMULATOR PROCLAIM ELITE 7 / 3662,70000122,CDM,278,RC,C1767,HCPCS,Outpatient,,,33000,33000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19800,60,,15840,percent of total billed charges,60% of total Billed charges for outpatient setting,28010.4,84.88,,22408.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24750,75,,19800,percent of total billed charges,75% of total billed charges for outpatient setting,16500,50,,13200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26400,80,,21120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34650,105,,27720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11550,35,,9240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19800,60,,15840,percent of total billed charges,60% of total billed charges for outpatient setting,4237.2,34650,
NERVE STIMULATOR/LOCATOR / A-0003,6150688,CDM,272,RC,,,Outpatient,,,205.21,205.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.65,70,,114.92,percent of total billed charges,70% of total billed charges for outpatient setting,174.18,84.88,,139.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,102.61,50,,82.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.91,75,,123.13,percent of total billed charges,75% of total billed charges for outpatient setting,143.65,70,,114.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.35,12.84,,21.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.17,80,,131.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.35,12.84,,21.08,percent of total billed charges,12.84% of total billed charges,26.35,12.84,,21.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,133.39,65,,106.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.82,35,,57.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,184.69,90,,147.75,percent of total billed charges,90% of total billed charges for outpatient setting,26.35,184.69,
NET RESCUE RETRIEVAL / DGN-538-5,1953977,CDM,272,RC,,,Outpatient,,,346.44,346.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.51,70,,194.01,percent of total billed charges,70% of total billed charges for outpatient setting,294.06,84.88,,235.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.22,50,,138.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.83,75,,207.86,percent of total billed charges,75% of total billed charges for outpatient setting,242.51,70,,194.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,12.84,,35.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.15,80,,221.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,12.84,,35.58,percent of total billed charges,12.84% of total billed charges,44.48,12.84,,35.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,225.19,65,,180.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.25,35,,97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.8,90,,249.44,percent of total billed charges,90% of total billed charges for outpatient setting,44.48,311.8,
NEUORSTIMULATOR  / 1101,69169718,CDM,278,RC,C1820,HCPCS,Outpatient,,,22420,22420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13452,60,,10761.6,percent of total billed charges,60% of total Billed charges for outpatient setting,19030.1,84.88,,15224.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16815,75,,13452,percent of total billed charges,75% of total billed charges for outpatient setting,11210,50,,8968,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2878.73,12.84,,2302.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17936,80,,14348.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2878.73,12.84,,2302.98,percent of total billed charges,12.84% of total billed charges,2878.73,12.84,,2302.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23541,105,,18832.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7847,35,,6277.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13452,60,,10761.6,percent of total billed charges,60% of total billed charges for outpatient setting,2878.73,23541,
NEURO ADVANCED PROCEDURE CHARGE,6100065,CDM,360,RC,,,Outpatient,,,12600,12600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820,70,,7056,percent of total billed charges,70% of total billed charges for outpatient setting,10694.88,84.88,,8555.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,6300,50,,5040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9450,75,,7560,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617.84,12.84,,1294.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10080,80,,8064,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617.84,12.84,,1294.27,percent of total billed charges,12.84% of total billed charges,1617.84,12.84,,1294.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4410,35,,3528,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11340,90,,9072,percent of total billed charges,90% of total billed charges for outpatient setting,1617.84,11340,
NEURO FLEX 2.5X2.5,69161661,CDM,278,RC,,,Outpatient,,,2747.2,2747.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1648.32,60,,1318.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2331.82,84.88,,1865.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,1373.6,50,,1098.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2060.4,75,,1648.32,percent of total billed charges,75% of total billed charges for outpatient setting,1373.6,50,,1098.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.74,12.84,,282.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.76,80,,1758.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.74,12.84,,282.19,percent of total billed charges,12.84% of total billed charges,352.74,12.84,,282.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2884.56,105,,2307.65,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.52,35,,769.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1648.32,60,,1318.66,percent of total billed charges,60% of total billed charges for outpatient setting,352.74,2884.56,
NEUROFLEX 2.5MM X 2.5CM  / CNCF2525,69169599,CDM,278,RC,C9355,HCPCS,Outpatient,,,2378.8,2378.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1427.28,60,,1141.82,percent of total billed charges,60% of total Billed charges for outpatient setting,2019.13,84.88,,1615.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,192.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1784.1,75,,1427.28,percent of total billed charges,75% of total billed charges for outpatient setting,1189.4,50,,951.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.44,12.84,,244.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1903.04,80,,1522.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.44,12.84,,244.35,percent of total billed charges,12.84% of total billed charges,305.44,12.84,,244.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2497.74,105,,1998.19,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.58,35,,666.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1427.28,60,,1141.82,percent of total billed charges,60% of total billed charges for outpatient setting,192.96,2497.74,
NEUROMUSCULAR JUNCTION TESTING EA NERVE,6000623,CDM,740,RC,95937,HCPCS,Outpatient,,,334.97,334.97,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.48,70,,187.58,percent of total billed charges,70% of total billed charges for outpatient setting,284.32,84.88,,227.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.49,50,,133.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.23,75,,200.98,percent of total billed charges,75% of total billed charges for outpatient setting,234.48,70,,187.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.01,12.84,,34.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.98,80,,214.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.01,12.84,,34.41,percent of total billed charges,12.84% of total billed charges,43.01,12.84,,34.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.24,35,,93.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,301.47,90,,241.18,percent of total billed charges,90% of total billed charges for outpatient setting,43.01,323,
NEUROMYELITIS OPTICA AUTOAB IGG SERUM,200466,CDM,301,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
NEUROSTIMULATOR VERIFY EXTERNAL / 353101,70000527,CDM,272,RC,,,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1124.76,65,,899.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1557.36,90,,1245.89,percent of total billed charges,90% of total billed charges for outpatient setting,222.18,1557.36,
NEUROSURG TIER 1 OR TIME,6100131,CDM,360,RC,,,Outpatient,,,5000,5000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,70,,2800,percent of total billed charges,70% of total billed charges for outpatient setting,4244,84.88,,3395.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750,75,,3000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4000,80,,3200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,35,,1400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4500,90,,3600,percent of total billed charges,90% of total billed charges for outpatient setting,642,4500,
NEUROSURG TIER 2 OR TIME,6100132,CDM,360,RC,,,Outpatient,,,10000,10000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7000,70,,5600,percent of total billed charges,70% of total billed charges for outpatient setting,8488,84.88,,6790.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,5000,50,,4000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7500,75,,6000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8000,80,,6400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,1284,12.84,,1027.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,35,,2800,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9000,90,,7200,percent of total billed charges,90% of total billed charges for outpatient setting,1284,9000,
NEUROSURG TIER 3 OR TIME,6100133,CDM,360,RC,,,Outpatient,,,15000,15000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10500,70,,8400,percent of total billed charges,70% of total billed charges for outpatient setting,12732,84.88,,10185.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,7500,50,,6000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11250,75,,9000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926,12.84,,1540.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12000,80,,9600,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926,12.84,,1540.8,percent of total billed charges,12.84% of total billed charges,1926,12.84,,1540.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,35,,4200,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13500,90,,10800,percent of total billed charges,90% of total billed charges for outpatient setting,1926,13500,
NEUROSURG TIER 4 OR TIME,6100134,CDM,360,RC,,,Outpatient,,,20000,20000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14000,70,,11200,percent of total billed charges,70% of total billed charges for outpatient setting,16976,84.88,,13580.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,10000,50,,8000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15000,75,,12000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2568,12.84,,2054.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16000,80,,12800,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2568,12.84,,2054.4,percent of total billed charges,12.84% of total billed charges,2568,12.84,,2054.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7000,35,,5600,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18000,90,,14400,percent of total billed charges,90% of total billed charges for outpatient setting,2000,18000,
NEUROSURG TIER 5 OR TIME,6100135,CDM,360,RC,,,Outpatient,,,30000,30000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21000,70,,16800,percent of total billed charges,70% of total billed charges for outpatient setting,25464,84.88,,20371.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,15000,50,,12000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22500,75,,18000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3852,12.84,,3081.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24000,80,,19200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3852,12.84,,3081.6,percent of total billed charges,12.84% of total billed charges,3852,12.84,,3081.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10500,35,,8400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27000,90,,21600,percent of total billed charges,90% of total billed charges for outpatient setting,2000,27000,
NEUROSURG TIER 6 OR TIME,6100136,CDM,360,RC,,,Outpatient,,,50000,50000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35000,70,,28000,percent of total billed charges,70% of total billed charges for outpatient setting,42440,84.88,,33952,percent of total billed charges,84.88% of total billed charges for outpatient setting,25000,50,,20000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37500,75,,30000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6420,12.84,,5136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40000,80,,32000,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6420,12.84,,5136,percent of total billed charges,12.84% of total billed charges,6420,12.84,,5136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17500,35,,14000,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45000,90,,36000,percent of total billed charges,90% of total billed charges for outpatient setting,2000,45000,
NEUTRAPHOS : POWDER PACKETS,3302925,CDM,259,RC,,,Outpatient,,,14.49,14.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.14,70,,8.11,percent of total billed charges,70% of total billed charges for outpatient setting,12.3,84.88,,9.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.25,50,,5.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.87,75,,8.7,percent of total billed charges,75% of total billed charges for outpatient setting,10.14,70,,8.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,80,,9.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.42,65,,7.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,35,,4.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.04,90,,10.43,percent of total billed charges,90% of total billed charges for outpatient setting,1.86,13.04,
NEXIUM (ESOMEPRAZOLE) CAP:20 MG,3302735,CDM,259,RC,,,Outpatient,,,19.92,19.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.94,70,,11.15,percent of total billed charges,70% of total billed charges for outpatient setting,16.91,84.88,,13.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.96,50,,7.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.94,75,,11.95,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,70,,11.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,80,,12.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.95,65,,10.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,35,,5.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.93,90,,14.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.93,
NF-CASODEX TAB 50MG,3304292,CDM,250,RC,,,Outpatient,,,12.93,12.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.05,70,,7.24,percent of total billed charges,70% of total billed charges for outpatient setting,10.97,84.88,,8.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.47,50,,5.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.7,75,,7.76,percent of total billed charges,75% of total billed charges for outpatient setting,9.05,70,,7.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,80,,8.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,1.66,12.84,,1.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.4,65,,6.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.53,35,,3.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.64,90,,9.31,percent of total billed charges,90% of total billed charges for outpatient setting,1.66,11.64,
NF-CLONIDINE (genericCATAPRES) 0.2MG TAB,3300847,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
NF-GLIMEPIRIDE ORAL TABLET 2MG,3314060,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NF-LEVETIRACETAM ORAL TABLET 250MG,3305737,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NF-PRAVASTATIN(genPRAVACHOL)40 MG TAB,3302679,CDM,259,RC,,,Outpatient,,,7.19,7.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,70,,4.02,percent of total billed charges,70% of total billed charges for outpatient setting,6.1,84.88,,4.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.6,50,,2.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.39,75,,4.31,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,70,,4.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,80,,4.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.67,65,,3.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,35,,2.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.47,90,,5.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.92,6.47,
NF-SUMATRIPTAN SUCCINATE ORAL TABLET 50M,3308002,CDM,250,RC,,,Outpatient,,,5.41,5.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,70,,3.03,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,84.88,,3.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.71,50,,2.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.06,75,,3.25,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,70,,3.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,80,,3.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.52,65,,2.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,35,,1.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.87,90,,3.9,percent of total billed charges,90% of total billed charges for outpatient setting,0.69,4.87,
NF-TRAZODONE HCL ORAL TABLET 100MG,3304081,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NIACIN (NIACOR SR) CAP : 125 MG,3301655,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NIACIN (NIACOR TR) TAB : 500 MG,3301656,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NIACIN(VITA B3) NIASPAN ER: 500MG,3303306,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
"NIACIN, VITAMIN B3",220255,CDM,300,RC,84591,HCPCS,Outpatient,,,76.77,69.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.74,70,,42.99,percent of total billed charges,70% of total billed charges for outpatient setting,65.16,84.88,,52.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.58,75,,46.06,percent of total billed charges,75% of total billed charges for outpatient setting,53.74,70,,42.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.42,80,,49.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,100,,,Fee Schedule,100% of Custom Fee Schedule,69.09,90,,55.27,percent of total billed charges,90% of total billed charges for outpatient setting,16.13,69.09,
NICARDIPINE (CARDENE) CAP : 20 MG,3301657,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NICARDIPINE (CARDENE) CAP : 20 MG,3301658,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NICARDIPINE (CARDENE) CAP : 30 MG,3301659,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
"NICKEL, SERUM",200423,CDM,300,RC,83885,HCPCS,Outpatient,,,110.3,99.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.21,70,,61.77,percent of total billed charges,70% of total billed charges for outpatient setting,93.62,84.88,,74.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.73,75,,66.18,percent of total billed charges,75% of total billed charges for outpatient setting,77.21,70,,61.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.24,80,,70.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,35.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of Custom Fee Schedule,99.27,90,,79.42,percent of total billed charges,90% of total billed charges for outpatient setting,24.51,99.27,
"NICOTINE & METABOLITE SCREEN,SERUM",220765,CDM,310,RC,80323,HCPCS,Outpatient,,,41.72,37.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,70,,23.36,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,84.88,,28.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,31.29,75,,25.03,percent of total billed charges,75% of total billed charges for outpatient setting,29.2,70,,23.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,80,,26.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.55,90,,30.04,percent of total billed charges,90% of total billed charges for outpatient setting,5.36,40.85,
"NICOTINE & METABOLITE SCREEN,URINE",220768,CDM,301,RC,G0480,HCPCS,Outpatient,,,514.94,463.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.46,70,,288.37,percent of total billed charges,70% of total billed charges for outpatient setting,437.08,84.88,,349.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,386.21,75,,308.97,percent of total billed charges,75% of total billed charges for outpatient setting,360.46,70,,288.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.95,80,,329.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,79.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.53,100,,,Fee Schedule,100% of Custom Fee Schedule,463.45,90,,370.76,percent of total billed charges,90% of total billed charges for outpatient setting,79.94,463.45,
NICOTINE (NICODERM CQ) PATCH : 14MG/24HR,3301663,CDM,259,RC,,,Outpatient,,,11.63,11.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.14,70,,6.51,percent of total billed charges,70% of total billed charges for outpatient setting,9.87,84.88,,7.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.82,50,,4.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.72,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,70,,6.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,80,,7.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.56,65,,6.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.47,90,,8.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.47,
NICOTINE (NICODERM CQ) PATCH : 7MG/24HR,3301664,CDM,259,RC,,,Outpatient,,,78.63,78.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.04,70,,44.03,percent of total billed charges,70% of total billed charges for outpatient setting,66.74,84.88,,53.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.32,50,,31.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.97,75,,47.18,percent of total billed charges,75% of total billed charges for outpatient setting,55.04,70,,44.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,12.84,,8.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.9,80,,50.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,12.84,,8.08,percent of total billed charges,12.84% of total billed charges,10.1,12.84,,8.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.11,65,,40.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.52,35,,22.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.77,90,,56.62,percent of total billed charges,90% of total billed charges for outpatient setting,10.1,70.77,
NICOTINE (NICORETTE) GUM : 2MG,3301667,CDM,259,RC,,,Outpatient,,,78.26,78.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.78,70,,43.82,percent of total billed charges,70% of total billed charges for outpatient setting,66.43,84.88,,53.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.13,50,,31.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.7,75,,46.96,percent of total billed charges,75% of total billed charges for outpatient setting,54.78,70,,43.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.61,80,,50.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.87,65,,40.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.39,35,,21.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.43,90,,56.34,percent of total billed charges,90% of total billed charges for outpatient setting,10.05,70.43,
NICOTINE (NICORETTE) GUM : 4MG,3301666,CDM,259,RC,,,Outpatient,,,78.26,78.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.78,70,,43.82,percent of total billed charges,70% of total billed charges for outpatient setting,66.43,84.88,,53.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.13,50,,31.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.7,75,,46.96,percent of total billed charges,75% of total billed charges for outpatient setting,54.78,70,,43.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.61,80,,50.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,10.05,12.84,,8.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.87,65,,40.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.39,35,,21.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.43,90,,56.34,percent of total billed charges,90% of total billed charges for outpatient setting,10.05,70.43,
NICOTINE PATCH 14MG/24HR,3301660,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NICOTINE PATCH 21MG/24HR,3301661,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NICOTINE PATCH 7 MG/24HR:,3301662,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NIFEDIPINE (ADALAT CC)TAB: 60 MG,3302796,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
NIFEDIPINE (ADALAT) TAB: 30 MG,3301671,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NIFEDIPINE (ADALAT) TAB: 90 MG,3301672,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
NIFEDIPINE (genericADALAT CC)ER 30MG TAB,3301670,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NIFEDIPINE (PROCARDIA ER) TAB : 30 MG,3301669,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
NIFEDIPINE (PROCARDIA XL):60MG,3303292,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
NIFEDIPINE (PROCARDIA) CAP 10 MG,3301668,CDM,259,RC,,,Outpatient,,,12.84,12.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,70,,7.19,percent of total billed charges,70% of total billed charges for outpatient setting,10.9,84.88,,8.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.42,50,,5.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.63,75,,7.7,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,70,,7.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,80,,8.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.35,65,,6.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,35,,3.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.56,90,,9.25,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.56,
NISOLDIPINE (SULAR) ER 20MG: TAB,3303161,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NITROFURANTOIN (MACROBID)CAPS: 100MG,33028292,CDM,259,RC,,,Outpatient,,,8.45,8.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.92,70,,4.74,percent of total billed charges,70% of total billed charges for outpatient setting,7.17,84.88,,5.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.23,50,,3.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.34,75,,5.07,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,70,,4.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,12.84,,0.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.76,80,,5.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,1.08,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.49,65,,4.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,35,,2.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.61,90,,6.09,percent of total billed charges,90% of total billed charges for outpatient setting,1.08,7.61,
NITROFURANTOIN (MACRODANTIN) 50MG CAP,3301673,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NITROFURANTOIN (MACRODANTIN) CAP: 50 MG,3301674,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NITROFURANTOIN MACROCRYSTALS 50 MG,3313698,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NITROFURANTOIN(MACROBID)100 MG,3303174,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NITROGLYCERIN (DEPONIT) PATCH : 0.4 MG,3301695,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NITROGLYCERIN (NITRO BID) INJ 5MG/ML:10M,3301683,CDM,250,RC,,,Outpatient,,,42.59,42.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.81,70,,23.85,percent of total billed charges,70% of total billed charges for outpatient setting,36.15,84.88,,28.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.3,50,,17.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.94,75,,25.55,percent of total billed charges,75% of total billed charges for outpatient setting,29.81,70,,23.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.07,80,,27.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.68,65,,22.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,35,,11.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.33,90,,30.66,percent of total billed charges,90% of total billed charges for outpatient setting,5.47,38.33,
NITROGLYCERIN (NITRO-BID) 2% OINT 1GM,3301693,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NITROGLYCERIN (NITRO-BID) 2% OINT:1GM FP,3301687,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NITROGLYCERIN (NITROBID) OINT : 30GM,3301679,CDM,259,RC,,,Outpatient,,,24.91,24.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,70,,13.95,percent of total billed charges,70% of total billed charges for outpatient setting,21.14,84.88,,16.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.46,50,,9.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,75,,14.94,percent of total billed charges,75% of total billed charges for outpatient setting,17.44,70,,13.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.93,80,,15.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.19,65,,12.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,35,,6.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.42,90,,17.94,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,22.42,
NITROGLYCERIN (NITROBID) OINT : 60 MG,3301681,CDM,259,RC,,,Outpatient,,,28.64,28.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,70,,16.04,percent of total billed charges,70% of total billed charges for outpatient setting,24.31,84.88,,19.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.32,50,,11.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.48,75,,17.18,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,70,,16.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,12.84,,2.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,80,,18.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,3.68,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.62,65,,14.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,35,,8.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.78,90,,20.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.68,25.78,
NITROGLYCERIN (NITROLINGUAL)SPRAY 0.4MG:,3301692,CDM,259,RC,,,Outpatient,,,335.03,335.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.52,70,,187.62,percent of total billed charges,70% of total billed charges for outpatient setting,284.37,84.88,,227.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.52,50,,134.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.27,75,,201.02,percent of total billed charges,75% of total billed charges for outpatient setting,234.52,70,,187.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.02,12.84,,34.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.02,80,,214.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.02,12.84,,34.42,percent of total billed charges,12.84% of total billed charges,43.02,12.84,,34.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.77,65,,174.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.26,35,,93.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,301.53,90,,241.22,percent of total billed charges,90% of total billed charges for outpatient setting,43.02,301.53,
NITROGLYCERIN (NITROQUICK ER)CAP : 6.5MG,3301675,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
NITROGLYCERIN (NITROQUICK) CAP : 2.5 MG,3301680,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
NITROGLYCERIN (NITROQUICK) CAP : 9 MG,3301676,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
NITROGLYCERIN (NITROQUICK) TAB: 0.3 MG,3301677,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NITROGLYCERIN (NITROQUICK) TAB: 0.3 MG,3301684,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
NITROGLYCERIN (NITROQUICK) TAB: 0.6 MG,3301678,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
NITROGLYCERIN (NITROSTAT) TAB: 0.4 MG,3301691,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NITROGLYCERIN (NITROSTAT) TAB: 0.6 MG,3301685,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NITROGLYCERIN 0.2 MG PATCH:(TRANSDERM-N),3301688,CDM,259,RC,,,Outpatient,,,4.92,4.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,84.88,,3.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.46,50,,1.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.69,75,,2.95,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,80,,3.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.2,65,,2.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.43,90,,3.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.63,4.43,
NITROGLYCERIN 0.4 MG PATCH:(TRANSDERM-N),3301689,CDM,259,RC,,,Outpatient,,,5.61,5.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,70,,3.14,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,84.88,,3.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.81,50,,2.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.21,75,,3.37,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,70,,3.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,80,,3.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.65,65,,2.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,35,,1.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.05,90,,4.04,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,5.05,
NITROGLYCERIN 0.4MG SL TAB,3301690,CDM,259,RC,,,Outpatient,,,51.71,51.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.2,70,,28.96,percent of total billed charges,70% of total billed charges for outpatient setting,43.89,84.88,,35.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.86,50,,20.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.78,75,,31.02,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,70,,28.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.64,12.84,,5.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.37,80,,33.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.64,12.84,,5.31,percent of total billed charges,12.84% of total billed charges,6.64,12.84,,5.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.61,65,,26.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,35,,14.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.54,90,,37.23,percent of total billed charges,90% of total billed charges for outpatient setting,6.64,46.54,
NITROGLYCERIN 0.6 MG PATCH:(TRANSDERM-N),3301694,CDM,259,RC,,,Outpatient,,,6.21,6.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,84.88,,4.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,50,,2.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.66,75,,3.73,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,80,,3.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.04,65,,3.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.59,90,,4.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.59,
NITROGLYCERIN 1/150MG (NITROQUICK) TAB:,3301686,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NITROGLYCERIN 200 MCG/ML  250 ML,3302932,CDM,250,RC,,,Outpatient,,,66.24,66.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,56.22,84.88,,44.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.12,50,,26.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.68,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,80,,42.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.06,65,,34.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,35,,18.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.62,90,,47.7,percent of total billed charges,90% of total billed charges for outpatient setting,8.51,59.62,
NITROGLYCERIN SA (NITROSTAT) CAP : 6.5MG,3301682,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
NITROPRUSSIDE (NITROPRESS) SDV 25MG/ML:1,3301697,CDM,250,RC,,,Outpatient,,,5.46,5.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,84.88,,3.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,50,,2.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.55,65,,2.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.91,90,,3.93,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.91,
NITROPRUSSIDE (NITROPRESS) SDV 25MG/ML:1,3301696,CDM,250,RC,,,Outpatient,,,26.42,26.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,70,,14.79,percent of total billed charges,70% of total billed charges for outpatient setting,22.43,84.88,,17.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.21,50,,10.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.82,75,,15.86,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,70,,14.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.14,80,,16.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,3.39,12.84,,2.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,65,,13.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,35,,7.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.78,90,,19.02,percent of total billed charges,90% of total billed charges for outpatient setting,3.39,23.78,
NITROTROL INHALER 10MG/CARTRIDGE:ORAL,3303198,CDM,259,RC,,,Outpatient,,,584.36,584.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.05,70,,327.24,percent of total billed charges,70% of total billed charges for outpatient setting,496,84.88,,396.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,292.18,50,,233.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.27,75,,350.62,percent of total billed charges,75% of total billed charges for outpatient setting,409.05,70,,327.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.03,12.84,,60.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.49,80,,373.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.03,12.84,,60.02,percent of total billed charges,12.84% of total billed charges,75.03,12.84,,60.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,379.83,65,,303.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.53,35,,163.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,525.92,90,,420.74,percent of total billed charges,90% of total billed charges for outpatient setting,75.03,525.92,
NIZATIDINE (AXID) 150 MG CAP:,3302622,CDM,259,RC,,,Outpatient,,,9.65,9.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.76,70,,5.41,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,84.88,,6.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.83,50,,3.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.24,75,,5.79,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,70,,5.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.72,80,,6.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.27,65,,5.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,35,,2.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.69,90,,6.95,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,8.69,
NK CELLS TOTAL COUNT,201661,CDM,310,RC,86357,HCPCS,Outpatient,,,169.79,152.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,144.12,84.88,,115.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.34,75,,101.87,percent of total billed charges,75% of total billed charges for outpatient setting,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.83,80,,108.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,55.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of Custom Fee Schedule,152.81,90,,122.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,152.81,
NM ADENOSINE INJ 6 MG THERAPEUTIC,3300540,CDM,636,RC,J0153,HCPCS,Outpatient,,,73.28,73.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.3,70,,41.04,percent of total billed charges,70% of total billed charges for outpatient setting,62.2,84.88,,49.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.96,75,,43.97,percent of total billed charges,75% of total billed charges for outpatient setting,51.3,70,,41.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,12.84,,7.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.62,80,,46.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,12.84,,7.53,percent of total billed charges,12.84% of total billed charges,9.41,12.84,,7.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.63,65,,38.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,100,,,Fee Schedule,100% of Custom Fee Schedule,65.95,90,,52.76,percent of total billed charges,90% of total billed charges for outpatient setting,0.51,65.95,
NM ADENOSINE INJ:30 MG DIAGNOSTIC,3303275,CDM,636,RC,J0152,HCPCS,Outpatient,,,359.26,359.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.48,70,,201.18,percent of total billed charges,70% of total billed charges for outpatient setting,304.94,84.88,,243.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.63,50,,143.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.45,75,,215.56,percent of total billed charges,75% of total billed charges for outpatient setting,251.48,70,,201.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.13,12.84,,36.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.41,80,,229.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.13,12.84,,36.9,percent of total billed charges,12.84% of total billed charges,46.13,12.84,,36.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,233.52,65,,186.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.74,35,,100.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,323.33,90,,258.66,percent of total billed charges,90% of total billed charges for outpatient setting,46.13,323.33,
NM ADRENAL IMAGING,3000515,CDM,341,RC,78075,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1376.85,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM BONE SCAN 3 PHASE,3000395,CDM,341,RC,78315,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.35,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM BONE SCAN LIMITED,3000391,CDM,341,RC,78300,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.35,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM BONE SCAN SPECT,3000400,CDM,341,RC,78803,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM BONE SCAN WHOLE BODY,3000390,CDM,341,RC,78306,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.35,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM BRAIN SCAN W/VASCULAR FLOW,3000005,CDM,341,RC,78606,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,634.26,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM BRAIN SPECT,3000162,CDM,341,RC,78803,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM CARDIAC SHUNT DETECTION,3000425,CDM,341,RC,78428,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM CARDIAC STRESS TEST,3000826,CDM,482,RC,93017,HCPCS,Outpatient,,,819.89,819.89,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,695.92,84.88,,556.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,614.92,75,,491.94,percent of total billed charges,75% of total billed charges for outpatient setting,573.92,70,,459.14,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,105.27,12.84,,84.216,percent of total billed charges,12.84% of total billed charges,415.02,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,655.91,80,,524.73,percent of total billed charges,80% of total billed charges for outpatient setting,332.02,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,105.27,12.84,,84.22,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,354,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,290.51,100,,,Fee Schedule,100% of Custom Fee Schedule,737.9,90,,590.32,percent of total billed charges,90% of total billed charges for outpatient setting,105.27,737.9,
NM CSF IMAGING SHUNT EVALUATION,3000025,CDM,341,RC,78645,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,634.26,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM CSF IMAGING SPEC,3000030,CDM,341,RC,78647,HCPCS,Outpatient,,,1755.61,1316.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.93,70,,983.14,percent of total billed charges,70% of total billed charges for outpatient setting,1490.16,84.88,,1192.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,877.81,50,,702.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.71,75,,1053.37,percent of total billed charges,75% of total billed charges for outpatient setting,1228.93,70,,983.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.42,12.84,,180.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.49,80,,1123.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.42,12.84,,180.34,percent of total billed charges,12.84% of total billed charges,225.42,12.84,,180.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.26,100,,,Fee Schedule,100% of Custom Fee Schedule,1580.05,90,,1264.04,percent of total billed charges,90% of total billed charges for outpatient setting,225.42,1580.05,
NM CSF LEAK,3000035,CDM,341,RC,78650,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,634.26,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM DACRYOCYSTOGRAPHY,3000040,CDM,341,RC,78660,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193.52,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM DMSA RENAL SCAN,3000050,CDM,341,RC,78700,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM DMSA RENAL SCAN,3000900,CDM,341,RC,78700,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM DVT IMAGING PEPTIDE,3000440,CDM,341,RC,78456,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,878.73,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM ESOPHAGEAL MOTILITY,3000310,CDM,341,RC,78258,HCPCS,Outpatient,,,811.23,608.42,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,688.57,84.88,,550.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,608.42,75,,486.74,percent of total billed charges,75% of total billed charges for outpatient setting,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,104.16,12.84,,83.328,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,648.98,80,,519.18,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,730.11,90,,584.09,percent of total billed charges,90% of total billed charges for outpatient setting,104.16,774,
NM FIRST PASS,3000154,CDM,341,RC,78481,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM GA67 PER MCI,3000690,CDM,343,RC,A9556,HCPCS,Outpatient,,,112.81,84.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.97,70,,63.18,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,84.88,,76.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,145.77,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,84.61,75,,67.69,percent of total billed charges,75% of total billed charges for outpatient setting,78.97,70,,63.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.48,12.84,,11.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.25,80,,72.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.48,12.84,,11.58,percent of total billed charges,12.84% of total billed charges,14.48,12.84,,11.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.33,65,,58.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.53,90,,81.22,percent of total billed charges,90% of total billed charges for outpatient setting,14.48,145.77,
NM GASTRIC EMPTYING,3000325,CDM,341,RC,78264,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM GASTRIC EMPTYING DRP,2500002,CDM,341,RC,78264,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM GE REFLUX STUDY,3000320,CDM,341,RC,78262,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM GI BLEEDING SCAN,3000355,CDM,341,RC,78278,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM HEPATOBIL SCAN W/CCK,3000291,CDM,341,RC,78227,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.2,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM HEPATOBILIARY SCAN,3000290,CDM,341,RC,78226,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.2,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM I123 CAPSULE/100uCi,3000545,CDM,343,RC,,,Outpatient,,,151.55,113.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.09,70,,84.87,percent of total billed charges,70% of total billed charges for outpatient setting,128.64,84.88,,102.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.78,50,,60.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.66,75,,90.93,percent of total billed charges,75% of total billed charges for outpatient setting,106.09,70,,84.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.46,12.84,,15.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.24,80,,96.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.46,12.84,,15.57,percent of total billed charges,12.84% of total billed charges,19.46,12.84,,15.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.51,65,,78.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.04,35,,42.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.4,90,,109.12,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,136.4,
NM I131 MIBG 0.5/mCi,3000660,CDM,343,RC,A9508,HCPCS,Outpatient,,,2294.71,1721.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1606.3,70,,1285.04,percent of total billed charges,70% of total billed charges for outpatient setting,1947.75,84.88,,1558.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,842.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1721.03,75,,1376.82,percent of total billed charges,75% of total billed charges for outpatient setting,1606.3,70,,1285.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.64,12.84,,235.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1835.77,80,,1468.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.64,12.84,,235.71,percent of total billed charges,12.84% of total billed charges,294.64,12.84,,235.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1491.56,65,,1193.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2065.24,90,,1652.19,percent of total billed charges,90% of total billed charges for outpatient setting,294.64,2065.24,
NM I131 THERAPY CAPSULE (1-5mCi),3000600,CDM,343,RC,,,Outpatient,,,883.96,662.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.77,70,,495.02,percent of total billed charges,70% of total billed charges for outpatient setting,750.31,84.88,,600.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,441.98,50,,353.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.97,75,,530.38,percent of total billed charges,75% of total billed charges for outpatient setting,618.77,70,,495.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,12.84,,90.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.17,80,,565.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,12.84,,90.8,percent of total billed charges,12.84% of total billed charges,113.5,12.84,,90.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,574.57,65,,459.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.39,35,,247.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,795.56,90,,636.45,percent of total billed charges,90% of total billed charges for outpatient setting,113.5,795.56,
NM IN111 OXYQUINOLINE/0.5mCi,3000555,CDM,343,RC,,,Outpatient,,,2235.36,1676.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1564.75,70,,1251.8,percent of total billed charges,70% of total billed charges for outpatient setting,1897.37,84.88,,1517.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,1117.68,50,,894.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1676.52,75,,1341.22,percent of total billed charges,75% of total billed charges for outpatient setting,1564.75,70,,1251.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.02,12.84,,229.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1788.29,80,,1430.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.02,12.84,,229.62,percent of total billed charges,12.84% of total billed charges,287.02,12.84,,229.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1452.98,65,,1162.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.38,35,,625.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2011.82,90,,1609.46,percent of total billed charges,90% of total billed charges for outpatient setting,287.02,2011.82,
NM IN111 PENTATE/0.5mCi,3000560,CDM,343,RC,,,Outpatient,,,5343.71,4007.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3740.6,70,,2992.48,percent of total billed charges,70% of total billed charges for outpatient setting,4535.74,84.88,,3628.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,2671.86,50,,2137.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4007.78,75,,3206.22,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.13,12.84,,548.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4274.97,80,,3419.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.13,12.84,,548.9,percent of total billed charges,12.84% of total billed charges,686.13,12.84,,548.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3473.41,65,,2778.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1870.3,35,,1496.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4809.34,90,,3847.47,percent of total billed charges,90% of total billed charges for outpatient setting,686.13,4809.34,
NM IN111 PENTETREOTIDE/3.0mCi,3000720,CDM,343,RC,A9572,HCPCS,Outpatient,,,3156.49,2367.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2209.54,70,,1767.63,percent of total billed charges,70% of total billed charges for outpatient setting,2679.23,84.88,,2143.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,5398.2,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2367.37,75,,1893.9,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.29,12.84,,324.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.19,80,,2020.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.29,12.84,,324.23,percent of total billed charges,12.84% of total billed charges,405.29,12.84,,324.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2051.72,65,,1641.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2840.84,90,,2272.67,percent of total billed charges,90% of total billed charges for outpatient setting,405.29,5398.2,
NM IN111 PROSTASCINT/DOSE; UP TO 10mCi,3000655,CDM,343,RC,A9507,HCPCS,Outpatient,,,5222.81,3917.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3655.97,70,,2924.78,percent of total billed charges,70% of total billed charges for outpatient setting,4433.12,84.88,,3546.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4747.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3917.11,75,,3133.69,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.61,12.84,,536.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4178.25,80,,3342.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.61,12.84,,536.49,percent of total billed charges,12.84% of total billed charges,670.61,12.84,,536.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3394.83,65,,2715.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4700.53,90,,3760.42,percent of total billed charges,90% of total billed charges for outpatient setting,670.61,4747.69,
NM IN111 SATUMAMABPENDETIDE,3000535,CDM,343,RC,,,Outpatient,,,115.62,86.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.93,70,,64.74,percent of total billed charges,70% of total billed charges for outpatient setting,98.14,84.88,,78.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.81,50,,46.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.72,75,,69.38,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,70,,64.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.5,80,,74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.15,65,,60.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.47,35,,32.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.06,90,,83.25,percent of total billed charges,90% of total billed charges for outpatient setting,14.85,104.06,
NM IN131 THERAPY CAPSULE (EA ADD'L),3000525,CDM,343,RC,,,Outpatient,,,115.62,86.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.93,70,,64.74,percent of total billed charges,70% of total billed charges for outpatient setting,98.14,84.88,,78.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.81,50,,46.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.72,75,,69.38,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,70,,64.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.5,80,,74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,14.85,12.84,,11.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.15,65,,60.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.47,35,,32.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.06,90,,83.25,percent of total billed charges,90% of total billed charges for outpatient setting,14.85,104.06,
NM INFLAMMATORY LOCALIZATION SPECT (WBC),3000150,CDM,341,RC,78807,HCPCS,Outpatient,,,1017.72,763.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.4,70,,569.92,percent of total billed charges,70% of total billed charges for outpatient setting,863.84,84.88,,691.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,508.86,50,,407.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,763.29,75,,610.63,percent of total billed charges,75% of total billed charges for outpatient setting,712.4,70,,569.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.68,12.84,,104.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.18,80,,651.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.68,12.84,,104.54,percent of total billed charges,12.84% of total billed charges,130.68,12.84,,104.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,915.95,90,,732.76,percent of total billed charges,90% of total billed charges for outpatient setting,130.68,915.95,
NM INFLAMMATORY LOCALIZATION WHOLE BODY,3000145,CDM,341,RC,78806,HCPCS,Outpatient,,,1755.61,1316.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.93,70,,983.14,percent of total billed charges,70% of total billed charges for outpatient setting,1490.16,84.88,,1192.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,877.81,50,,702.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.71,75,,1053.37,percent of total billed charges,75% of total billed charges for outpatient setting,1228.93,70,,983.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.42,12.84,,180.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.49,80,,1123.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.42,12.84,,180.34,percent of total billed charges,12.84% of total billed charges,225.42,12.84,,180.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,1580.05,90,,1264.04,percent of total billed charges,90% of total billed charges for outpatient setting,225.42,1580.05,
NM LEVEEN SHUNT PATENCY,3000370,CDM,341,RC,78291,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM LIVER AND SPLEEN SCAN,3000275,CDM,341,RC,78215,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.2,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM LIVER IMAGING W/VASCULAR AND SPECT,3000270,CDM,341,RC,78803,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM LIVER IMAGING W/VASCULAR FLOW,3000260,CDM,341,RC,78202,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.2,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1672.69,
NM LIVER SPECT,3000265,CDM,341,RC,78803,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM LUNG PERFUSION ONLY,3000156,CDM,341,RC,78580,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,364.02,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM LUNG SCAN QUANT DIFF PERF / VENT,3000163,CDM,341,RC,78598,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,512.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM LUNG SCAN QUANT DIFF PULM PERFUSION,3000161,CDM,341,RC,78597,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,364.02,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM LUNG VENT (AERESOL OR GAS) AND PERF,3000160,CDM,341,RC,78582,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,512.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM LUNG VENT ONLY (AEROSOL OR GAS),3000158,CDM,341,RC,78579,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,364.02,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM LYMPHOSCINTIGRAPHY,3000245,CDM,341,RC,78195,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,412,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM MECKEL'S DIVERTICULUM STUDY,3000365,CDM,341,RC,78290,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM MUGA SCAN,3000153,CDM,341,RC,78472,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM MYOCARD PERF EF/WM MULTIPLE,3000499,CDM,341,RC,78452,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARD PERF WM/EF SINGLE,3000148,CDM,341,RC,78451,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARD PERF. EF/WM MULTI-SAMP,3000911,CDM,341,RC,78452,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARD PERF. EF/WM SINGLE-SAMP,3000913,CDM,341,RC,78451,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARD PERFUSION EF/WM SINGLE,3000147,CDM,341,RC,78451,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARD PERFUSION EF/WM SINGLE-SAMP,3000912,CDM,341,RC,78451,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1372.33,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM MYOCARDIAL INFARCT PLANAR,3000151,CDM,341,RC,78466,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM MYOCARDIAL INFARCT PLANAR / SPECT,3000152,CDM,341,RC,78469,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1672.69,
NM NON-CARDIAC VASCULAR FLOW,3000430,CDM,341,RC,78445,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM OCTREATIDE ACETATE 1MG,3000620,CDM,343,RC,,,Outpatient,,,974.87,731.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.41,70,,545.93,percent of total billed charges,70% of total billed charges for outpatient setting,827.47,84.88,,661.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,487.44,50,,389.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,731.15,75,,584.92,percent of total billed charges,75% of total billed charges for outpatient setting,682.41,70,,545.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.17,12.84,,100.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.9,80,,623.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.17,12.84,,100.14,percent of total billed charges,12.84% of total billed charges,125.17,12.84,,100.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,633.67,65,,506.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.2,35,,272.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,877.38,90,,701.9,percent of total billed charges,90% of total billed charges for outpatient setting,125.17,877.38,
NM PARATHYROID,3000510,CDM,341,RC,78070,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,341.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM PARATHYROID W/ SPECT,3000511,CDM,341,RC,78071,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,878.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM RADIOPHARMACEUTICAL VOIDING CYSTOGRAM,3000100,CDM,341,RC,78740,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM RENOGRAM TRIPLE RENAL SCAN,3000065,CDM,341,RC,78707,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM RENOGRAM W/RX,3000070,CDM,341,RC,78708,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM RENOGRAM WO AND W RX,3000910,CDM,341,RC,78709,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM SALIVARY GLAND IMAGING,3000295,CDM,341,RC,78230,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM SENT NODE INJ ONLY BILAT,3000140,CDM,341,RC,38792,HCPCS,Outpatient,,,1256.97,942.73,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.88,70,,703.9,percent of total billed charges,70% of total billed charges for outpatient setting,1066.92,84.88,,853.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,628.49,50,,502.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,942.73,75,,754.18,percent of total billed charges,75% of total billed charges for outpatient setting,879.88,70,,703.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.39,12.84,,129.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1005.58,80,,804.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.39,12.84,,129.11,percent of total billed charges,12.84% of total billed charges,161.39,12.84,,129.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.94,35,,351.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1131.27,90,,905.02,percent of total billed charges,90% of total billed charges for outpatient setting,161.39,1131.27,
NM SENT NODE INJ ONLY BILAT,3000198,CDM,341,RC,38792,HCPCS,Outpatient,,,2542.68,1907.01,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1779.88,70,,1423.9,percent of total billed charges,70% of total billed charges for outpatient setting,2158.23,84.88,,1726.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1271.34,50,,1017.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1907.01,75,,1525.61,percent of total billed charges,75% of total billed charges for outpatient setting,1779.88,70,,1423.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.48,12.84,,261.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.14,80,,1627.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.48,12.84,,261.18,percent of total billed charges,12.84% of total billed charges,326.48,12.84,,261.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.94,35,,711.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2288.41,90,,1830.73,percent of total billed charges,90% of total billed charges for outpatient setting,326.48,2288.41,
NM SENTINEL NODE INJECTION ONLY,3000146,CDM,341,RC,38792,HCPCS,Outpatient,,,1143.45,857.59,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,800.42,70,,640.34,percent of total billed charges,70% of total billed charges for outpatient setting,970.56,84.88,,776.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,50,,388.8,percent of total billed charges,50% of total Billed charges for outpatient setting,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,857.59,75,,686.07,percent of total billed charges,75% of total billed charges for outpatient setting,800.42,70,,640.34,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.26,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.82,12.84,,117.456,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,914.76,80,,731.81,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.82,12.84,,117.46,percent of total billed charges,12.84% of total billed charges,146.82,12.84,,117.46,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.23,100,,,Fee Schedule,100% of Custom Fee Schedule,1029.11,90,,823.29,percent of total billed charges,90% of total billed charges for outpatient setting,146.82,1029.11,
NM SODIUM P32/mCi,3000715,CDM,343,RC,A9563,HCPCS,Outpatient,,,916.68,687.51,,733.34,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.68,70,,513.34,percent of total billed charges,70% of total billed charges for outpatient setting,778.08,84.88,,622.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,347.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,687.51,75,,550.01,percent of total billed charges,75% of total billed charges for outpatient setting,641.68,70,,513.34,percent of total billed charges,70% of total billed charges for outpatient setting,779.17,170,,,Fee Schedule,170% of Medicare OPPS rate,985.43,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,117.7,12.84,,94.16,percent of total billed charges,12.84% of total billed charges,802.09,175,,,Fee Schedule,175% of Medicare OPPS rate,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,733.34,80,,586.67,percent of total billed charges,80% of total billed charges for outpatient setting,641.66,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,572.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,117.7,12.84,,94.16,percent of total billed charges,12.84% of total billed charges,117.7,12.84,,94.16,percent of total billed charges,12.84% of total billed charges,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,595.84,65,,476.67,percent of total billed charges,65% of total billed charges for outpatient setting,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,458.34,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,265.36,100,,,Fee Schedule,100% of Custom Fee Schedule,825.01,90,,660.01,percent of total billed charges,90% of total billed charges for outpatient setting,117.7,985.43,
NM TC99 ACUTECT; UP TO 20mCi,3000645,CDM,636,RC,A9504,HCPCS,Outpatient,,,2199.1,2199.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1539.37,70,,1231.5,percent of total billed charges,70% of total billed charges for outpatient setting,1866.6,84.88,,1493.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,1099.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1649.33,75,,1319.46,percent of total billed charges,75% of total billed charges for outpatient setting,1539.37,70,,1231.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.36,12.84,,225.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1759.28,80,,1407.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.36,12.84,,225.89,percent of total billed charges,12.84% of total billed charges,282.36,12.84,,225.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1429.42,65,,1143.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.69,35,,615.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1979.19,90,,1583.35,percent of total billed charges,90% of total billed charges for outpatient setting,282.36,1979.19,
NM TC99 ARCITUMOMAB; up to 40mCi,3000595,CDM,343,RC,A9568,HCPCS,Outpatient,,,5717.74,4288.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4002.42,70,,3201.94,percent of total billed charges,70% of total billed charges for outpatient setting,4853.22,84.88,,3882.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,2858.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,4288.31,75,,3430.65,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.16,12.84,,587.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4574.19,80,,3659.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.16,12.84,,587.33,percent of total billed charges,12.84% of total billed charges,734.16,12.84,,587.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3716.53,65,,2973.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2001.21,35,,1600.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5145.97,90,,4116.78,percent of total billed charges,90% of total billed charges for outpatient setting,734.16,5145.97,
NM TC99 BICISATE; UP TO 25mCi,3000695,CDM,343,RC,A9557,HCPCS,Outpatient,,,1781.35,1336.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246.95,70,,997.56,percent of total billed charges,70% of total billed charges for outpatient setting,1512.01,84.88,,1209.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,401.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1336.01,75,,1068.81,percent of total billed charges,75% of total billed charges for outpatient setting,1246.95,70,,997.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.73,12.84,,182.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.08,80,,1140.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.73,12.84,,182.98,percent of total billed charges,12.84% of total billed charges,228.73,12.84,,182.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1157.88,65,,926.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.22,90,,1282.58,percent of total billed charges,90% of total billed charges for outpatient setting,228.73,1603.22,
NM TC99 DEPREOTIDE (NEOTECT);up to 35mCi,3000670,CDM,343,RC,A9536,HCPCS,Outpatient,,,894.26,670.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.98,70,,500.78,percent of total billed charges,70% of total billed charges for outpatient setting,759.05,84.88,,607.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,447.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,670.7,75,,536.56,percent of total billed charges,75% of total billed charges for outpatient setting,625.98,70,,500.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.82,12.84,,91.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.41,80,,572.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.82,12.84,,91.86,percent of total billed charges,12.84% of total billed charges,114.82,12.84,,91.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,581.27,65,,465.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.99,35,,250.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,804.83,90,,643.86,percent of total billed charges,90% of total billed charges for outpatient setting,114.82,804.83,
NM TC99 DISOFENIN (HEPATOLITE); UP TO 15,3000665,CDM,343,RC,A9510,HCPCS,Outpatient,,,395.89,296.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.12,70,,221.7,percent of total billed charges,70% of total billed charges for outpatient setting,336.03,84.88,,268.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,296.92,75,,237.54,percent of total billed charges,75% of total billed charges for outpatient setting,277.12,70,,221.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,12.84,,40.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.71,80,,253.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,12.84,,40.66,percent of total billed charges,12.84% of total billed charges,50.83,12.84,,40.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.33,65,,205.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.3,90,,285.04,percent of total billed charges,90% of total billed charges for outpatient setting,50.83,356.3,
NM TC99 DTPA; UP TO 25mCi,3000585,CDM,343,RC,A9539,HCPCS,Outpatient,,,210.6,157.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.42,70,,117.94,percent of total billed charges,70% of total billed charges for outpatient setting,178.76,84.88,,143.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,157.95,75,,126.36,percent of total billed charges,75% of total billed charges for outpatient setting,147.42,70,,117.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.04,12.84,,21.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.48,80,,134.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.04,12.84,,21.63,percent of total billed charges,12.84% of total billed charges,27.04,12.84,,21.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.89,65,,109.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.54,90,,151.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.34,189.54,
NM TC99 EXAMETAZIME; up to 25mCi,3000575,CDM,343,RC,A9521,HCPCS,Outpatient,,,1958.51,1468.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1370.96,70,,1096.77,percent of total billed charges,70% of total billed charges for outpatient setting,1662.38,84.88,,1329.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,1572.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1468.88,75,,1175.1,percent of total billed charges,75% of total billed charges for outpatient setting,1370.96,70,,1096.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.47,12.84,,201.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1566.81,80,,1253.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.47,12.84,,201.18,percent of total billed charges,12.84% of total billed charges,251.47,12.84,,201.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1273.03,65,,1018.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1762.66,90,,1410.13,percent of total billed charges,90% of total billed charges for outpatient setting,251.47,1762.66,
NM TC99 GLUCEPATATE/up to 25mCi,3000710,CDM,343,RC,A9550,HCPCS,Outpatient,,,104.67,78.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.27,70,,58.62,percent of total billed charges,70% of total billed charges for outpatient setting,88.84,84.88,,71.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.5,75,,62.8,percent of total billed charges,75% of total billed charges for outpatient setting,73.27,70,,58.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,12.84,,10.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.74,80,,66.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,12.84,,10.75,percent of total billed charges,12.84% of total billed charges,13.44,12.84,,10.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.04,65,,54.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.63,35,,29.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.2,90,,75.36,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,94.2,
NM TC99 GLUCOHEPTONATE; up to 25mCi,3000605,CDM,343,RC,A9550,HCPCS,Outpatient,,,497.13,372.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.99,70,,278.39,percent of total billed charges,70% of total billed charges for outpatient setting,421.96,84.88,,337.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,248.57,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,372.85,75,,298.28,percent of total billed charges,75% of total billed charges for outpatient setting,347.99,70,,278.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.83,12.84,,51.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.7,80,,318.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.83,12.84,,51.06,percent of total billed charges,12.84% of total billed charges,63.83,12.84,,51.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323.13,65,,258.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174,35,,139.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,447.42,90,,357.94,percent of total billed charges,90% of total billed charges for outpatient setting,63.83,447.42,
NM TC99 LABELED RBC'S/ UP TO 30mCi,3000735,CDM,343,RC,A9560,HCPCS,Outpatient,,,682.28,511.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.6,70,,382.08,percent of total billed charges,70% of total billed charges for outpatient setting,579.12,84.88,,463.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,511.71,75,,409.37,percent of total billed charges,75% of total billed charges for outpatient setting,477.6,70,,382.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.82,80,,436.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,87.6,12.84,,70.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,443.48,65,,354.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.05,90,,491.24,percent of total billed charges,90% of total billed charges for outpatient setting,87.6,614.05,
NM TC99 MAA / up to 10mCi,3000565,CDM,343,RC,A9540,HCPCS,Outpatient,,,38.45,28.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,70,,21.54,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,84.88,,26.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,28.84,75,,23.07,percent of total billed charges,75% of total billed charges for outpatient setting,26.92,70,,21.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.76,80,,24.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,4.94,12.84,,3.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.99,65,,19.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.61,90,,27.69,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,34.61,
NM TC99 MAG3; up to 15mCi,3000834,CDM,343,RC,A9562,HCPCS,Outpatient,,,1394.48,1045.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,976.14,70,,780.91,percent of total billed charges,70% of total billed charges for outpatient setting,1183.63,84.88,,946.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,836.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1045.86,75,,836.69,percent of total billed charges,75% of total billed charges for outpatient setting,976.14,70,,780.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.58,80,,892.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,906.41,65,,725.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1255.03,90,,1004.02,percent of total billed charges,90% of total billed charges for outpatient setting,179.05,1255.03,
NM TC99 MDP/DOSE; UP TO 30mCi,3000640,CDM,636,RC,A9503,HCPCS,Outpatient,,,105.3,105.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.71,70,,58.97,percent of total billed charges,70% of total billed charges for outpatient setting,89.38,84.88,,71.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,78.98,75,,63.18,percent of total billed charges,75% of total billed charges for outpatient setting,73.71,70,,58.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.52,12.84,,10.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,80,,67.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.52,12.84,,10.82,percent of total billed charges,12.84% of total billed charges,13.52,12.84,,10.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.45,65,,54.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.77,90,,75.82,percent of total billed charges,90% of total billed charges for outpatient setting,13.52,94.77,
NM TC99 MEBROFENIN (CHOLETEC); 15mCi,3000580,CDM,343,RC,A9537,HCPCS,Outpatient,,,238.09,178.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.66,70,,133.33,percent of total billed charges,70% of total billed charges for outpatient setting,202.09,84.88,,161.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,178.57,75,,142.86,percent of total billed charges,75% of total billed charges for outpatient setting,166.66,70,,133.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,12.84,,24.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.47,80,,152.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,12.84,,24.46,percent of total billed charges,12.84% of total billed charges,30.57,12.84,,24.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.76,65,,123.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.28,90,,171.42,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,214.28,
NM TC99 MERTIATIDE/up to 15mCi,3000705,CDM,343,RC,A9562,HCPCS,Outpatient,,,1394.48,1045.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,976.14,70,,780.91,percent of total billed charges,70% of total billed charges for outpatient setting,1183.63,84.88,,946.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,836.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1045.86,75,,836.69,percent of total billed charges,75% of total billed charges for outpatient setting,976.14,70,,780.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.58,80,,892.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,179.05,12.84,,143.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,906.41,65,,725.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1255.03,90,,1004.02,percent of total billed charges,90% of total billed charges for outpatient setting,179.05,1255.03,
NM TC99 MYOVIEW/ PER STUDY DOSE,3000635,CDM,636,RC,A9502,HCPCS,Outpatient,,,738.98,738.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.29,70,,413.83,percent of total billed charges,70% of total billed charges for outpatient setting,627.25,84.88,,501.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,554.24,75,,443.39,percent of total billed charges,75% of total billed charges for outpatient setting,517.29,70,,413.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.89,12.84,,75.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.18,80,,472.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.89,12.84,,75.91,percent of total billed charges,12.84% of total billed charges,94.89,12.84,,75.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480.34,65,,384.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.08,90,,532.06,percent of total billed charges,90% of total billed charges for outpatient setting,94.89,665.08,
NM TC99 OXIDRONATE/up to 30mCi,3000725,CDM,343,RC,A9561,HCPCS,Outpatient,,,169.98,127.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.99,70,,95.19,percent of total billed charges,70% of total billed charges for outpatient setting,144.28,84.88,,115.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.49,75,,101.99,percent of total billed charges,75% of total billed charges for outpatient setting,118.99,70,,95.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,12.84,,17.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.98,80,,108.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,12.84,,17.46,percent of total billed charges,12.84% of total billed charges,21.83,12.84,,17.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.49,65,,88.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.98,90,,122.38,percent of total billed charges,90% of total billed charges for outpatient setting,21.83,152.98,
NM TC99 PERTECHNETATE; per 1mCi,3000586,CDM,255,RC,A9512,HCPCS,Outpatient,,,157.17,157.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.02,70,,88.02,percent of total billed charges,70% of total billed charges for outpatient setting,133.41,84.88,,106.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,117.88,75,,94.3,percent of total billed charges,75% of total billed charges for outpatient setting,110.02,70,,88.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.18,12.84,,16.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.74,80,,100.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.18,12.84,,16.14,percent of total billed charges,12.84% of total billed charges,20.18,12.84,,16.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.16,65,,81.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.01,35,,44.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.45,90,,113.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.21,141.45,
NM TC99 PYROPHOSPHATE; up to 25mCi,3000590,CDM,343,RC,A9538,HCPCS,Outpatient,,,197.8,148.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.46,70,,110.77,percent of total billed charges,70% of total billed charges for outpatient setting,167.89,84.88,,134.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,148.35,75,,118.68,percent of total billed charges,75% of total billed charges for outpatient setting,138.46,70,,110.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.4,12.84,,20.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.24,80,,126.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.4,12.84,,20.32,percent of total billed charges,12.84% of total billed charges,25.4,12.84,,20.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128.57,65,,102.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.02,90,,142.42,percent of total billed charges,90% of total billed charges for outpatient setting,17.3,178.02,
NM TC99 SESTAMIBI/per study dose,3000630,CDM,636,RC,A9500,HCPCS,Outpatient,,,536.5,536.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.55,70,,300.44,percent of total billed charges,70% of total billed charges for outpatient setting,455.38,84.88,,364.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,402.38,75,,321.9,percent of total billed charges,75% of total billed charges for outpatient setting,375.55,70,,300.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,12.84,,55.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.2,80,,343.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,12.84,,55.11,percent of total billed charges,12.84% of total billed charges,68.89,12.84,,55.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,348.73,65,,278.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.85,90,,386.28,percent of total billed charges,90% of total billed charges for outpatient setting,68.89,482.85,
NM TC99 SUCCIMER; up to 10mCi,3000610,CDM,343,RC,A9551,HCPCS,Outpatient,,,632.74,474.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.92,70,,354.34,percent of total billed charges,70% of total billed charges for outpatient setting,537.07,84.88,,429.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,647.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,474.56,75,,379.65,percent of total billed charges,75% of total billed charges for outpatient setting,442.92,70,,354.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.24,12.84,,64.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.19,80,,404.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.24,12.84,,64.99,percent of total billed charges,12.84% of total billed charges,81.24,12.84,,64.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,411.28,65,,329.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.47,90,,455.58,percent of total billed charges,90% of total billed charges for outpatient setting,81.24,647.37,
NM TC99 SULFUR COLLOID; up to 20mCi,3000615,CDM,343,RC,A9541,HCPCS,Outpatient,,,239.97,179.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.98,70,,134.38,percent of total billed charges,70% of total billed charges for outpatient setting,203.69,84.88,,162.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,179.98,75,,143.98,percent of total billed charges,75% of total billed charges for outpatient setting,167.98,70,,134.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.81,12.84,,24.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.98,80,,153.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.81,12.84,,24.65,percent of total billed charges,12.84% of total billed charges,30.81,12.84,,24.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.98,65,,124.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.97,90,,172.78,percent of total billed charges,90% of total billed charges for outpatient setting,30.81,215.97,
NM TC99 TILMANOCEPT (LYMPHOSEEK) 0.5 mCi,3000582,CDM,636,RC,A9520,HCPCS,Outpatient,,,806.26,806.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.38,70,,451.5,percent of total billed charges,70% of total billed charges for outpatient setting,684.35,84.88,,547.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,507.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,604.7,75,,483.76,percent of total billed charges,75% of total billed charges for outpatient setting,564.38,70,,451.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.52,12.84,,82.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.01,80,,516.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.52,12.84,,82.82,percent of total billed charges,12.84% of total billed charges,103.52,12.84,,82.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,524.07,65,,419.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.5,100,,,Fee Schedule,100% of Custom Fee Schedule,725.63,90,,580.5,percent of total billed charges,90% of total billed charges for outpatient setting,103.52,725.63,
NM TESTICULAR W/FLOW,3000110,CDM,341,RC,78761,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM THALLIUM 201/mCi; PER mCi,3000650,CDM,636,RC,A9505,HCPCS,Outpatient,,,136.24,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.37,70,,76.3,percent of total billed charges,70% of total billed charges for outpatient setting,115.64,84.88,,92.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,102.18,75,,81.74,percent of total billed charges,75% of total billed charges for outpatient setting,95.37,70,,76.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,12.84,,13.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.99,80,,87.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.49,12.84,,13.99,percent of total billed charges,12.84% of total billed charges,17.49,12.84,,13.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.56,65,,70.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.62,90,,98.1,percent of total billed charges,90% of total billed charges for outpatient setting,17.49,173.75,
NM THYROID CA WHOLE BODY SCAN,3000500,CDM,341,RC,78018,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM THYROID SCAN ONLY,3000480,CDM,341,RC,78013,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,218.17,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM THYROID UPTAKE W/SCAN MULTIPLE,3000475,CDM,341,RC,78014,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,341.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM THYROID UPTAKE W/SCAN SINGLE,3000470,CDM,341,RC,78014,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,341.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM TRIPLE RENAL RENOGRAM WO RX,3000905,CDM,341,RC,78707,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,496.08,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM TUMOR LOCALIZATION (SPECT),3000135,CDM,341,RC,78803,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM TUMOR LOCALIZATION WHOLE BODY-GALLIUM,3000130,CDM,341,RC,78802,HCPCS,Outpatient,,,4048.9,3036.68,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2834.23,70,,2267.38,percent of total billed charges,70% of total billed charges for outpatient setting,3436.71,84.88,,2749.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3036.68,75,,2429.34,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,519.88,12.84,,415.904,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3239.12,80,,2591.3,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,519.88,12.84,,415.9,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,781.52,100,,,Fee Schedule,100% of Custom Fee Schedule,3644.01,90,,2915.21,percent of total billed charges,90% of total billed charges for outpatient setting,519.88,3644.01,
NM UREA BREATH TEST ACQUISITION,3000330,CDM,310,RC,78267,HCPCS,Outpatient,,,21.78,19.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.25,70,,12.2,percent of total billed charges,70% of total billed charges for outpatient setting,18.49,84.88,,14.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.34,75,,13.07,percent of total billed charges,75% of total billed charges for outpatient setting,15.25,70,,12.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.42,80,,13.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,100,,,Fee Schedule,100% of Custom Fee Schedule,19.6,90,,15.68,percent of total billed charges,90% of total billed charges for outpatient setting,10.83,19.6,
NM UREA BREATH TEST ANALYSIS,3000335,CDM,310,RC,78268,HCPCS,Outpatient,,,185.87,167.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.11,70,,104.09,percent of total billed charges,70% of total billed charges for outpatient setting,157.77,84.88,,126.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,139.4,75,,111.52,percent of total billed charges,75% of total billed charges for outpatient setting,130.11,70,,104.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.7,80,,118.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.88,100,,,Fee Schedule,100% of Custom Fee Schedule,167.28,90,,133.82,percent of total billed charges,90% of total billed charges for outpatient setting,39.84,167.28,
NM VENOGRAM BILATERAL,3000450,CDM,341,RC,78458,HCPCS,Outpatient,,,1169.21,876.91,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,992.43,84.88,,793.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,876.91,75,,701.53,percent of total billed charges,75% of total billed charges for outpatient setting,818.45,70,,654.76,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,150.13,12.84,,120.104,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,935.37,80,,748.3,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,150.13,12.84,,120.1,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,1052.29,90,,841.83,percent of total billed charges,90% of total billed charges for outpatient setting,150.13,1052.29,
NM VENOGRAM UNILATERAL,3000445,CDM,341,RC,78457,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1672.69,
NM VQ LUNG SCAN AEROSOL,3000159,CDM,341,RC,78582,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,512.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM VQ LUNG SCN XENON,3000157,CDM,341,RC,78582,HCPCS,Outpatient,,,1517.32,1137.99,,701.62,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,1287.9,84.88,,1030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,630.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1137.99,75,,910.39,percent of total billed charges,75% of total billed charges for outpatient setting,1062.12,70,,849.7,percent of total billed charges,70% of total billed charges for outpatient setting,745.47,170,,,Fee Schedule,170% of Medicare OPPS rate,942.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,194.82,12.84,,155.856,percent of total billed charges,12.84% of total billed charges,767.4,175,,,Fee Schedule,175% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1213.86,80,,971.09,percent of total billed charges,80% of total billed charges for outpatient setting,613.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,548.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,194.82,12.84,,155.86,percent of total billed charges,12.84% of total billed charges,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,438.51,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,512.56,100,,,Fee Schedule,100% of Custom Fee Schedule,1365.59,90,,1092.47,percent of total billed charges,90% of total billed charges for outpatient setting,194.82,1365.59,
NM XE133/10mCi,3000700,CDM,343,RC,A9558,HCPCS,Outpatient,,,138.43,103.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.9,70,,77.52,percent of total billed charges,70% of total billed charges for outpatient setting,117.5,84.88,,94,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,103.82,75,,83.06,percent of total billed charges,75% of total billed charges for outpatient setting,96.9,70,,77.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.77,12.84,,14.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.74,80,,88.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.77,12.84,,14.22,percent of total billed charges,12.84% of total billed charges,17.77,12.84,,14.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.98,65,,71.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.59,90,,99.67,percent of total billed charges,90% of total billed charges for outpatient setting,17.77,240.28,
NO RINSE BODY WASH: 118 ML,3303776,CDM,259,RC,,,Outpatient,,,9.83,9.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,8.34,84.88,,6.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.92,50,,3.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.37,75,,5.9,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,80,,6.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.39,65,,5.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,35,,2.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.85,90,,7.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.26,8.85,
NON DEHP IV FAT EMULSION ADM SET:,3303268,CDM,259,RC,,,Outpatient,,,24.19,24.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,20.53,84.88,,16.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.1,50,,9.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.14,75,,14.51,percent of total billed charges,75% of total billed charges for outpatient setting,16.93,70,,13.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,80,,15.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.72,65,,12.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.47,35,,6.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.77,90,,17.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,21.77,
NOREPINEPHRINE (LEVOPHED) AMP :1MG/ML 4M,3301699,CDM,250,RC,,,Outpatient,,,32.42,32.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.69,70,,18.15,percent of total billed charges,70% of total billed charges for outpatient setting,27.52,84.88,,22.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.21,50,,12.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,75,,19.46,percent of total billed charges,75% of total billed charges for outpatient setting,22.69,70,,18.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.94,80,,20.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.07,65,,16.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.35,35,,9.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.18,90,,23.34,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,29.18,
NOREPINEPHRINE (LEVOPHED) AMP :1MG/ML 4M,3301698,CDM,250,RC,,,Outpatient,,,33.16,33.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.21,70,,18.57,percent of total billed charges,70% of total billed charges for outpatient setting,28.15,84.88,,22.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.58,50,,13.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.87,75,,19.9,percent of total billed charges,75% of total billed charges for outpatient setting,23.21,70,,18.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,12.84,,3.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.53,80,,21.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,12.84,,3.41,percent of total billed charges,12.84% of total billed charges,4.26,12.84,,3.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.55,65,,17.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,35,,9.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.84,90,,23.87,percent of total billed charges,90% of total billed charges for outpatient setting,4.26,29.84,
NORIAN DRILLABLE 5CC INJECT /07.704.005S,69169520,CDM,278,RC,C1713,HCPCS,Outpatient,,,3501,3501,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100.6,60,,1680.48,percent of total billed charges,60% of total Billed charges for outpatient setting,2971.65,84.88,,2377.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625.75,75,,2100.6,percent of total billed charges,75% of total billed charges for outpatient setting,1750.5,50,,1400.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.53,12.84,,359.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800.8,80,,2240.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.53,12.84,,359.62,percent of total billed charges,12.84% of total billed charges,449.53,12.84,,359.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3676.05,105,,2940.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225.35,35,,980.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2100.6,60,,1680.48,percent of total billed charges,60% of total billed charges for outpatient setting,449.53,3676.05,
NORIAN DRILLABLE INJECT 10CC/07.704.010S,69169307,CDM,278,RC,C1713,HCPCS,Outpatient,,,6880.5,6880.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4128.3,60,,3302.64,percent of total billed charges,60% of total Billed charges for outpatient setting,5840.17,84.88,,4672.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5160.38,75,,4128.3,percent of total billed charges,75% of total billed charges for outpatient setting,3440.25,50,,2752.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,12.84,,706.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5504.4,80,,4403.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,12.84,,706.77,percent of total billed charges,12.84% of total billed charges,883.46,12.84,,706.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7224.53,105,,5779.62,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2408.18,35,,1926.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4128.3,60,,3302.64,percent of total billed charges,60% of total billed charges for outpatient setting,883.46,7224.53,
NORMAL SALINE FLUSH 10 ML VIAL,3303031,CDM,272,RC,A4216,HCPCS,Outpatient,,,18.9,18.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,16.04,84.88,,12.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.18,75,,11.34,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,80,,12.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.29,65,,9.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.01,90,,13.61,percent of total billed charges,90% of total billed charges for outpatient setting,0.45,17.01,
NORMAL SALINE FLUSH SYRINGE 10ML,3302675,CDM,272,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NORTRIPTYLINE (PAMELOR) 25MG: CAP,3306215,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
NORTRIPTYLINE (PAMELOR) CAP : 25 MG,3301700,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NORTRIPTYLINE (PAMELOR) CAP : 25 MG,3301701,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NOVASURE DEVICE KIT /NS2000US,69162850,CDM,272,RC,,,Outpatient,,,2320,2320,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624,70,,1299.2,percent of total billed charges,70% of total billed charges for outpatient setting,1969.22,84.88,,1575.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1160,50,,928,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1740,75,,1392,percent of total billed charges,75% of total billed charges for outpatient setting,1624,70,,1299.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.89,12.84,,238.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856,80,,1484.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.89,12.84,,238.31,percent of total billed charges,12.84% of total billed charges,297.89,12.84,,238.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1508,65,,1206.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,812,35,,649.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2088,90,,1670.4,percent of total billed charges,90% of total billed charges for outpatient setting,297.89,2088,
NOVASURE STERLIZED DEVICE NS2013KIT,69161793,CDM,272,RC,,,Outpatient,,,4116.53,4116.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2881.57,70,,2305.26,percent of total billed charges,70% of total billed charges for outpatient setting,3494.11,84.88,,2795.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2058.27,50,,1646.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3087.4,75,,2469.92,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.56,12.84,,422.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3293.22,80,,2634.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.56,12.84,,422.85,percent of total billed charges,12.84% of total billed charges,528.56,12.84,,422.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2675.74,65,,2140.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.79,35,,1152.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3704.88,90,,2963.9,percent of total billed charges,90% of total billed charges for outpatient setting,528.56,3704.88,
NOVOLIN N  INSULIN10 ML,3303052,CDM,250,RC,,,Outpatient,,,72.81,72.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,70,,40.78,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,84.88,,49.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.41,50,,29.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.61,75,,43.69,percent of total billed charges,75% of total billed charges for outpatient setting,50.97,70,,40.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.35,12.84,,7.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,80,,46.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.35,12.84,,7.48,percent of total billed charges,12.84% of total billed charges,9.35,12.84,,7.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.33,65,,37.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.48,35,,20.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.53,90,,52.42,percent of total billed charges,90% of total billed charges for outpatient setting,9.35,65.53,
NOVOLOG INSULIN 10ML,3313155,CDM,636,RC,J1815,HCPCS,Outpatient,,,1185.41,1185.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,829.79,70,,663.83,percent of total billed charges,70% of total billed charges for outpatient setting,1006.18,84.88,,804.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,889.06,75,,711.25,percent of total billed charges,75% of total billed charges for outpatient setting,829.79,70,,663.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.21,12.84,,121.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.33,80,,758.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.21,12.84,,121.77,percent of total billed charges,12.84% of total billed charges,152.21,12.84,,121.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,770.52,65,,616.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,100,,,Fee Schedule,100% of Custom Fee Schedule,1066.87,90,,853.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,1066.87,
NOZIN NASAL SANITIZER 12ML BTL,70000365,CDM,270,RC,,,Outpatient,,,105.97,105.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.18,70,,59.34,percent of total billed charges,70% of total billed charges for outpatient setting,89.95,84.88,,71.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.99,50,,42.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.48,75,,63.58,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,70,,59.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.78,80,,67.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.88,65,,55.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.09,35,,29.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.37,90,,76.3,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,95.37,
NOZIN NASAL SANITIZER 250CT,70000041,CDM,270,RC,,,Outpatient,,,18.09,18.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,70,,10.13,percent of total billed charges,70% of total billed charges for outpatient setting,15.35,84.88,,12.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.05,50,,7.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.57,75,,10.86,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,70,,10.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,12.84,,1.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.47,80,,11.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,2.32,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.76,65,,9.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,35,,5.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.28,90,,13.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,16.28,
NR-ALPHA 1-ANTITRYPSIN,220398,CDM,301,RC,82103,HCPCS,Outpatient,,,60.48,54.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.34,70,,33.87,percent of total billed charges,70% of total billed charges for outpatient setting,51.34,84.88,,41.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.36,75,,36.29,percent of total billed charges,75% of total billed charges for outpatient setting,42.34,70,,33.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.38,80,,38.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.61,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.48,100,,,Fee Schedule,100% of Custom Fee Schedule,54.43,90,,43.54,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,54.43,
NS 0.45% SOLN 1000ML,3302489,CDM,258,RC,J7799,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.45% SOLN: 500ML,3302485,CDM,258,RC,,,Outpatient,,,151.22,151.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,128.36,84.88,,102.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.61,50,,60.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.42,75,,90.74,percent of total billed charges,75% of total billed charges for outpatient setting,105.85,70,,84.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.98,80,,96.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,19.42,12.84,,15.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.29,65,,78.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.1,90,,108.88,percent of total billed charges,90% of total billed charges for outpatient setting,19.42,136.1,
NS 0.45%/ KCL 20 MEQ SOLN 1000ML,3303362,CDM,636,RC,J3480,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,2.92,
NS 0.45%/ KCL 30 MEQ SOLN: 1000ML,3303363,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS 0.45%/ KCL 40 MEQ SOLN: 1000ML,3303364,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS 0.45%/KCL 10 MEQ SOLN 1000ML,3303361,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS 0.9 SOLN 50ML,3302476,CDM,272,RC,A4216,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.9% SOLN 1000ML,3302490,CDM,258,RC,J7030,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.9% SOLN 100ML,3302477,CDM,258,RC,J7050,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.9% SOLN 250ML,3302479,CDM,258,RC,J7050,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.9% SOLN 500ML,3302483,CDM,258,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
NS 0.9% SOLN: 150ML,3302481,CDM,258,RC,,,Outpatient,,,148.26,148.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,125.84,84.88,,100.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.13,50,,59.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.2,75,,88.96,percent of total billed charges,75% of total billed charges for outpatient setting,103.78,70,,83.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.61,80,,94.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,19.04,12.84,,15.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.37,65,,77.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,35,,41.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.43,90,,106.74,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,133.43,
NS 0.9%/ KCL 10 MEQ SOLN 1000ML,3303365,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS 0.9%/ KCL 20MEQ SOLN 1000ML,3303766,CDM,636,RC,J3480,HCPCS,Outpatient,,,50.35,50.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.25,70,,28.2,percent of total billed charges,70% of total billed charges for outpatient setting,42.74,84.88,,34.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,37.76,75,,30.21,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,70,,28.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,12.84,,5.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,80,,32.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,12.84,,5.17,percent of total billed charges,12.84% of total billed charges,6.46,12.84,,5.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.73,65,,26.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,45.32,90,,36.26,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,45.32,
NS 0.9%/ KCL 30 MEQ SOLN 1000ML,3303767,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS 0.9%/ KCL 40 MEQ SOLN 1000 ML,3303768,CDM,636,RC,J3480,HCPCS,Outpatient,,,48.8,48.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,41.42,84.88,,33.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.6,75,,29.28,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,70,,27.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.04,80,,31.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,6.27,12.84,,5.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.72,65,,25.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,43.92,90,,35.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,43.92,
NS FLUSH 5 ML SYRINGE,3305085,CDM,272,RC,,,Outpatient,,,18.9,18.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,16.04,84.88,,12.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.45,50,,7.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.18,75,,11.34,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,80,,12.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.29,65,,9.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,35,,5.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.01,90,,13.61,percent of total billed charges,90% of total billed charges for outpatient setting,2.43,17.01,
NS URINE CUPS / DYND30335,2590223,CDM,270,RC,,,Outpatient,,,0.81,0.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,70,,0.46,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,84.88,,0.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.41,50,,0.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.61,75,,0.49,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,70,,0.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,80,,0.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.53,65,,0.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.28,35,,0.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.73,90,,0.58,percent of total billed charges,90% of total billed charges for outpatient setting,0.1,0.73,
"N-TELOPEPTIDE NTX, URINE",220893,CDM,300,RC,82523,HCPCS,Outpatient,,,84.06,75.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,71.35,84.88,,57.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,63.05,75,,50.44,percent of total billed charges,75% of total billed charges for outpatient setting,58.84,70,,47.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.25,80,,53.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.45,100,,,Fee Schedule,100% of Custom Fee Schedule,75.65,90,,60.52,percent of total billed charges,90% of total billed charges for outpatient setting,18.68,75.65,
NU GUAZE PLAIN 1IN / KC7600,6152143,CDM,272,RC,,,Outpatient,,,25.91,25.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,21.99,84.88,,17.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.96,50,,10.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.43,75,,15.54,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,70,,14.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,80,,16.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.33,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.84,65,,13.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,35,,7.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.32,90,,18.66,percent of total billed charges,90% of total billed charges for outpatient setting,3.33,23.32,
NUCEL ALLOGRAFT 0.5CC   /NC-1000,69169156,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
NUT CONDYLE T2 / 1895-5001S,70000687,CDM,278,RC,C1713,HCPCS,Outpatient,,,719.97,719.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.98,60,,345.58,percent of total billed charges,60% of total Billed charges for outpatient setting,611.11,84.88,,488.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.98,75,,431.98,percent of total billed charges,75% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.98,80,,460.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,719.97,65,,575.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.99,35,,201.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,431.98,60,,345.58,percent of total billed charges,60% of total billed charges for outpatient setting,92.44,719.97,
NUT CONNECTING SHORT M8X / 4933-1-010,70000667,CDM,278,RC,C1713,HCPCS,Outpatient,,,132.37,132.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.42,60,,63.54,percent of total billed charges,60% of total Billed charges for outpatient setting,112.36,84.88,,89.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.28,75,,79.42,percent of total billed charges,75% of total billed charges for outpatient setting,66.19,50,,52.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.9,80,,84.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.37,65,,105.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,35,,37.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.42,60,,63.54,percent of total billed charges,60% of total billed charges for outpatient setting,17,132.37,
NUT FOR RING/ROD M6 / 4933-1-701,70000666,CDM,278,RC,C1713,HCPCS,Outpatient,,,132.37,132.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.42,60,,63.54,percent of total billed charges,60% of total Billed charges for outpatient setting,112.36,84.88,,89.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.28,75,,79.42,percent of total billed charges,75% of total billed charges for outpatient setting,66.19,50,,52.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.9,80,,84.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,17,12.84,,13.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.37,65,,105.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,35,,37.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.42,60,,63.54,percent of total billed charges,60% of total billed charges for outpatient setting,17,132.37,
NUT TX IMP (SUPLENA) SOL : VANILLA 8 OZ,3301702,CDM,259,RC,,,Outpatient,,,8.55,8.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,7.26,84.88,,5.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.28,50,,3.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.41,75,,5.13,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,80,,5.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.56,65,,4.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,35,,2.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.7,90,,6.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.7,
NUTRITIONALS (OSTEO FLEX MAX S)TAB:500MG,3301703,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
NYSTATIN (MYCOLOG II) CRM : 30GM,3301711,CDM,259,RC,,,Outpatient,,,20.11,20.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.08,70,,11.26,percent of total billed charges,70% of total billed charges for outpatient setting,17.07,84.88,,13.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.06,50,,8.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.08,75,,12.06,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,70,,11.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.09,80,,12.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.07,65,,10.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.04,35,,5.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.1,90,,14.48,percent of total billed charges,90% of total billed charges for outpatient setting,2.58,18.1,
NYSTATIN (MYCOLOG II) OINT: 60 GM,3301712,CDM,259,RC,,,Outpatient,,,34.03,34.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.82,70,,19.06,percent of total billed charges,70% of total billed charges for outpatient setting,28.88,84.88,,23.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.02,50,,13.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.52,75,,20.42,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,70,,19.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,12.84,,3.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.22,80,,21.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,12.84,,3.5,percent of total billed charges,12.84% of total billed charges,4.37,12.84,,3.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.12,65,,17.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,35,,9.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.63,90,,24.5,percent of total billed charges,90% of total billed charges for outpatient setting,4.37,30.63,
NYSTATIN (MYCOSTATIN) CRM  100MU : 30GM,3301704,CDM,259,RC,,,Outpatient,,,20.5,20.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.35,70,,11.48,percent of total billed charges,70% of total billed charges for outpatient setting,17.4,84.88,,13.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.25,50,,8.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.38,75,,12.3,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,70,,11.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,12.84,,2.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.4,80,,13.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,12.84,,2.1,percent of total billed charges,12.84% of total billed charges,2.63,12.84,,2.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.33,65,,10.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,35,,5.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.45,90,,14.76,percent of total billed charges,90% of total billed charges for outpatient setting,2.63,18.45,
NYSTATIN (MYCOSTATIN) OINT 15 GM,3301705,CDM,259,RC,,,Outpatient,,,100.4,100.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,70,,56.22,percent of total billed charges,70% of total billed charges for outpatient setting,85.22,84.88,,68.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.2,50,,40.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.3,75,,60.24,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,70,,56.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.32,80,,64.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.26,65,,52.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.14,35,,28.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.36,90,,72.29,percent of total billed charges,90% of total billed charges for outpatient setting,12.89,90.36,
NYSTATIN (MYCOSTATIN) SUSP 100MU  60ML,3301708,CDM,259,RC,,,Outpatient,,,60.26,60.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,84.88,,40.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.13,50,,24.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.2,75,,36.16,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,70,,33.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.74,12.84,,6.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.21,80,,38.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.74,12.84,,6.19,percent of total billed charges,12.84% of total billed charges,7.74,12.84,,6.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.17,65,,31.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.09,35,,16.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.23,90,,43.38,percent of total billed charges,90% of total billed charges for outpatient setting,7.74,54.23,
NYSTATIN (MYCOSTATIN) SUSP 100MU : 60ML,3301707,CDM,259,RC,,,Outpatient,,,16.85,16.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.8,70,,9.44,percent of total billed charges,70% of total billed charges for outpatient setting,14.3,84.88,,11.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.43,50,,6.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.64,75,,10.11,percent of total billed charges,75% of total billed charges for outpatient setting,11.8,70,,9.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,12.84,,1.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,80,,10.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,12.84,,1.73,percent of total billed charges,12.84% of total billed charges,2.16,12.84,,1.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.95,65,,8.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.9,35,,4.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.17,90,,12.14,percent of total billed charges,90% of total billed charges for outpatient setting,2.16,15.17,
NYSTATIN (MYCOSTATIN) SUSP 100MU : 60ML,3301706,CDM,259,RC,,,Outpatient,,,44.22,44.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,70,,24.76,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,84.88,,30.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,50,,17.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.17,75,,26.54,percent of total billed charges,75% of total billed charges for outpatient setting,30.95,70,,24.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.38,80,,28.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.68,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.74,65,,22.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.48,35,,12.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.8,90,,31.84,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,39.8,
NYSTATIN TOPICAL POWDER 15 GM,3301709,CDM,259,RC,,,Outpatient,,,25.52,25.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,70,,14.29,percent of total billed charges,70% of total billed charges for outpatient setting,21.66,84.88,,17.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.76,50,,10.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.14,75,,15.31,percent of total billed charges,75% of total billed charges for outpatient setting,17.86,70,,14.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.28,12.84,,2.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.42,80,,16.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.28,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,3.28,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.59,65,,13.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,35,,7.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.97,90,,18.38,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,22.97,
NYSTATIN(genericMYCOSTATIN) POWDER 15 GM,3301710,CDM,259,RC,,,Outpatient,,,78.5,78.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,70,,43.96,percent of total billed charges,70% of total billed charges for outpatient setting,66.63,84.88,,53.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.25,50,,31.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.88,75,,47.1,percent of total billed charges,75% of total billed charges for outpatient setting,54.95,70,,43.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,12.84,,8.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.8,80,,50.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,12.84,,8.06,percent of total billed charges,12.84% of total billed charges,10.08,12.84,,8.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.03,65,,40.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.48,35,,21.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.65,90,,56.52,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,70.65,
O2 10 HOURS,5100057,CDM,272,RC,,,Outpatient,,,318.19,318.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.73,70,,178.18,percent of total billed charges,70% of total billed charges for outpatient setting,270.08,84.88,,216.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.1,50,,127.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.64,75,,190.91,percent of total billed charges,75% of total billed charges for outpatient setting,222.73,70,,178.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.86,12.84,,32.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.55,80,,203.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.86,12.84,,32.69,percent of total billed charges,12.84% of total billed charges,40.86,12.84,,32.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,206.82,65,,165.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.37,35,,89.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.37,90,,229.1,percent of total billed charges,90% of total billed charges for outpatient setting,40.86,286.37,
O2 15 HOURS,5100058,CDM,272,RC,,,Outpatient,,,477.28,477.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.1,70,,267.28,percent of total billed charges,70% of total billed charges for outpatient setting,405.12,84.88,,324.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,238.64,50,,190.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.96,75,,286.37,percent of total billed charges,75% of total billed charges for outpatient setting,334.1,70,,267.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,12.84,,49.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.82,80,,305.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,12.84,,49.02,percent of total billed charges,12.84% of total billed charges,61.28,12.84,,49.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,310.23,65,,248.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.05,35,,133.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,429.55,90,,343.64,percent of total billed charges,90% of total billed charges for outpatient setting,61.28,429.55,
O2 20 HOURS,5100059,CDM,272,RC,,,Outpatient,,,636.37,636.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,540.15,84.88,,432.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.19,50,,254.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.28,75,,381.82,percent of total billed charges,75% of total billed charges for outpatient setting,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.1,80,,407.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.64,65,,330.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.73,35,,178.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.73,90,,458.18,percent of total billed charges,90% of total billed charges for outpatient setting,81.71,572.73,
O2 24 HOURS,5100061,CDM,272,RC,,,Outpatient,,,763.64,763.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.55,70,,427.64,percent of total billed charges,70% of total billed charges for outpatient setting,648.18,84.88,,518.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,381.82,50,,305.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,572.73,75,,458.18,percent of total billed charges,75% of total billed charges for outpatient setting,534.55,70,,427.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.05,12.84,,78.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.91,80,,488.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.05,12.84,,78.44,percent of total billed charges,12.84% of total billed charges,98.05,12.84,,78.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,496.37,65,,397.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.27,35,,213.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,687.28,90,,549.82,percent of total billed charges,90% of total billed charges for outpatient setting,98.05,687.28,
O2 5 HOURS,5100056,CDM,272,RC,,,Outpatient,,,159.1,159.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.37,70,,89.1,percent of total billed charges,70% of total billed charges for outpatient setting,135.04,84.88,,108.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.55,50,,63.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.33,75,,95.46,percent of total billed charges,75% of total billed charges for outpatient setting,111.37,70,,89.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.43,12.84,,16.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.28,80,,101.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.43,12.84,,16.34,percent of total billed charges,12.84% of total billed charges,20.43,12.84,,16.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,103.42,65,,82.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.69,35,,44.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.19,90,,114.55,percent of total billed charges,90% of total billed charges for outpatient setting,20.43,143.19,
O2 PER HOUR,5100055,CDM,272,RC,,,Outpatient,,,31.79,31.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,84.88,,21.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.9,50,,12.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.84,75,,19.07,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,80,,20.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.66,65,,16.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.13,35,,8.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.61,90,,22.89,percent of total billed charges,90% of total billed charges for outpatient setting,4.08,28.61,
O2 PER HOUR,6100016,CDM,272,RC,,,Outpatient,,,31.79,31.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,84.88,,21.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.9,50,,12.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.84,75,,19.07,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,80,,20.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.66,65,,16.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.13,35,,8.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.61,90,,22.89,percent of total billed charges,90% of total billed charges for outpatient setting,4.08,28.61,
"O2, ADDITIONAL 30 MINUTES",6100017,CDM,272,RC,,,Outpatient,,,15.91,15.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,84.88,,10.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.96,50,,6.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,75,,9.54,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,80,,10.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.34,65,,8.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.32,90,,11.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.04,14.32,
OATS 2.0 SNGL USE KT 12MM / ABS-8981-12S,69169823,CDM,272,RC,,,Outpatient,,,2450,2450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1715,70,,1372,percent of total billed charges,70% of total billed charges for outpatient setting,2079.56,84.88,,1663.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1837.5,75,,1470,percent of total billed charges,75% of total billed charges for outpatient setting,1715,70,,1372,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,80,,1568,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1592.5,65,,1274,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.5,35,,686,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2205,90,,1764,percent of total billed charges,90% of total billed charges for outpatient setting,314.58,2205,
OB PAD 9-1/2IN REG NS BAG / NON241286Z,6150050,CDM,270,RC,,,Outpatient,,,0.54,0.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,70,,0.3,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,84.88,,0.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.27,50,,0.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.41,75,,0.33,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,70,,0.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,80,,0.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.35,65,,0.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.19,35,,0.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.49,90,,0.39,percent of total billed charges,90% of total billed charges for outpatient setting,0.07,0.49,
OB PAD 9-1/2IN REG NS BAG // NON241286,70000060,CDM,270,RC,,,Outpatient,,,0.98,0.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,70,,0.55,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,84.88,,0.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.49,50,,0.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.74,75,,0.59,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,70,,0.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,12.84,,0.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,80,,0.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,12.84,,0.1,percent of total billed charges,12.84% of total billed charges,0.13,12.84,,0.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.64,65,,0.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,35,,0.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.88,90,,0.7,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,0.88,
OBSERV DIRECT ADMISSION,511001,CDM,762,RC,G0379,HCPCS,Outpatient,,,105.89,105.89,,748.64,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,74.12,70,,59.3,percent of total billed charges,70% of total billed charges for outpatient setting,89.88,84.88,,71.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,724.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,79.42,75,,63.54,percent of total billed charges,75% of total billed charges for outpatient setting,74.12,70,,59.3,percent of total billed charges,70% of total billed charges for outpatient setting,795.42,170,,,Fee Schedule,170% of Medicare OPPS rate,1005.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,818.82,175,,,Fee Schedule,175% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,84.71,80,,67.77,percent of total billed charges,80% of total billed charges for outpatient setting,655.04,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,584.87,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,13.6,12.84,,10.88,percent of total billed charges,12.84% of total billed charges,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1161,65,,928.8,percent of total billed charges,65% of total billed charges for outpatient setting,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,390,100,,,Fee Schedule,100% of Custom Fee Schedule,95.3,90,,76.24,percent of total billed charges,90% of total billed charges for outpatient setting,13.6,1161,
OBSERV SERVICES PER HOUR,511000,CDM,762,RC,G0378,HCPCS,Outpatient,,,61.35,61.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.95,70,,34.36,percent of total billed charges,70% of total billed charges for outpatient setting,52.07,84.88,,41.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.01,75,,36.81,percent of total billed charges,75% of total billed charges for outpatient setting,42.95,70,,34.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,12.84,,6.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.08,80,,39.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,7.88,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1161,65,,928.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.22,90,,44.18,percent of total billed charges,90% of total billed charges for outpatient setting,7.88,1161,
OBSERVATION INITIAL 1 HOUR,99021,CDM,762,RC,G0379,HCPCS,Outpatient,,,269.5,269.5,,748.64,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,188.65,70,,150.92,percent of total billed charges,70% of total billed charges for outpatient setting,228.75,84.88,,183,percent of total billed charges,84.88% of total billed charges for outpatient setting,724.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,202.13,75,,161.7,percent of total billed charges,75% of total billed charges for outpatient setting,188.65,70,,150.92,percent of total billed charges,70% of total billed charges for outpatient setting,795.42,170,,,Fee Schedule,170% of Medicare OPPS rate,1005.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.6,12.84,,27.68,percent of total billed charges,12.84% of total billed charges,818.82,175,,,Fee Schedule,175% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,215.6,80,,172.48,percent of total billed charges,80% of total billed charges for outpatient setting,655.04,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,584.87,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.6,12.84,,27.68,percent of total billed charges,12.84% of total billed charges,34.6,12.84,,27.68,percent of total billed charges,12.84% of total billed charges,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1161,65,,928.8,percent of total billed charges,65% of total billed charges for outpatient setting,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,390,100,,,Fee Schedule,100% of Custom Fee Schedule,242.55,90,,194.04,percent of total billed charges,90% of total billed charges for outpatient setting,34.6,1161,
OBSERVATION ROOM EACH ADDL HOUR,99022,CDM,762,RC,G0378,HCPCS,Outpatient,,,219.61,219.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.73,70,,122.98,percent of total billed charges,70% of total billed charges for outpatient setting,186.4,84.88,,149.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,164.71,75,,131.77,percent of total billed charges,75% of total billed charges for outpatient setting,153.73,70,,122.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.2,12.84,,22.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.69,80,,140.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.2,12.84,,22.56,percent of total billed charges,12.84% of total billed charges,28.2,12.84,,22.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1161,65,,928.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.65,90,,158.12,percent of total billed charges,90% of total billed charges for outpatient setting,24.14,1161,
OBTRYX CRVD SINGLE SYST DEVICE,69161934,CDM,278,RC,,,Outpatient,,,2455.2,2455.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1473.12,60,,1178.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2083.97,84.88,,1667.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,1227.6,50,,982.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1841.4,75,,1473.12,percent of total billed charges,75% of total billed charges for outpatient setting,1227.6,50,,982.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.25,12.84,,252.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1964.16,80,,1571.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.25,12.84,,252.2,percent of total billed charges,12.84% of total billed charges,315.25,12.84,,252.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2577.96,105,,2062.37,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,859.32,35,,687.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1473.12,60,,1178.5,percent of total billed charges,60% of total billed charges for outpatient setting,315.25,2577.96,
OBTRYX TRANSOBTURATOR SLING SYST. CURVD,69161488,CDM,278,RC,C1771,HCPCS,Outpatient,,,2336,2336,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1401.6,60,,1121.28,percent of total billed charges,60% of total Billed charges for outpatient setting,1982.8,84.88,,1586.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752,75,,1401.6,percent of total billed charges,75% of total billed charges for outpatient setting,1168,50,,934.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.94,12.84,,239.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1868.8,80,,1495.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.94,12.84,,239.95,percent of total billed charges,12.84% of total billed charges,299.94,12.84,,239.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2452.8,105,,1962.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.6,35,,654.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1401.6,60,,1121.28,percent of total billed charges,60% of total billed charges for outpatient setting,299.94,2452.8,
OCCULT BLD FECAL IMMUNOASSAY-LABCORP,200005,CDM,300,RC,G0328,HCPCS,Outpatient,,,81.23,73.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.86,70,,45.49,percent of total billed charges,70% of total billed charges for outpatient setting,68.95,84.88,,55.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.92,75,,48.74,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,70,,45.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,12.84,,8.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.98,80,,51.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,10.43,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,100,,,Fee Schedule,100% of Custom Fee Schedule,73.11,90,,58.49,percent of total billed charges,90% of total billed charges for outpatient setting,10.43,73.11,
"OCCULT BLD STL PEROXIDASE, NEOPLASM SCR",200022,CDM,300,RC,82270,HCPCS,Outpatient,,,19.71,17.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,17.74,
"OCCULT BLD STL PEROXIDASE, NON-NEOPLASM",200006,CDM,300,RC,82272,HCPCS,Outpatient,,,19.04,17.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,16.16,84.88,,12.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.28,75,,11.42,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,80,,12.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.14,90,,13.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,17.14,
OCCULT BLD STOOL 1-3 SIM,201220,CDM,300,RC,82270,HCPCS,Outpatient,,,19.71,17.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,17.74,
OCCULT BLOOD COMPETENCY,201912,CDM,300,RC,82272,HCPCS,Outpatient,,,19.04,17.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,16.16,84.88,,12.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.28,75,,11.42,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,70,,10.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.23,80,,12.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.14,90,,13.71,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,17.14,
OCCULT BLOOD STOOL x3 SIMULTANEOUS,200130,CDM,300,RC,82270,HCPCS,Outpatient,,,19.71,17.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,100,,,Fee Schedule,100% of Custom Fee Schedule,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,17.74,
OCEAN NASAL SPY(SODIUM CL 0.65%) 45ML,3301991,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OCTAGAM (IVIG) 10GM/200ML,3303330,CDM,250,RC,J1568,HCPCS,Outpatient,,,2962.7,2962.7,,67.36,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2073.89,70,,1659.11,percent of total billed charges,70% of total billed charges for outpatient setting,2514.74,84.88,,2011.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2222.03,75,,1777.62,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,71.56,170,,,Fee Schedule,170% of Medicare OPPS rate,90.51,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,380.41,12.84,,304.328,percent of total billed charges,12.84% of total billed charges,73.67,175,,,Fee Schedule,175% of Medicare OPPS rate,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2370.16,80,,1896.13,percent of total billed charges,80% of total billed charges for outpatient setting,58.94,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,52.62,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,380.41,12.84,,304.33,percent of total billed charges,12.84% of total billed charges,380.41,12.84,,304.33,percent of total billed charges,12.84% of total billed charges,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1925.76,65,,1540.61,percent of total billed charges,65% of total billed charges for outpatient setting,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,42.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,36.43,100,,,Fee Schedule,100% of Custom Fee Schedule,2666.43,90,,2133.14,percent of total billed charges,90% of total billed charges for outpatient setting,36.43,2666.43,
OCTREOTIDE (SANDOSTATIN) 0.05MG/ML AMP :,3301714,CDM,250,RC,,,Outpatient,,,93.59,93.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.51,70,,52.41,percent of total billed charges,70% of total billed charges for outpatient setting,79.44,84.88,,63.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.8,50,,37.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.19,75,,56.15,percent of total billed charges,75% of total billed charges for outpatient setting,65.51,70,,52.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.87,80,,59.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,12.02,12.84,,9.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.83,65,,48.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.76,35,,26.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.23,90,,67.38,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,84.23,
OCTREOTIDE (SANDOSTATIN) 0.1MG/ML AMP :,3301715,CDM,250,RC,,,Outpatient,,,49.15,49.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.41,70,,27.53,percent of total billed charges,70% of total billed charges for outpatient setting,41.72,84.88,,33.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.58,50,,19.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.86,75,,29.49,percent of total billed charges,75% of total billed charges for outpatient setting,34.41,70,,27.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.31,12.84,,5.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.32,80,,31.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.31,12.84,,5.05,percent of total billed charges,12.84% of total billed charges,6.31,12.84,,5.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.95,65,,25.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.2,35,,13.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.24,90,,35.39,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,44.24,
OCTREOTIDE (SANDOSTATIN) INJ 0.2MG/ML :,3301713,CDM,250,RC,,,Outpatient,,,399.93,399.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.95,70,,223.96,percent of total billed charges,70% of total billed charges for outpatient setting,339.46,84.88,,271.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,199.97,50,,159.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.95,75,,239.96,percent of total billed charges,75% of total billed charges for outpatient setting,279.95,70,,223.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.94,80,,255.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,51.35,12.84,,41.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.95,65,,207.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.98,35,,111.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,359.94,90,,287.95,percent of total billed charges,90% of total billed charges for outpatient setting,51.35,359.94,
OCUVITE: TAB,3303029,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
OFFSET COUPLER 6MM  71424227,69161485,CDM,278,RC,,,Outpatient,,,2796.58,2796.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.95,60,,1342.36,percent of total billed charges,60% of total Billed charges for outpatient setting,2373.74,84.88,,1898.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2097.44,75,,1677.95,percent of total billed charges,75% of total billed charges for outpatient setting,1398.29,50,,1118.63,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.26,80,,1789.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,359.08,12.84,,287.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2936.41,105,,2349.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.8,35,,783.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.95,60,,1342.36,percent of total billed charges,60% of total billed charges for outpatient setting,359.08,2936.41,
OFLOXACIN OPHTH SOL 0.3% 5ML,3301716,CDM,259,RC,,,Outpatient,,,48.37,48.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.86,70,,27.09,percent of total billed charges,70% of total billed charges for outpatient setting,41.06,84.88,,32.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.19,50,,19.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.28,75,,29.02,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,70,,27.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,12.84,,4.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,80,,30.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.21,12.84,,4.97,percent of total billed charges,12.84% of total billed charges,6.21,12.84,,4.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.44,65,,25.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.93,35,,13.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.53,90,,34.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.21,43.53,
OLANZAPINE (ZYPREXA) TAB: 2.5 MG,3301717,CDM,259,RC,,,Outpatient,,,14.02,14.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,11.9,84.88,,9.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.01,50,,5.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.52,75,,8.42,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,80,,8.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.11,65,,7.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,35,,3.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.62,90,,10.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,12.62,
OLANZAPINE (ZYPREXA) TAB: 2.5 MG,3301719,CDM,259,RC,,,Outpatient,,,15.73,15.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.01,70,,8.81,percent of total billed charges,70% of total billed charges for outpatient setting,13.35,84.88,,10.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.87,50,,6.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.8,75,,9.44,percent of total billed charges,75% of total billed charges for outpatient setting,11.01,70,,8.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,80,,10.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.22,65,,8.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,35,,4.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.16,90,,11.33,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.16,
OLANZAPINE (ZYPREXA) TAB: 5 MG,3301718,CDM,259,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
OLIGOCLONAL BANDING,201067,CDM,301,RC,83916,HCPCS,Outpatient,,,123.26,110.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,70,,69.02,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,84.88,,83.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.09,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,92.45,75,,73.96,percent of total billed charges,75% of total billed charges for outpatient setting,86.28,70,,69.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.61,80,,78.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.13,100,,,Fee Schedule,100% of Custom Fee Schedule,110.93,90,,88.74,percent of total billed charges,90% of total billed charges for outpatient setting,20.12,110.93,
OLMESARTAN(BENICAR): 40MG,3302760,CDM,259,RC,,,Outpatient,,,12.98,12.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,11.02,84.88,,8.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.49,50,,5.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.74,75,,7.79,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,80,,8.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.44,65,,6.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,35,,3.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.68,90,,9.34,percent of total billed charges,90% of total billed charges for outpatient setting,1.67,11.68,
OLOPATADINE (PATANOL) OPTH SOL 0.1%:5ML,3301720,CDM,259,RC,,,Outpatient,,,194.57,194.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,70,,108.96,percent of total billed charges,70% of total billed charges for outpatient setting,165.15,84.88,,132.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,97.29,50,,77.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.93,75,,116.74,percent of total billed charges,75% of total billed charges for outpatient setting,136.2,70,,108.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,12.84,,19.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.66,80,,124.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,12.84,,19.98,percent of total billed charges,12.84% of total billed charges,24.98,12.84,,19.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,126.47,65,,101.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,35,,54.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,175.11,90,,140.09,percent of total billed charges,90% of total billed charges for outpatient setting,24.98,175.11,
OLSALAZINE (DIPENTUM) CAP:250MG,3301721,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
OMEPRAZOLE (genericPRILOSEC) CAP 20 MG,3301722,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OMIDRIA 1%/0.3% 4ML ADDED TO BSS 500MLS,3310242,CDM,250,RC,J1097,HCPCS,Outpatient,,,2014.4,2014.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410.08,70,,1128.06,percent of total billed charges,70% of total billed charges for outpatient setting,1709.82,84.88,,1367.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1510.8,75,,1208.64,percent of total billed charges,75% of total billed charges for outpatient setting,1410.08,70,,1128.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.52,80,,1289.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1309.36,65,,1047.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.97,100,,,Fee Schedule,100% of Custom Fee Schedule,1812.96,90,,1450.37,percent of total billed charges,90% of total billed charges for outpatient setting,117.97,1812.96,
OMNI SURGICAL SYSTEM / 1-108,69169548,CDM,278,RC,C1889,HCPCS,Outpatient,,,2798,2798,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.8,60,,1343.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2374.94,84.88,,1899.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2098.5,75,,1678.8,percent of total billed charges,75% of total billed charges for outpatient setting,1399,50,,1119.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.26,12.84,,287.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2238.4,80,,1790.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.26,12.84,,287.41,percent of total billed charges,12.84% of total billed charges,359.26,12.84,,287.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2937.9,105,,2350.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.3,35,,783.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1678.8,60,,1343.04,percent of total billed charges,60% of total billed charges for outpatient setting,359.26,2937.9,
OMNIBLOC W/ STRAP BITE BLOCKS / GIS-11-M,70000828,CDM,272,RC,,,Outpatient,,,19.95,19.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,16.93,84.88,,13.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.98,50,,7.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.96,75,,11.97,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,70,,11.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.96,80,,12.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.97,65,,10.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,35,,5.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.96,90,,14.37,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.96,
OMNICEF(CEFDINIR):300 MG,3303049,CDM,259,RC,,,Outpatient,,,10.63,10.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,70,,5.95,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,84.88,,7.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.32,50,,4.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.97,75,,6.38,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,70,,5.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,80,,6.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.91,65,,5.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,35,,2.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.57,90,,7.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.36,9.57,
OMNIPAQUE 300 MGI/ML 10ML VIAL,3314128,CDM,255,RC,Q9967,HCPCS,Outpatient,,,203.82,203.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.67,70,,114.14,percent of total billed charges,70% of total billed charges for outpatient setting,173,84.88,,138.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,152.87,75,,122.3,percent of total billed charges,75% of total billed charges for outpatient setting,142.67,70,,114.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.17,12.84,,20.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,80,,130.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.17,12.84,,20.94,percent of total billed charges,12.84% of total billed charges,26.17,12.84,,20.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.48,65,,105.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,183.44,90,,146.75,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,183.44,
OMNIPAQUE 300 MGI/ML 50ML BOTTLE,3314151,CDM,255,RC,Q9967,HCPCS,Outpatient,,,220.5,220.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.35,70,,123.48,percent of total billed charges,70% of total billed charges for outpatient setting,187.16,84.88,,149.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,165.38,75,,132.3,percent of total billed charges,75% of total billed charges for outpatient setting,154.35,70,,123.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,12.84,,22.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,80,,141.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,12.84,,22.65,percent of total billed charges,12.84% of total billed charges,28.31,12.84,,22.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.33,65,,114.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,198.45,90,,158.76,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,198.45,
OMNIPAQUE 350 MGI/ML 100ML BOTTLE,69160790,CDM,255,RC,Q9967,HCPCS,Outpatient,,,381.16,381.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.81,70,,213.45,percent of total billed charges,70% of total billed charges for outpatient setting,323.53,84.88,,258.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,285.87,75,,228.7,percent of total billed charges,75% of total billed charges for outpatient setting,266.81,70,,213.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.94,12.84,,39.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.93,80,,243.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.94,12.84,,39.15,percent of total billed charges,12.84% of total billed charges,48.94,12.84,,39.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,247.75,65,,198.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,100,,,Fee Schedule,100% of Custom Fee Schedule,343.04,90,,274.43,percent of total billed charges,90% of total billed charges for outpatient setting,0.13,343.04,
ONABOTULINUMTOXINA(BOTOX) 100units INJ,3307265,CDM,636,RC,J0585,HCPCS,Outpatient,,,2047.83,2047.83,,9.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1433.48,70,,1146.78,percent of total billed charges,70% of total billed charges for outpatient setting,1738.2,84.88,,1390.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1535.87,75,,1228.7,percent of total billed charges,75% of total billed charges for outpatient setting,1433.48,70,,1146.78,percent of total billed charges,70% of total billed charges for outpatient setting,10.59,170,,,Fee Schedule,170% of Medicare OPPS rate,13.39,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,262.94,12.84,,210.352,percent of total billed charges,12.84% of total billed charges,10.9,175,,,Fee Schedule,175% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1638.26,80,,1310.61,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,7.78,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,262.94,12.84,,210.35,percent of total billed charges,12.84% of total billed charges,262.94,12.84,,210.35,percent of total billed charges,12.84% of total billed charges,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1331.09,65,,1064.87,percent of total billed charges,65% of total billed charges for outpatient setting,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.23,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,6.47,100,,,Fee Schedule,100% of Custom Fee Schedule,1843.05,90,,1474.44,percent of total billed charges,90% of total billed charges for outpatient setting,6.23,1843.05,
ONDANSETRON (genericZOFRAN) ODT 4MG,3302933,CDM,259,RC,Q0162,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.02,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,2.92,
ONDANSETRON (genericZOFRAN)4MG/2ML VIAL,3302621,CDM,636,RC,J2405,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.09,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.09,2.92,
ONDANSETRON (genericZOFRAN)ODT 4MG,3302631,CDM,259,RC,Q0162,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.02,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,2.78,
ONDANSETRON (ZOFRAN) MDV 2MG/ML:20ML,3301724,CDM,636,RC,J2405,HCPCS,Outpatient,,,702.78,702.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.95,70,,393.56,percent of total billed charges,70% of total billed charges for outpatient setting,596.52,84.88,,477.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,527.09,75,,421.67,percent of total billed charges,75% of total billed charges for outpatient setting,491.95,70,,393.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,12.84,,72.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.22,80,,449.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,12.84,,72.19,percent of total billed charges,12.84% of total billed charges,90.24,12.84,,72.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,456.81,65,,365.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.09,100,,,Fee Schedule,100% of Custom Fee Schedule,632.5,90,,506,percent of total billed charges,90% of total billed charges for outpatient setting,0.09,632.5,
ONDANSETRON (ZOFRAN) SDV :2MG/ML 20ML,3301723,CDM,250,RC,,,Outpatient,,,70.3,70.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,70,,39.37,percent of total billed charges,70% of total billed charges for outpatient setting,59.67,84.88,,47.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.15,50,,28.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.73,75,,42.18,percent of total billed charges,75% of total billed charges for outpatient setting,49.21,70,,39.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,12.84,,7.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.24,80,,44.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,12.84,,7.22,percent of total billed charges,12.84% of total billed charges,9.03,12.84,,7.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.7,65,,36.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,35,,19.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.27,90,,50.62,percent of total billed charges,90% of total billed charges for outpatient setting,9.03,63.27,
ONDANSETRON(ZOFRAN ODT)TAB: 8 MG,3302755,CDM,259,RC,Q0162,HCPCS,Outpatient,,,13.06,13.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,11.09,84.88,,8.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,9.8,75,,7.84,percent of total billed charges,75% of total billed charges for outpatient setting,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.45,80,,8.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.49,65,,6.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.02,100,,,Fee Schedule,100% of Custom Fee Schedule,11.75,90,,9.4,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,11.75,
OPSITE 4X5 / 30166-020,5150147,CDM,272,RC,,,Outpatient,,,27.16,27.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,70,,15.21,percent of total billed charges,70% of total billed charges for outpatient setting,23.05,84.88,,18.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.58,50,,10.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.37,75,,16.3,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,70,,15.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,80,,17.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.65,65,,14.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.51,35,,7.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.44,90,,19.55,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,24.44,
OPTIC FORAMINA,2400065,CDM,320,RC,70190,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
OPTION 28MM BIOLOX / 650-1057,71000332,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
OPTION 36MM BIOLOX / 650-1057,71000051,CDM,278,RC,C1776,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
OPTISON 3ML INJECTION / 2707-18,71000341,CDM,636,RC,Q9956,HCPCS,Outpatient,,,312,312,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,70,,174.72,percent of total billed charges,70% of total billed charges for outpatient setting,264.83,84.88,,211.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,234,75,,187.2,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,70,,174.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,12.84,,32.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,80,,199.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,12.84,,32.05,percent of total billed charges,12.84% of total billed charges,40.06,12.84,,32.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,202.8,65,,162.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.74,100,,,Fee Schedule,100% of Custom Fee Schedule,280.8,90,,224.64,percent of total billed charges,90% of total billed charges for outpatient setting,33.63,280.8,
OR  30 Minutes or Less,6100025,CDM,360,RC,,,Outpatient,,,2986.49,2986.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.54,70,,1672.43,percent of total billed charges,70% of total billed charges for outpatient setting,2534.93,84.88,,2027.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,1493.25,50,,1194.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2239.87,75,,1791.9,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.47,12.84,,306.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2389.19,80,,1911.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.47,12.84,,306.78,percent of total billed charges,12.84% of total billed charges,383.47,12.84,,306.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.27,35,,836.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2687.84,90,,2150.27,percent of total billed charges,90% of total billed charges for outpatient setting,383.47,2687.84,
OR ABORT CANCEL PRIOR TO PROCEDURE,6100023,CDM,360,RC,,,Outpatient,,,216.95,216.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.87,70,,121.5,percent of total billed charges,70% of total billed charges for outpatient setting,184.15,84.88,,147.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.48,50,,86.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.71,75,,130.17,percent of total billed charges,75% of total billed charges for outpatient setting,151.87,70,,121.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,12.84,,22.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.56,80,,138.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,12.84,,22.29,percent of total billed charges,12.84% of total billed charges,27.86,12.84,,22.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.93,35,,60.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,195.26,90,,156.21,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,195.26,
OR ABORTED OR CANCELLED PROCEDURE,6100024,CDM,360,RC,,,Outpatient,,,1410.13,1410.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.09,70,,789.67,percent of total billed charges,70% of total billed charges for outpatient setting,1196.92,84.88,,957.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,705.07,50,,564.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1057.6,75,,846.08,percent of total billed charges,75% of total billed charges for outpatient setting,987.09,70,,789.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.06,12.84,,144.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.1,80,,902.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.06,12.84,,144.85,percent of total billed charges,12.84% of total billed charges,181.06,12.84,,144.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.55,35,,394.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1269.12,90,,1015.3,percent of total billed charges,90% of total billed charges for outpatient setting,181.06,1269.12,
OR ADD'L 30 MIN,2200977,CDM,360,RC,,,Outpatient,,,2150.65,2150.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505.46,70,,1204.37,percent of total billed charges,70% of total billed charges for outpatient setting,1825.47,84.88,,1460.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1075.33,50,,860.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612.99,75,,1290.39,percent of total billed charges,75% of total billed charges for outpatient setting,1505.46,70,,1204.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,12.84,,220.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.52,80,,1376.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,12.84,,220.91,percent of total billed charges,12.84% of total billed charges,276.14,12.84,,220.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.73,35,,602.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1935.59,90,,1548.47,percent of total billed charges,90% of total billed charges for outpatient setting,276.14,1935.59,
OR ADD'L 30 MIN,6100020,CDM,360,RC,,,Outpatient,,,2150.65,2150.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505.46,70,,1204.37,percent of total billed charges,70% of total billed charges for outpatient setting,1825.47,84.88,,1460.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1075.33,50,,860.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612.99,75,,1290.39,percent of total billed charges,75% of total billed charges for outpatient setting,1505.46,70,,1204.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,12.84,,220.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.52,80,,1376.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,12.84,,220.91,percent of total billed charges,12.84% of total billed charges,276.14,12.84,,220.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.73,35,,602.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1935.59,90,,1548.47,percent of total billed charges,90% of total billed charges for outpatient setting,276.14,1935.59,
OR ADD'L 30 MIN,6000012,CDM,360,RC,,,Outpatient,,,2215.17,2215.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1550.62,70,,1240.5,percent of total billed charges,70% of total billed charges for outpatient setting,1880.24,84.88,,1504.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1107.59,50,,886.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1661.38,75,,1329.1,percent of total billed charges,75% of total billed charges for outpatient setting,1550.62,70,,1240.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.43,12.84,,227.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1772.14,80,,1417.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.43,12.84,,227.54,percent of total billed charges,12.84% of total billed charges,284.43,12.84,,227.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.31,35,,620.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1993.65,90,,1594.92,percent of total billed charges,90% of total billed charges for outpatient setting,284.43,1993.65,
OR FIRST HOUR,2200976,CDM,360,RC,,,Outpatient,,,5775,5775,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4042.5,70,,3234,percent of total billed charges,70% of total billed charges for outpatient setting,4901.82,84.88,,3921.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,2887.5,50,,2310,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4331.25,75,,3465,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4620,80,,3696,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2021.25,35,,1617,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5197.5,90,,4158,percent of total billed charges,90% of total billed charges for outpatient setting,741.51,5197.5,
OR FIRST HOUR,6000011,CDM,360,RC,,,Outpatient,,,5775,5775,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4042.5,70,,3234,percent of total billed charges,70% of total billed charges for outpatient setting,4901.82,84.88,,3921.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,2887.5,50,,2310,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4331.25,75,,3465,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4620,80,,3696,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2021.25,35,,1617,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5197.5,90,,4158,percent of total billed charges,90% of total billed charges for outpatient setting,741.51,5197.5,
OR FIRST HOUR,6100015,CDM,360,RC,,,Outpatient,,,5775,5775,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4042.5,70,,3234,percent of total billed charges,70% of total billed charges for outpatient setting,4901.82,84.88,,3921.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,2887.5,50,,2310,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4331.25,75,,3465,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4620,80,,3696,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,741.51,12.84,,593.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2021.25,35,,1617,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5197.5,90,,4158,percent of total billed charges,90% of total billed charges for outpatient setting,741.51,5197.5,
OR FIRST HOUR/NEW TECH,6100018,CDM,360,RC,,,Outpatient,,,6825,6825,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4777.5,70,,3822,percent of total billed charges,70% of total billed charges for outpatient setting,5793.06,84.88,,4634.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,3412.5,50,,2730,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5118.75,75,,4095,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.33,12.84,,701.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460,80,,4368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.33,12.84,,701.06,percent of total billed charges,12.84% of total billed charges,876.33,12.84,,701.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2388.75,35,,1911,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6142.5,90,,4914,percent of total billed charges,90% of total billed charges for outpatient setting,876.33,6142.5,
OR LESS THAN 30 MIN,6000013,CDM,360,RC,,,Outpatient,,,3076.09,3076.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2153.26,70,,1722.61,percent of total billed charges,70% of total billed charges for outpatient setting,2610.99,84.88,,2088.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,1538.05,50,,1230.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2307.07,75,,1845.66,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.97,12.84,,315.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460.87,80,,1968.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.97,12.84,,315.98,percent of total billed charges,12.84% of total billed charges,394.97,12.84,,315.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1076.63,35,,861.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2768.48,90,,2214.78,percent of total billed charges,90% of total billed charges for outpatient setting,394.97,2768.48,
OR TIME FOR LOOP RECORDER PLACEMENT,6100041,CDM,360,RC,,,Outpatient,,,13313.27,13313.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9319.29,70,,7455.43,percent of total billed charges,70% of total billed charges for outpatient setting,11300.3,84.88,,9040.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,6656.64,50,,5325.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9984.95,75,,7987.96,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.42,12.84,,1367.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10650.62,80,,8520.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.42,12.84,,1367.54,percent of total billed charges,12.84% of total billed charges,1709.42,12.84,,1367.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.64,35,,3727.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11981.94,90,,9585.55,percent of total billed charges,90% of total billed charges for outpatient setting,1709.42,11981.94,
OR TIME FOR LOOP RECORDER PLACEMENT - MX,6100040,CDM,360,RC,,,Outpatient,,,13313.27,13313.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9319.29,70,,7455.43,percent of total billed charges,70% of total billed charges for outpatient setting,11300.3,84.88,,9040.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,6656.64,50,,5325.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9984.95,75,,7987.96,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.42,12.84,,1367.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10650.62,80,,8520.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.42,12.84,,1367.54,percent of total billed charges,12.84% of total billed charges,1709.42,12.84,,1367.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.64,35,,3727.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11981.94,90,,9585.55,percent of total billed charges,90% of total billed charges for outpatient setting,1709.42,11981.94,
ORA DETERMINATION OF REFRACTIVE STATE,6100070,CDM,920,RC,92015,HCPCS,Outpatient,,,175,175,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,70,,98,percent of total billed charges,70% of total billed charges for outpatient setting,148.54,84.88,,118.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.25,75,,105,percent of total billed charges,75% of total billed charges for outpatient setting,122.5,70,,98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,12.84,,17.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,80,,112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,12.84,,17.98,percent of total billed charges,12.84% of total billed charges,22.47,12.84,,17.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,226,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.25,35,,49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,157.5,90,,126,percent of total billed charges,90% of total billed charges for outpatient setting,22.47,226,
ORAL RAE CUFF 5.5,5050066,CDM,272,RC,,,Outpatient,,,45.54,45.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.88,70,,25.5,percent of total billed charges,70% of total billed charges for outpatient setting,38.65,84.88,,30.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.77,50,,18.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.16,75,,27.33,percent of total billed charges,75% of total billed charges for outpatient setting,31.88,70,,25.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.85,12.84,,4.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.43,80,,29.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.85,12.84,,4.68,percent of total billed charges,12.84% of total billed charges,5.85,12.84,,4.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.6,65,,23.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,35,,12.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.99,90,,32.79,percent of total billed charges,90% of total billed charges for outpatient setting,5.85,40.99,
ORAL RAE CUFF 6.0,5050067,CDM,272,RC,,,Outpatient,,,42.96,42.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.07,70,,24.06,percent of total billed charges,70% of total billed charges for outpatient setting,36.46,84.88,,29.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.48,50,,17.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,75,,25.78,percent of total billed charges,75% of total billed charges for outpatient setting,30.07,70,,24.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,12.84,,4.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.37,80,,27.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,5.52,12.84,,4.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.92,65,,22.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,35,,12.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.66,90,,30.93,percent of total billed charges,90% of total billed charges for outpatient setting,5.52,38.66,
ORAL RAE CUFF 6.5,7650205,CDM,272,RC,,,Outpatient,,,40.81,40.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,34.64,84.88,,27.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.41,50,,16.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.61,75,,24.49,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.65,80,,26.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.53,65,,21.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.28,35,,11.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.73,90,,29.38,percent of total billed charges,90% of total billed charges for outpatient setting,5.24,36.73,
ORAL RAE CUFF 7.0 / 76270,7650210,CDM,272,RC,,,Outpatient,,,31.53,31.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,70,,17.66,percent of total billed charges,70% of total billed charges for outpatient setting,26.76,84.88,,21.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.77,50,,12.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.65,75,,18.92,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,70,,17.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.22,80,,20.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,4.05,12.84,,3.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.49,65,,16.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,35,,8.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.38,90,,22.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.05,28.38,
ORAL RAE CUFF 7.5 WITH TGUARD / 76275,7650215,CDM,272,RC,,,Outpatient,,,41.71,41.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,70,,23.36,percent of total billed charges,70% of total billed charges for outpatient setting,35.4,84.88,,28.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.86,50,,16.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.28,75,,25.02,percent of total billed charges,75% of total billed charges for outpatient setting,29.2,70,,23.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.37,80,,26.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,5.36,12.84,,4.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.11,65,,21.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,35,,11.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.54,90,,30.03,percent of total billed charges,90% of total billed charges for outpatient setting,5.36,37.54,
ORAL RAE CUFF 8.0,7650220,CDM,272,RC,,,Outpatient,,,42.61,42.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,36.17,84.88,,28.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.31,50,,17.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.96,75,,25.57,percent of total billed charges,75% of total billed charges for outpatient setting,29.83,70,,23.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,80,,27.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.7,65,,22.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.91,35,,11.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.35,90,,30.68,percent of total billed charges,90% of total billed charges for outpatient setting,5.47,38.35,
ORAL RAE UNCUFF 4.0,7650175,CDM,272,RC,,,Outpatient,,,30.41,30.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,84.88,,20.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.21,50,,12.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,75,,18.25,percent of total billed charges,75% of total billed charges for outpatient setting,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.77,65,,15.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.37,90,,21.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.37,
ORAL RAE UNCUFF 4.5,7650180,CDM,272,RC,,,Outpatient,,,30.41,30.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,84.88,,20.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.21,50,,12.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,75,,18.25,percent of total billed charges,75% of total billed charges for outpatient setting,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.77,65,,15.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.37,90,,21.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.37,
ORAL RAE UNCUFF 5.0,7650185,CDM,272,RC,,,Outpatient,,,30.41,30.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,84.88,,20.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.21,50,,12.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,75,,18.25,percent of total billed charges,75% of total billed charges for outpatient setting,21.29,70,,17.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.77,65,,15.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.37,90,,21.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.37,
ORBITS COMPLETE MINIMUM OF FOUR VIEWS,2400070,CDM,320,RC,70200,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
ORGANIC ACID URINE,220014,CDM,301,RC,83918,HCPCS,Outpatient,,,106.2,95.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.34,70,,59.47,percent of total billed charges,70% of total billed charges for outpatient setting,90.14,84.88,,72.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,79.65,75,,63.72,percent of total billed charges,75% of total billed charges for outpatient setting,74.34,70,,59.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.96,80,,67.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.21,100,,,Fee Schedule,100% of Custom Fee Schedule,95.58,90,,76.46,percent of total billed charges,90% of total billed charges for outpatient setting,21.18,95.58,
"ORGANISM IDENTIFICATION,BACTERIA",201359,CDM,300,RC,87071,HCPCS,Outpatient,,,44.51,40.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,37.78,84.88,,30.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,33.38,75,,26.7,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.61,80,,28.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,40.06,90,,32.05,percent of total billed charges,90% of total billed charges for outpatient setting,7.14,40.06,
"ORGANISM IDENTIFICATION,FUNGUS",201361,CDM,300,RC,87106,HCPCS,Outpatient,,,46.44,41.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,39.42,84.88,,31.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.83,75,,27.86,percent of total billed charges,75% of total billed charges for outpatient setting,32.51,70,,26.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.15,80,,29.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.07,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of Custom Fee Schedule,41.8,90,,33.44,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,41.8,
ORGANISM IDENTIFICATION/ANAEROBIC,201360,CDM,300,RC,87073,HCPCS,Outpatient,,,43.47,39.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,36.9,84.88,,29.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.6,75,,26.08,percent of total billed charges,75% of total billed charges for outpatient setting,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.78,80,,27.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.9,100,,,Fee Schedule,100% of Custom Fee Schedule,39.12,90,,31.3,percent of total billed charges,90% of total billed charges for outpatient setting,7.14,39.12,
ORLISTAT (XENICAL) CAP: 120 MG,3301725,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
ORTHO TIER 1 OR TIME,6100100,CDM,360,RC,,,Outpatient,,,5000,5000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,70,,2800,percent of total billed charges,70% of total billed charges for outpatient setting,4244,84.88,,3395.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750,75,,3000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4000,80,,3200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,35,,1400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4500,90,,3600,percent of total billed charges,90% of total billed charges for outpatient setting,642,4500,
ORTHO TIER 2 OR TIME,6100102,CDM,360,RC,,,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,70,,4480,percent of total billed charges,70% of total billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7200,90,,5760,percent of total billed charges,90% of total billed charges for outpatient setting,1027.2,7200,
ORTHO TIER 3 OR TIME,6100103,CDM,360,RC,,,Outpatient,,,12000,12000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8400,70,,6720,percent of total billed charges,70% of total billed charges for outpatient setting,10185.6,84.88,,8148.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,6000,50,,4800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9000,75,,7200,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9600,80,,7680,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,35,,3360,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10800,90,,8640,percent of total billed charges,90% of total billed charges for outpatient setting,1540.8,10800,
ORTHO TIER 4 OR TIME,6100104,CDM,360,RC,,,Outpatient,,,18000,18000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12600,70,,10080,percent of total billed charges,70% of total billed charges for outpatient setting,15278.4,84.88,,12222.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,9000,50,,7200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13500,75,,10800,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14400,80,,11520,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6300,35,,5040,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16200,90,,12960,percent of total billed charges,90% of total billed charges for outpatient setting,2000,16200,
ORTHO TIER 5 OR TIME,6100105,CDM,360,RC,,,Outpatient,,,25000,25000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17500,70,,14000,percent of total billed charges,70% of total billed charges for outpatient setting,21220,84.88,,16976,percent of total billed charges,84.88% of total billed charges for outpatient setting,12500,50,,10000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18750,75,,15000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20000,80,,16000,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8750,35,,7000,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22500,90,,18000,percent of total billed charges,90% of total billed charges for outpatient setting,2000,22500,
ORTHOFIX 6MM MED / CDM-625,7173690,CDM,278,RC,C1889,HCPCS,Outpatient,,,17150,17150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10290,60,,8232,percent of total billed charges,60% of total Billed charges for outpatient setting,14556.92,84.88,,11645.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12862.5,75,,10290,percent of total billed charges,75% of total billed charges for outpatient setting,8575,50,,6860,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2202.06,12.84,,1761.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720,80,,10976,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2202.06,12.84,,1761.65,percent of total billed charges,12.84% of total billed charges,2202.06,12.84,,1761.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18007.5,105,,14406,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6002.5,35,,4802,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10290,60,,8232,percent of total billed charges,60% of total billed charges for outpatient setting,2202.06,18007.5,
ORTHOFIX 7MM MED LONG / CDM-735L,7173688,CDM,278,RC,C1889,HCPCS,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
OSELTAMIVIR (TAMIFLU) 75 MG,3301726,CDM,259,RC,,,Outpatient,,,100.38,100.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.27,70,,56.22,percent of total billed charges,70% of total billed charges for outpatient setting,85.2,84.88,,68.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.19,50,,40.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.29,75,,60.23,percent of total billed charges,75% of total billed charges for outpatient setting,70.27,70,,56.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.3,80,,64.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,12.89,12.84,,10.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.25,65,,52.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.13,35,,28.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.34,90,,72.27,percent of total billed charges,90% of total billed charges for outpatient setting,12.89,90.34,
"OSMOLALITY, SERUM",220884,CDM,301,RC,83930,HCPCS,Outpatient,,,29.75,26.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,84.88,,20.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.31,75,,17.85,percent of total billed charges,75% of total billed charges for outpatient setting,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.8,80,,19.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.65,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,100,,,Fee Schedule,100% of Custom Fee Schedule,26.78,90,,21.42,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,26.78,
"OSMOLALITY, URINE",202452,CDM,301,RC,83935,HCPCS,Outpatient,,,30.69,27.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,26.05,84.88,,20.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.02,75,,18.42,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,70,,17.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,80,,19.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of Custom Fee Schedule,27.62,90,,22.1,percent of total billed charges,90% of total billed charges for outpatient setting,6.82,27.62,
OSSEOUS SURVEY INFANT,2400910,CDM,320,RC,77075,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
OSTEOCHONDRAL FLAP REPR INSTR. AR-4009S,69161725,CDM,272,RC,,,Outpatient,,,913.44,913.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.41,70,,511.53,percent of total billed charges,70% of total billed charges for outpatient setting,775.33,84.88,,620.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,456.72,50,,365.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,685.08,75,,548.06,percent of total billed charges,75% of total billed charges for outpatient setting,639.41,70,,511.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.75,80,,584.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,593.74,65,,474.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.7,35,,255.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,822.1,90,,657.68,percent of total billed charges,90% of total billed charges for outpatient setting,117.29,822.1,
OSTEOCONDUCTIVE MATRIX PLUS 5CC/OCMP5,69169243,CDM,278,RC,,,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,60,,907.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1890,65,,1512,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1134,60,,907.2,percent of total billed charges,60% of total billed charges for outpatient setting,242.68,1890,
OSTEOSET PELLET 1.25CC INJTR / 87003012,69169397,CDM,278,RC,C1713,HCPCS,Outpatient,,,2554.13,2554.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.48,60,,1225.98,percent of total billed charges,60% of total Billed charges for outpatient setting,2167.95,84.88,,1734.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.6,75,,1532.48,percent of total billed charges,75% of total billed charges for outpatient setting,1277.07,50,,1021.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2043.3,80,,1634.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2681.84,105,,2145.47,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.95,35,,715.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1532.48,60,,1225.98,percent of total billed charges,60% of total billed charges for outpatient setting,327.95,2681.84,
OSTEOSET PELLET INJECTOR 5CC / 87004805,69162512,CDM,278,RC,C1713,HCPCS,Outpatient,,,2774.63,2774.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1664.78,60,,1331.82,percent of total billed charges,60% of total Billed charges for outpatient setting,2355.11,84.88,,1884.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080.97,75,,1664.78,percent of total billed charges,75% of total billed charges for outpatient setting,1387.32,50,,1109.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.26,12.84,,285.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2219.7,80,,1775.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.26,12.84,,285.01,percent of total billed charges,12.84% of total billed charges,356.26,12.84,,285.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2913.36,105,,2330.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,971.12,35,,776.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1664.78,60,,1331.82,percent of total billed charges,60% of total billed charges for outpatient setting,356.26,2913.36,
OSTEOTOME 10.5MM 8IN MRLND / 2422-31-000,71000871,CDM,272,RC,,,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568,70,,1254.4,percent of total billed charges,70% of total billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1568,70,,1254.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1456,65,,1164.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2016,90,,1612.8,percent of total billed charges,90% of total billed charges for outpatient setting,287.62,2016,
OSTEOTOME 10MM 1.5IN MRLND / 2422-42-000,71000876,CDM,272,RC,,,Outpatient,,,1858.5,1858.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.95,70,,1040.76,percent of total billed charges,70% of total billed charges for outpatient setting,1577.49,84.88,,1261.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,929.25,50,,743.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1393.88,75,,1115.1,percent of total billed charges,75% of total billed charges for outpatient setting,1300.95,70,,1040.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.63,12.84,,190.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.8,80,,1189.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.63,12.84,,190.9,percent of total billed charges,12.84% of total billed charges,238.63,12.84,,190.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1208.03,65,,966.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.48,35,,520.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1672.65,90,,1338.12,percent of total billed charges,90% of total billed charges for outpatient setting,238.63,1672.65,
OSTEOTOME 10MM 3IN MRLND / 2422-44-000,71000872,CDM,272,RC,,,Outpatient,,,1858.5,1858.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.95,70,,1040.76,percent of total billed charges,70% of total billed charges for outpatient setting,1577.49,84.88,,1261.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,929.25,50,,743.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1393.88,75,,1115.1,percent of total billed charges,75% of total billed charges for outpatient setting,1300.95,70,,1040.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.63,12.84,,190.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.8,80,,1189.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.63,12.84,,190.9,percent of total billed charges,12.84% of total billed charges,238.63,12.84,,190.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1208.03,65,,966.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.48,35,,520.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1672.65,90,,1338.12,percent of total billed charges,90% of total billed charges for outpatient setting,238.63,1672.65,
OSTEOTOME 12MM MORELAND / 2422-75-000,71000874,CDM,272,RC,,,Outpatient,,,2402,2402,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1681.4,70,,1345.12,percent of total billed charges,70% of total billed charges for outpatient setting,2038.82,84.88,,1631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,1201,50,,960.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1801.5,75,,1441.2,percent of total billed charges,75% of total billed charges for outpatient setting,1681.4,70,,1345.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.42,12.84,,246.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1921.6,80,,1537.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.42,12.84,,246.74,percent of total billed charges,12.84% of total billed charges,308.42,12.84,,246.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1561.3,65,,1249.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.7,35,,672.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2161.8,90,,1729.44,percent of total billed charges,90% of total billed charges for outpatient setting,308.42,2161.8,
OSTEOTOME 12X120MM FLEX / 6210-0-710,71000469,CDM,278,RC,C1713,HCPCS,Outpatient,,,1243.52,1243.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.11,60,,596.89,percent of total billed charges,60% of total Billed charges for outpatient setting,1055.5,84.88,,844.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.64,75,,746.11,percent of total billed charges,75% of total billed charges for outpatient setting,621.76,50,,497.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.82,80,,795.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1243.52,65,,994.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.23,35,,348.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,746.11,60,,596.89,percent of total billed charges,60% of total billed charges for outpatient setting,159.67,1243.52,
OSTEOTOME 12X93MM FLEX / 6210-0-740,71000377,CDM,278,RC,C1713,HCPCS,Outpatient,,,1243.52,1243.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.11,60,,596.89,percent of total billed charges,60% of total Billed charges for outpatient setting,1055.5,84.88,,844.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.64,75,,746.11,percent of total billed charges,75% of total billed charges for outpatient setting,621.76,50,,497.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.82,80,,795.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1243.52,65,,994.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.23,35,,348.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,746.11,60,,596.89,percent of total billed charges,60% of total billed charges for outpatient setting,159.67,1243.52,
OSTEOTOME 6.0X67MM FLEX / 6210-0-720,71000378,CDM,272,RC,,,Outpatient,,,1243.52,1243.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,870.46,70,,696.37,percent of total billed charges,70% of total billed charges for outpatient setting,1055.5,84.88,,844.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,621.76,50,,497.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,932.64,75,,746.11,percent of total billed charges,75% of total billed charges for outpatient setting,870.46,70,,696.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.82,80,,795.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,808.29,65,,646.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.23,35,,348.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1119.17,90,,895.34,percent of total billed charges,90% of total billed charges for outpatient setting,159.67,1119.17,
OSTEOTOME 6.4X120MM FLEX / 6210-0-100,71000674,CDM,272,RC,,,Outpatient,,,805.04,805.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.53,70,,450.82,percent of total billed charges,70% of total billed charges for outpatient setting,683.32,84.88,,546.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,402.52,50,,322.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,603.78,75,,483.02,percent of total billed charges,75% of total billed charges for outpatient setting,563.53,70,,450.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.37,12.84,,82.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.03,80,,515.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.37,12.84,,82.7,percent of total billed charges,12.84% of total billed charges,103.37,12.84,,82.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,523.28,65,,418.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.76,35,,225.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,724.54,90,,579.63,percent of total billed charges,90% of total billed charges for outpatient setting,103.37,724.54,
OSTEOTOME 6MM 3IN MORELAND / 2422-43-000,71000875,CDM,272,RC,,,Outpatient,,,2331,2331,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.7,70,,1305.36,percent of total billed charges,70% of total billed charges for outpatient setting,1978.55,84.88,,1582.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1165.5,50,,932.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1748.25,75,,1398.6,percent of total billed charges,75% of total billed charges for outpatient setting,1631.7,70,,1305.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.8,80,,1491.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1515.15,65,,1212.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.85,35,,652.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2097.9,90,,1678.32,percent of total billed charges,90% of total billed charges for outpatient setting,299.3,2097.9,
OSTEOTOME 6MM 6IN MRLND / 2422-45-000,71000873,CDM,272,RC,,,Outpatient,,,2331,2331,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.7,70,,1305.36,percent of total billed charges,70% of total billed charges for outpatient setting,1978.55,84.88,,1582.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1165.5,50,,932.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1748.25,75,,1398.6,percent of total billed charges,75% of total billed charges for outpatient setting,1631.7,70,,1305.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.8,80,,1491.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,299.3,12.84,,239.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1515.15,65,,1212.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.85,35,,652.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2097.9,90,,1678.32,percent of total billed charges,90% of total billed charges for outpatient setting,299.3,2097.9,
OSTEOTOME 8.0X80MM FLEX / 6210-0-730,71000379,CDM,272,RC,,,Outpatient,,,1243.52,1243.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,870.46,70,,696.37,percent of total billed charges,70% of total billed charges for outpatient setting,1055.5,84.88,,844.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,621.76,50,,497.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,932.64,75,,746.11,percent of total billed charges,75% of total billed charges for outpatient setting,870.46,70,,696.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.82,80,,795.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,159.67,12.84,,127.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,808.29,65,,646.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.23,35,,348.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1119.17,90,,895.34,percent of total billed charges,90% of total billed charges for outpatient setting,159.67,1119.17,
OSTOMY SKIN CARE (ALOE) LOT:240ML,3301727,CDM,259,RC,,,Outpatient,,,5.04,5.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,84.88,,3.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.52,50,,2.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.78,75,,3.02,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,80,,3.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.28,65,,2.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,35,,1.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.54,90,,3.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.65,4.54,
OT ACTIVITIES OF DAILY LIVING,5100192,CDM,430,RC,97535,HCPCS,Outpatient,,,98.5,98.5,GO,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,70,,55.16,percent of total billed charges,70% of total billed charges for outpatient setting,83.61,84.88,,66.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.25,50,,39.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.88,75,,59.1,percent of total billed charges,75% of total billed charges for outpatient setting,68.95,70,,55.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.8,80,,63.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.48,35,,27.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.65,90,,70.92,percent of total billed charges,90% of total billed charges for outpatient setting,12.65,156,
OT EVALUATION,5100190,CDM,430,RC,97165,HCPCS,Outpatient,,,251.83,251.83,GO,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.28,70,,141.02,percent of total billed charges,70% of total billed charges for outpatient setting,213.75,84.88,,171,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.92,50,,100.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.87,75,,151.1,percent of total billed charges,75% of total billed charges for outpatient setting,176.28,70,,141.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.33,12.84,,25.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.46,80,,161.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.33,12.84,,25.86,percent of total billed charges,12.84% of total billed charges,32.33,12.84,,25.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.14,35,,70.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.65,90,,181.32,percent of total billed charges,90% of total billed charges for outpatient setting,32.33,226.65,
OT NEUROMUSCULAR REEDUCATION,5100193,CDM,430,RC,97112,HCPCS,Outpatient,,,182.25,182.25,GO,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,70,,102.06,percent of total billed charges,70% of total billed charges for outpatient setting,154.69,84.88,,123.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.13,50,,72.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.69,75,,109.35,percent of total billed charges,75% of total billed charges for outpatient setting,127.58,70,,102.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.8,80,,116.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.79,35,,51.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,164.03,90,,131.22,percent of total billed charges,90% of total billed charges for outpatient setting,23.4,164.03,
OT PROCEDURE  EA 15 MINUTES,5100194,CDM,430,RC,97110,HCPCS,Outpatient,,,178.46,178.46,GO,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,151.48,84.88,,121.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.23,50,,71.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.85,75,,107.08,percent of total billed charges,75% of total billed charges for outpatient setting,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,12.84,,18.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.77,80,,114.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,12.84,,18.33,percent of total billed charges,12.84% of total billed charges,22.91,12.84,,18.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.46,35,,49.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.61,90,,128.49,percent of total billed charges,90% of total billed charges for outpatient setting,22.91,160.61,
OTOBLOT 68KD AB,200818,CDM,301,RC,84181,HCPCS,Outpatient,,,76.64,68.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,65.05,84.88,,52.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.48,75,,45.98,percent of total billed charges,75% of total billed charges for outpatient setting,53.65,70,,42.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.31,80,,49.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,9.84,12.84,,7.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.87,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,100% of Custom Fee Schedule,68.98,90,,55.18,percent of total billed charges,90% of total billed charges for outpatient setting,9.84,68.98,
OVA / PARASITES-STOOL,222015,CDM,300,RC,87209,HCPCS,Outpatient,,,80.91,72.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.64,70,,45.31,percent of total billed charges,70% of total billed charges for outpatient setting,68.68,84.88,,54.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.68,75,,48.54,percent of total billed charges,75% of total billed charges for outpatient setting,56.64,70,,45.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.73,80,,51.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.08,100,,,Fee Schedule,100% of Custom Fee Schedule,72.82,90,,58.26,percent of total billed charges,90% of total billed charges for outpatient setting,17.98,72.82,
"OXALATE,QUANTITATIVE, 24HR URINE",202165,CDM,301,RC,83945,HCPCS,Outpatient,,,65.03,58.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.52,70,,36.42,percent of total billed charges,70% of total billed charges for outpatient setting,55.2,84.88,,44.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.77,75,,39.02,percent of total billed charges,75% of total billed charges for outpatient setting,45.52,70,,36.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.02,80,,41.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.8,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,100,,,Fee Schedule,100% of Custom Fee Schedule,58.53,90,,46.82,percent of total billed charges,90% of total billed charges for outpatient setting,14.45,58.53,
OXAZEPAM (SERAX) CAP : 15 MG,3301729,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
OXAZEPAM (SEREX) CAP : 10 MG,3301728,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
OXCARBAZEPINE TRILEPTAL,220901,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
OXFORD STABLECUT 506078,69161901,CDM,272,RC,,,Outpatient,,,1808.27,1808.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,1534.86,84.88,,1227.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,904.14,50,,723.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1356.2,75,,1084.96,percent of total billed charges,75% of total billed charges for outpatient setting,1265.79,70,,1012.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.62,80,,1157.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,232.18,12.84,,185.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1175.38,65,,940.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.89,35,,506.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.44,90,,1301.95,percent of total billed charges,90% of total billed charges for outpatient setting,232.18,1627.44,
OXICONAZOLE (OXISTAT) CRM 1% : 30GM,3301730,CDM,259,RC,,,Outpatient,,,104.54,104.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.18,70,,58.54,percent of total billed charges,70% of total billed charges for outpatient setting,88.73,84.88,,70.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.27,50,,41.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.41,75,,62.73,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,70,,58.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,12.84,,10.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.63,80,,66.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,13.42,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,67.95,65,,54.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.59,35,,29.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.09,90,,75.27,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,94.09,
OXYBUTYNIN (DITROPAN XL) TAB : 5 MG,3301731,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
OXYBUTYNIN (genericDITROPAN) TAB 5MG UD,3301733,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYBUTYNIN ER(genDITROPAN XL) 5MG TAB,3301732,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
OXYBUTYNIN ER(genDITROPAN XL)10 MG TAB,3305373,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYCODONE (PERCOLONE) TAB: 5 MG  U/D,3301734,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
OXYCODONE (PLAIN) 10MG TAB,3301735,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYCODONE (PLAIN) 5MG TAB,3302986,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
OXYCODONE 10-325MG(genericPERCOCET) TAB,3304466,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYCODONE 5-325MG(genericPERCOCET) TAB,3301740,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYCODONE 7.5 MG/APAP500MG: TAB,3302730,CDM,259,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
OXYCODONE ER (OXYCONTIN) 10MG TAB,3308156,CDM,259,RC,,,Outpatient,,,36.07,36.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.25,70,,20.2,percent of total billed charges,70% of total billed charges for outpatient setting,30.62,84.88,,24.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.04,50,,14.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.05,75,,21.64,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,70,,20.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,12.84,,3.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.86,80,,23.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.63,12.84,,3.7,percent of total billed charges,12.84% of total billed charges,4.63,12.84,,3.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.45,65,,18.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,35,,10.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.46,90,,25.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.63,32.46,
OXYCODONE ER (OXYCONTIN) 20MG TAB,3301737,CDM,259,RC,,,Outpatient,,,8.16,8.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,70,,4.57,percent of total billed charges,70% of total billed charges for outpatient setting,6.93,84.88,,5.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.08,50,,3.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.12,75,,4.9,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,70,,4.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,80,,5.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.3,65,,4.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,35,,2.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.34,90,,5.87,percent of total billed charges,90% of total billed charges for outpatient setting,1.05,7.34,
OXYCODONE ER (OXYCONTIN) 40MG TAB,3301738,CDM,259,RC,,,Outpatient,,,14.45,14.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,12.27,84.88,,9.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.23,50,,5.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.84,75,,8.67,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,70,,8.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,80,,9.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,1.86,12.84,,1.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.39,65,,7.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,35,,4.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.01,90,,10.41,percent of total billed charges,90% of total billed charges for outpatient setting,1.86,13.01,
OXYCODONE/APAP 10/650(PERCOCET):1 TAB,3302663,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
OXYGEN CATHETER 10FR  K21,6150453,CDM,272,RC,,,Outpatient,,,5.52,5.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,70,,3.09,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,84.88,,3.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.76,50,,2.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.14,75,,3.31,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,70,,3.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,80,,3.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.59,65,,2.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,35,,1.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.97,90,,3.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.71,4.97,
OXYGEN SAT - OVER NIGHT,1300020,CDM,460,RC,94762,HCPCS,Outpatient,,,247.23,247.23,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.06,70,,138.45,percent of total billed charges,70% of total billed charges for outpatient setting,209.85,84.88,,167.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,185.42,75,,148.34,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,70,,138.45,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,31.74,12.84,,25.392,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,197.78,80,,158.22,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,31.74,12.84,,25.39,percent of total billed charges,12.84% of total billed charges,31.74,12.84,,25.39,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,143,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,222.51,90,,178.01,percent of total billed charges,90% of total billed charges for outpatient setting,31.74,268.98,
OXYGEN SAT- OVER NIGHT,5100511,CDM,272,RC,94762,HCPCS,Outpatient,,,123.94,123.94,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,86.76,70,,69.41,percent of total billed charges,70% of total billed charges for outpatient setting,105.2,84.88,,84.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,92.96,75,,74.37,percent of total billed charges,75% of total billed charges for outpatient setting,86.76,70,,69.41,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,15.91,12.84,,12.728,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.15,80,,79.32,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,15.91,12.84,,12.73,percent of total billed charges,12.84% of total billed charges,15.91,12.84,,12.73,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,80.56,65,,64.45,percent of total billed charges,65% of total billed charges for outpatient setting,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,111.55,90,,89.24,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,268.98,
OXYGEN SAT SINGLE,5100510,CDM,460,RC,94760,HCPCS,Outpatient,,,60.88,60.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,70,,34.1,percent of total billed charges,70% of total billed charges for outpatient setting,51.67,84.88,,41.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.66,75,,36.53,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,70,,34.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.82,12.84,,6.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.7,80,,38.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.82,12.84,,6.26,percent of total billed charges,12.84% of total billed charges,7.82,12.84,,6.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.79,90,,43.83,percent of total billed charges,90% of total billed charges for outpatient setting,7.82,143,
OXYGEN SAT SINGLE,1300130,CDM,460,RC,94760,HCPCS,Outpatient,,,82.65,82.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,70,,46.29,percent of total billed charges,70% of total billed charges for outpatient setting,70.15,84.88,,56.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.99,75,,49.59,percent of total billed charges,75% of total billed charges for outpatient setting,57.86,70,,46.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,80,,52.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.39,90,,59.51,percent of total billed charges,90% of total billed charges for outpatient setting,10.61,143,
OXYGEN SENSOR MAX-10 / MAX-R112P10,69169530,CDM,270,RC,,,Outpatient,,,567.55,567.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.29,70,,317.83,percent of total billed charges,70% of total billed charges for outpatient setting,481.74,84.88,,385.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,283.78,50,,227.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425.66,75,,340.53,percent of total billed charges,75% of total billed charges for outpatient setting,397.29,70,,317.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.87,12.84,,58.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.04,80,,363.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.87,12.84,,58.3,percent of total billed charges,12.84% of total billed charges,72.87,12.84,,58.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,368.91,65,,295.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.64,35,,158.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,510.8,90,,408.64,percent of total billed charges,90% of total billed charges for outpatient setting,72.87,510.8,
OXYGEN TUBING 7' W/UNIV CONNECTOR/HU1925,69169032,CDM,270,RC,,,Outpatient,,,8.95,8.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,70,,5.02,percent of total billed charges,70% of total billed charges for outpatient setting,7.6,84.88,,6.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.48,50,,3.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.71,75,,5.37,percent of total billed charges,75% of total billed charges for outpatient setting,6.27,70,,5.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.16,80,,5.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.82,65,,4.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.06,90,,6.45,percent of total billed charges,90% of total billed charges for outpatient setting,1.15,8.06,
OXYMETAZOLINE (DRISTAN LA) SPRY : 15ML,3301741,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
OXYMETAZOLINE (DRISTAN LA) SPY:15ML,3301742,CDM,259,RC,,,Outpatient,,,5.52,5.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,70,,3.09,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,84.88,,3.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.76,50,,2.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.14,75,,3.31,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,70,,3.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,80,,3.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.59,65,,2.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,35,,1.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.97,90,,3.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.71,4.97,
OXYMETAZOLINE (genAFRIN CHILD)SPRAY 15ml,3314258,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
OXYMETAZOLINE (genericAFRIN) SPRAY 30ml,3302607,CDM,259,RC,,,Outpatient,,,23.6,23.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.52,70,,13.22,percent of total billed charges,70% of total billed charges for outpatient setting,20.03,84.88,,16.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.8,50,,9.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.7,75,,14.16,percent of total billed charges,75% of total billed charges for outpatient setting,16.52,70,,13.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,80,,15.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.03,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.34,65,,12.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,35,,6.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.24,90,,16.99,percent of total billed charges,90% of total billed charges for outpatient setting,3.03,21.24,
OXYTOCIN (PITOCIN) 10U/ML INJ  1 ML,3301744,CDM,636,RC,J2590,HCPCS,Outpatient,,,29.48,29.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,70,,16.51,percent of total billed charges,70% of total billed charges for outpatient setting,25.02,84.88,,20.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.11,75,,17.69,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,70,,16.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,12.84,,3.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.58,80,,18.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,12.84,,3.03,percent of total billed charges,12.84% of total billed charges,3.79,12.84,,3.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.16,65,,15.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.53,90,,21.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,26.53,
OXYTOCIN (PITOCIN) AMP 10U/ML:1ML,3301743,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PACEMAKER ADAPTA DR / ADDR01,70000132,CDM,278,RC,C1785,HCPCS,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
PACEMAKER ADAPTA DR SMALL / ADDRS1,70000143,CDM,278,RC,C1785,HCPCS,Outpatient,,,5600,5600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3360,60,,2688,percent of total billed charges,60% of total Billed charges for outpatient setting,4753.28,84.88,,3802.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,75,,3360,percent of total billed charges,75% of total billed charges for outpatient setting,2800,50,,2240,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.04,12.84,,575.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4480,80,,3584,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.04,12.84,,575.23,percent of total billed charges,12.84% of total billed charges,719.04,12.84,,575.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5880,105,,4704,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,35,,1568,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3360,60,,2688,percent of total billed charges,60% of total billed charges for outpatient setting,719.04,5880,
PACEMAKER ADVISA MRI SYSTEM PEEM,70000386,CDM,278,RC,C1786,HCPCS,Outpatient,,,8021.78,8021.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.07,60,,3850.46,percent of total billed charges,60% of total Billed charges for outpatient setting,6808.89,84.88,,5447.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.34,75,,4813.07,percent of total billed charges,75% of total billed charges for outpatient setting,4010.89,50,,3208.71,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030,12.84,,824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6417.42,80,,5133.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030,12.84,,824,percent of total billed charges,12.84% of total billed charges,1030,12.84,,824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8422.87,105,,6738.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2807.62,35,,2246.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4813.07,60,,3850.46,percent of total billed charges,60% of total billed charges for outpatient setting,1030,8422.87,
PACEMAKER ADVISA SR / A3SR01,70000680,CDM,275,RC,C1786,HCPCS,Outpatient,,,7100,7100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4970,70,,3976,percent of total billed charges,70% of total billed charges for outpatient setting,6026.48,84.88,,4821.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5325,75,,4260,percent of total billed charges,75% of total billed charges for outpatient setting,3550,50,,2840,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.64,12.84,,729.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5680,80,,4544,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.64,12.84,,729.31,percent of total billed charges,12.84% of total billed charges,911.64,12.84,,729.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7455,105,,5964,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2485,35,,1988,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6390,90,,5112,percent of total billed charges,90% of total billed charges for outpatient setting,911.64,7455,
PACEMAKER BATTERY CRT D314TRG,69162088,CDM,275,RC,C1785,HCPCS,Outpatient,,,51000,51000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35700,70,,28560,percent of total billed charges,70% of total billed charges for outpatient setting,43288.8,84.88,,34631.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38250,75,,30600,percent of total billed charges,75% of total billed charges for outpatient setting,25500,50,,20400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6548.4,12.84,,5238.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40800,80,,32640,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6548.4,12.84,,5238.72,percent of total billed charges,12.84% of total billed charges,6548.4,12.84,,5238.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53550,105,,42840,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17850,35,,14280,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45900,90,,36720,percent of total billed charges,90% of total billed charges for outpatient setting,6548.4,53550,
PACEMAKER BATTERY SENSIA DR / SEDR01,70000133,CDM,278,RC,C1785,HCPCS,Outpatient,,,5809.92,5809.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3485.95,60,,2788.76,percent of total billed charges,60% of total Billed charges for outpatient setting,4931.46,84.88,,3945.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4357.44,75,,3485.95,percent of total billed charges,75% of total billed charges for outpatient setting,2904.96,50,,2323.97,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.99,12.84,,596.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4647.94,80,,3718.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.99,12.84,,596.79,percent of total billed charges,12.84% of total billed charges,745.99,12.84,,596.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6100.42,105,,4880.34,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2033.47,35,,1626.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3485.95,60,,2788.76,percent of total billed charges,60% of total billed charges for outpatient setting,745.99,6100.42,
PACEMAKER DEFIB REPROGRAMMING,6100099,CDM,480,RC,93642,HCPCS,Outpatient,,,2394.83,2394.83,,1596.93,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,2032.73,84.88,,1626.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,1264.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1796.12,75,,1436.9,percent of total billed charges,75% of total billed charges for outpatient setting,1676.38,70,,1341.1,percent of total billed charges,70% of total billed charges for outpatient setting,1696.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2145.87,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,1746.64,175,,,Fee Schedule,175% of Medicare OPPS rate,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1915.86,80,,1532.69,percent of total billed charges,80% of total billed charges for outpatient setting,1397.3,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1247.59,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,307.5,12.84,,246,percent of total billed charges,12.84% of total billed charges,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,998.08,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,897.3,100,,,Fee Schedule,100% of Custom Fee Schedule,2155.35,90,,1724.28,percent of total billed charges,90% of total billed charges for outpatient setting,307.5,2155.35,
PACEMAKER REVO MRI / RVDR01,70000377,CDM,278,RC,C1785,HCPCS,Outpatient,,,7700,7700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4620,60,,3696,percent of total billed charges,60% of total Billed charges for outpatient setting,6535.76,84.88,,5228.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5775,75,,4620,percent of total billed charges,75% of total billed charges for outpatient setting,3850,50,,3080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,988.68,12.84,,790.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6160,80,,4928,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,988.68,12.84,,790.94,percent of total billed charges,12.84% of total billed charges,988.68,12.84,,790.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8085,105,,6468,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2695,35,,2156,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4620,60,,3696,percent of total billed charges,60% of total billed charges for outpatient setting,988.68,8085,
PACEMAKER SENSIA SR / SESR01,69159932,CDM,278,RC,C1786,HCPCS,Outpatient,,,4558,4558,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2734.8,60,,2187.84,percent of total billed charges,60% of total Billed charges for outpatient setting,3868.83,84.88,,3095.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3418.5,75,,2734.8,percent of total billed charges,75% of total billed charges for outpatient setting,2279,50,,1823.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.25,12.84,,468.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3646.4,80,,2917.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.25,12.84,,468.2,percent of total billed charges,12.84% of total billed charges,585.25,12.84,,468.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4785.9,105,,3828.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.3,35,,1276.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2734.8,60,,2187.84,percent of total billed charges,60% of total billed charges for outpatient setting,585.25,4785.9,
PACEMAKER VERSA DR / VEDR01,70000213,CDM,278,RC,C1785,HCPCS,Outpatient,,,5610.44,5610.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3366.26,60,,2693.01,percent of total billed charges,60% of total Billed charges for outpatient setting,4762.14,84.88,,3809.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4207.83,75,,3366.26,percent of total billed charges,75% of total billed charges for outpatient setting,2805.22,50,,2244.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.38,12.84,,576.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4488.35,80,,3590.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.38,12.84,,576.3,percent of total billed charges,12.84% of total billed charges,720.38,12.84,,576.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5890.96,105,,4712.77,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1963.65,35,,1570.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3366.26,60,,2693.01,percent of total billed charges,60% of total billed charges for outpatient setting,720.38,5890.96,
PACK AFFIRM EXTENSION DELVRY / 658.912S,69162361,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
PACK ANGIO,8370053,CDM,272,RC,,,Outpatient,,,530.34,530.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.24,70,,296.99,percent of total billed charges,70% of total billed charges for outpatient setting,450.15,84.88,,360.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,265.17,50,,212.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.76,75,,318.21,percent of total billed charges,75% of total billed charges for outpatient setting,371.24,70,,296.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,12.84,,54.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.27,80,,339.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,12.84,,54.48,percent of total billed charges,12.84% of total billed charges,68.1,12.84,,54.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344.72,65,,275.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.62,35,,148.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,477.31,90,,381.85,percent of total billed charges,90% of total billed charges for outpatient setting,68.1,477.31,
PACK ANT CERV SP CUSTM CARD / SNE43CSMSA,71500005,CDM,272,RC,,,Outpatient,,,597.16,597.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.01,70,,334.41,percent of total billed charges,70% of total billed charges for outpatient setting,506.87,84.88,,405.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,298.58,50,,238.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447.87,75,,358.3,percent of total billed charges,75% of total billed charges for outpatient setting,418.01,70,,334.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,12.84,,61.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.73,80,,382.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,12.84,,61.34,percent of total billed charges,12.84% of total billed charges,76.68,12.84,,61.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,388.15,65,,310.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.01,35,,167.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,537.44,90,,429.95,percent of total billed charges,90% of total billed charges for outpatient setting,76.68,537.44,
PACK BASIC OPTHALMIC  SEY43OPMSA,69159252,CDM,272,RC,,,Outpatient,,,225.7,225.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.99,70,,126.39,percent of total billed charges,70% of total billed charges for outpatient setting,191.57,84.88,,153.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.85,50,,90.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.28,75,,135.42,percent of total billed charges,75% of total billed charges for outpatient setting,157.99,70,,126.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.98,12.84,,23.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.56,80,,144.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.98,12.84,,23.18,percent of total billed charges,12.84% of total billed charges,28.98,12.84,,23.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.71,65,,117.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79,35,,63.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,203.13,90,,162.5,percent of total billed charges,90% of total billed charges for outpatient setting,28.98,203.13,
PACK CARPAL TUNNEL/SOP43CTMSG,6152728,CDM,272,RC,,,Outpatient,,,223.77,223.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.64,70,,125.31,percent of total billed charges,70% of total billed charges for outpatient setting,189.94,84.88,,151.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,111.89,50,,89.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.83,75,,134.26,percent of total billed charges,75% of total billed charges for outpatient setting,156.64,70,,125.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.73,12.84,,22.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.02,80,,143.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.73,12.84,,22.98,percent of total billed charges,12.84% of total billed charges,28.73,12.84,,22.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.45,65,,116.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.32,35,,62.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,201.39,90,,161.11,percent of total billed charges,90% of total billed charges for outpatient setting,28.73,201.39,
PACK CUSTOM CATARACT / AS5522-54,6152618,CDM,272,RC,,,Outpatient,,,1187.2,1187.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.04,70,,664.83,percent of total billed charges,70% of total billed charges for outpatient setting,1007.7,84.88,,806.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,593.6,50,,474.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890.4,75,,712.32,percent of total billed charges,75% of total billed charges for outpatient setting,831.04,70,,664.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.44,12.84,,121.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.76,80,,759.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.44,12.84,,121.95,percent of total billed charges,12.84% of total billed charges,152.44,12.84,,121.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,771.68,65,,617.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.52,35,,332.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1068.48,90,,854.78,percent of total billed charges,90% of total billed charges for outpatient setting,152.44,1068.48,
PACK CUSTOM CATH/SAN43CCMSC,2250150,CDM,272,RC,,,Outpatient,,,283.01,283.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.11,70,,158.49,percent of total billed charges,70% of total billed charges for outpatient setting,240.22,84.88,,192.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,141.51,50,,113.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.26,75,,169.81,percent of total billed charges,75% of total billed charges for outpatient setting,198.11,70,,158.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,12.84,,29.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.41,80,,181.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.34,12.84,,29.07,percent of total billed charges,12.84% of total billed charges,36.34,12.84,,29.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.96,65,,147.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.05,35,,79.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,254.71,90,,203.77,percent of total billed charges,90% of total billed charges for outpatient setting,36.34,254.71,
PACK CYSTO CUSTOM // DYNJ51665A,6152740,CDM,272,RC,,,Outpatient,,,154.96,154.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.47,70,,86.78,percent of total billed charges,70% of total billed charges for outpatient setting,131.53,84.88,,105.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.48,50,,61.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.22,75,,92.98,percent of total billed charges,75% of total billed charges for outpatient setting,108.47,70,,86.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,12.84,,15.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.97,80,,99.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,12.84,,15.92,percent of total billed charges,12.84% of total billed charges,19.9,12.84,,15.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.72,65,,80.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,35,,43.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.46,90,,111.57,percent of total billed charges,90% of total billed charges for outpatient setting,19.9,139.46,
PACK CYSTO CUSTOM CARD / SOT43CPMSA,71500002,CDM,272,RC,,,Outpatient,,,123.3,123.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.31,70,,69.05,percent of total billed charges,70% of total billed charges for outpatient setting,104.66,84.88,,83.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.65,50,,49.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.48,75,,73.98,percent of total billed charges,75% of total billed charges for outpatient setting,86.31,70,,69.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,12.84,,12.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.64,80,,78.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,12.84,,12.66,percent of total billed charges,12.84% of total billed charges,15.83,12.84,,12.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.15,65,,64.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.16,35,,34.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.97,90,,88.78,percent of total billed charges,90% of total billed charges for outpatient setting,15.83,110.97,
PACK CYSTOSCOPY / DYNJP5040,69162263,CDM,272,RC,,,Outpatient,,,51.41,51.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.99,70,,28.79,percent of total billed charges,70% of total billed charges for outpatient setting,43.64,84.88,,34.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.71,50,,20.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.56,75,,30.85,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,70,,28.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.6,12.84,,5.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.13,80,,32.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.6,12.84,,5.28,percent of total billed charges,12.84% of total billed charges,6.6,12.84,,5.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.42,65,,26.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.99,35,,14.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.27,90,,37.02,percent of total billed charges,90% of total billed charges for outpatient setting,6.6,46.27,
PACK DRAPE HEAD/NECK STERILE,6150213,CDM,272,RC,,,Outpatient,,,89.52,89.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.66,70,,50.13,percent of total billed charges,70% of total billed charges for outpatient setting,75.98,84.88,,60.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.76,50,,35.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.14,75,,53.71,percent of total billed charges,75% of total billed charges for outpatient setting,62.66,70,,50.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.49,12.84,,9.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.62,80,,57.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.49,12.84,,9.19,percent of total billed charges,12.84% of total billed charges,11.49,12.84,,9.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.19,65,,46.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.33,35,,25.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.57,90,,64.46,percent of total billed charges,90% of total billed charges for outpatient setting,11.49,80.57,
PACK ENDOSCOPY CUSTOM / DYNJ51666,6152726,CDM,272,RC,,,Outpatient,,,273.54,273.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.48,70,,153.18,percent of total billed charges,70% of total billed charges for outpatient setting,232.18,84.88,,185.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.77,50,,109.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.16,75,,164.13,percent of total billed charges,75% of total billed charges for outpatient setting,191.48,70,,153.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,12.84,,28.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.83,80,,175.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,12.84,,28.1,percent of total billed charges,12.84% of total billed charges,35.12,12.84,,28.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.8,65,,142.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.74,35,,76.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,246.19,90,,196.95,percent of total billed charges,90% of total billed charges for outpatient setting,35.12,246.19,
PACK FESS CUSTOM CARD / SEN43FPMSA,71500004,CDM,272,RC,,,Outpatient,,,169.15,169.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.41,70,,94.73,percent of total billed charges,70% of total billed charges for outpatient setting,143.57,84.88,,114.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.58,50,,67.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.86,75,,101.49,percent of total billed charges,75% of total billed charges for outpatient setting,118.41,70,,94.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.72,12.84,,17.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.32,80,,108.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.72,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,21.72,12.84,,17.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.95,65,,87.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.2,35,,47.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.24,90,,121.79,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,152.24,
PACK GEN LAP CUSTOM CARD / SBA43LPMSA,71500012,CDM,272,RC,,,Outpatient,,,401.52,401.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.06,70,,224.85,percent of total billed charges,70% of total billed charges for outpatient setting,340.81,84.88,,272.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.76,50,,160.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.14,75,,240.91,percent of total billed charges,75% of total billed charges for outpatient setting,281.06,70,,224.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.56,12.84,,41.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.22,80,,256.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.56,12.84,,41.25,percent of total billed charges,12.84% of total billed charges,51.56,12.84,,41.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.99,65,,208.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.53,35,,112.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.37,90,,289.1,percent of total billed charges,90% of total billed charges for outpatient setting,51.56,361.37,
PACK HEAD AND NECK / DYNJ51667,6152579,CDM,272,RC,,,Outpatient,,,199,199,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.3,70,,111.44,percent of total billed charges,70% of total billed charges for outpatient setting,168.91,84.88,,135.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.5,50,,79.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.25,75,,119.4,percent of total billed charges,75% of total billed charges for outpatient setting,139.3,70,,111.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.55,12.84,,20.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.2,80,,127.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.55,12.84,,20.44,percent of total billed charges,12.84% of total billed charges,25.55,12.84,,20.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.35,65,,103.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.65,35,,55.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.1,90,,143.28,percent of total billed charges,90% of total billed charges for outpatient setting,25.55,179.1,
PACK HEAD AND NECK CSTM / SEN43HPMSA,71500003,CDM,272,RC,,,Outpatient,,,215.55,215.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.89,70,,120.71,percent of total billed charges,70% of total billed charges for outpatient setting,182.96,84.88,,146.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.78,50,,86.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.66,75,,129.33,percent of total billed charges,75% of total billed charges for outpatient setting,150.89,70,,120.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.68,12.84,,22.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.44,80,,137.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.68,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,27.68,12.84,,22.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.11,65,,112.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.44,35,,60.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194,90,,155.2,percent of total billed charges,90% of total billed charges for outpatient setting,27.68,194,
PACK HIP SOP43HPGRG   GRMC,69162286,CDM,270,RC,,,Outpatient,,,446.31,446.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.42,70,,249.94,percent of total billed charges,70% of total billed charges for outpatient setting,378.83,84.88,,303.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,223.16,50,,178.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.73,75,,267.78,percent of total billed charges,75% of total billed charges for outpatient setting,312.42,70,,249.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.31,12.84,,45.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.05,80,,285.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.31,12.84,,45.85,percent of total billed charges,12.84% of total billed charges,57.31,12.84,,45.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,290.1,65,,232.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.21,35,,124.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,401.68,90,,321.34,percent of total billed charges,90% of total billed charges for outpatient setting,57.31,401.68,
PACK ICE STAY SRY SMALL,7650675,CDM,270,RC,,,Outpatient,,,10.52,10.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.36,70,,5.89,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,84.88,,7.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.26,50,,4.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.89,75,,6.31,percent of total billed charges,75% of total billed charges for outpatient setting,7.36,70,,5.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,80,,6.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,1.35,12.84,,1.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.84,65,,5.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,35,,2.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.47,90,,7.58,percent of total billed charges,90% of total billed charges for outpatient setting,1.35,9.47,
PACK JOINT TOTAL CSTM CARD / SOP43TKMSA,71500017,CDM,272,RC,,,Outpatient,,,219.08,219.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.36,70,,122.69,percent of total billed charges,70% of total billed charges for outpatient setting,185.96,84.88,,148.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.54,50,,87.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.31,75,,131.45,percent of total billed charges,75% of total billed charges for outpatient setting,153.36,70,,122.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,12.84,,22.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.26,80,,140.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,12.84,,22.5,percent of total billed charges,12.84% of total billed charges,28.13,12.84,,22.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.4,65,,113.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,35,,61.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,197.17,90,,157.74,percent of total billed charges,90% of total billed charges for outpatient setting,28.13,197.17,
PACK KNEE ARTHRO CSTM CARD / SOP43APMSA,71500013,CDM,272,RC,,,Outpatient,,,211.52,211.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.06,70,,118.45,percent of total billed charges,70% of total billed charges for outpatient setting,179.54,84.88,,143.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.76,50,,84.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.64,75,,126.91,percent of total billed charges,75% of total billed charges for outpatient setting,148.06,70,,118.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,12.84,,21.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.22,80,,135.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,12.84,,21.73,percent of total billed charges,12.84% of total billed charges,27.16,12.84,,21.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.49,65,,109.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,35,,59.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.37,90,,152.3,percent of total billed charges,90% of total billed charges for outpatient setting,27.16,190.37,
PACK KNEE ARTHROSCOPY // DYNJ51668,6152580,CDM,272,RC,,,Outpatient,,,238.63,238.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.04,70,,133.63,percent of total billed charges,70% of total billed charges for outpatient setting,202.55,84.88,,162.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.32,50,,95.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.97,75,,143.18,percent of total billed charges,75% of total billed charges for outpatient setting,167.04,70,,133.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.9,80,,152.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,30.64,12.84,,24.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.11,65,,124.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.52,35,,66.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.77,90,,171.82,percent of total billed charges,90% of total billed charges for outpatient setting,30.64,214.77,
PACK LAMINECTOMY CSTM CARD / SNE43LPMSA,71500006,CDM,272,RC,,,Outpatient,,,590.08,590.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.06,70,,330.45,percent of total billed charges,70% of total billed charges for outpatient setting,500.86,84.88,,400.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,295.04,50,,236.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.56,75,,354.05,percent of total billed charges,75% of total billed charges for outpatient setting,413.06,70,,330.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.77,12.84,,60.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.06,80,,377.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.77,12.84,,60.62,percent of total billed charges,12.84% of total billed charges,75.77,12.84,,60.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,383.55,65,,306.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.53,35,,165.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,531.07,90,,424.86,percent of total billed charges,90% of total billed charges for outpatient setting,75.77,531.07,
PACK LOWER EXTRMITY CARD / SOP43LEMSA,71500007,CDM,272,RC,,,Outpatient,,,222.4,222.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.68,70,,124.54,percent of total billed charges,70% of total billed charges for outpatient setting,188.77,84.88,,151.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,111.2,50,,88.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.8,75,,133.44,percent of total billed charges,75% of total billed charges for outpatient setting,155.68,70,,124.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,12.84,,22.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.92,80,,142.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,12.84,,22.85,percent of total billed charges,12.84% of total billed charges,28.56,12.84,,22.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,144.56,65,,115.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.84,35,,62.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,200.16,90,,160.13,percent of total billed charges,90% of total billed charges for outpatient setting,28.56,200.16,
PACK MINOR CUSTOM CARD / SOP43MPMSA,71500008,CDM,272,RC,,,Outpatient,,,163.1,163.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.17,70,,91.34,percent of total billed charges,70% of total billed charges for outpatient setting,138.44,84.88,,110.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.55,50,,65.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.33,75,,97.86,percent of total billed charges,75% of total billed charges for outpatient setting,114.17,70,,91.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.94,12.84,,16.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.48,80,,104.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.94,12.84,,16.75,percent of total billed charges,12.84% of total billed charges,20.94,12.84,,16.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.02,65,,84.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.09,35,,45.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.79,90,,117.43,percent of total billed charges,90% of total billed charges for outpatient setting,20.94,146.79,
PACK OSTOMY KIT/SUPPLIES,69160385,CDM,270,RC,,,Outpatient,,,3435.83,3435.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2405.08,70,,1924.06,percent of total billed charges,70% of total billed charges for outpatient setting,2916.33,84.88,,2333.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,1717.92,50,,1374.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2576.87,75,,2061.5,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.16,12.84,,352.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2748.66,80,,2198.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.16,12.84,,352.93,percent of total billed charges,12.84% of total billed charges,441.16,12.84,,352.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2233.29,65,,1786.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1202.54,35,,962.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3092.25,90,,2473.8,percent of total billed charges,90% of total billed charges for outpatient setting,441.16,3092.25,
PACK PEDIATRIC 29490,69161684,CDM,270,RC,,,Outpatient,,,112.68,112.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.88,70,,63.1,percent of total billed charges,70% of total billed charges for outpatient setting,95.64,84.88,,76.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.34,50,,45.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.51,75,,67.61,percent of total billed charges,75% of total billed charges for outpatient setting,78.88,70,,63.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.47,12.84,,11.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.14,80,,72.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.47,12.84,,11.58,percent of total billed charges,12.84% of total billed charges,14.47,12.84,,11.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.24,65,,58.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,35,,31.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,101.41,90,,81.13,percent of total billed charges,90% of total billed charges for outpatient setting,14.47,101.41,
PACK PERIGYN CUSTOM CARD / SMA43PPMSA,71500016,CDM,272,RC,,,Outpatient,,,71.54,71.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.08,70,,40.06,percent of total billed charges,70% of total billed charges for outpatient setting,60.72,84.88,,48.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.77,50,,28.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.66,75,,42.93,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,70,,40.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,12.84,,7.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.23,80,,45.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,12.84,,7.35,percent of total billed charges,12.84% of total billed charges,9.19,12.84,,7.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.5,65,,37.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.04,35,,20.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.39,90,,51.51,percent of total billed charges,90% of total billed charges for outpatient setting,9.19,64.39,
PACK PLASTIC CUSTOM CARD / SBA43PPMSA,71500015,CDM,272,RC,,,Outpatient,,,364.36,364.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.05,70,,204.04,percent of total billed charges,70% of total billed charges for outpatient setting,309.27,84.88,,247.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,182.18,50,,145.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,273.27,75,,218.62,percent of total billed charges,75% of total billed charges for outpatient setting,255.05,70,,204.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,12.84,,37.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.49,80,,233.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,12.84,,37.42,percent of total billed charges,12.84% of total billed charges,46.78,12.84,,37.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.83,65,,189.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.53,35,,102.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,327.92,90,,262.34,percent of total billed charges,90% of total billed charges for outpatient setting,46.78,327.92,
PACK PLASTIC P&S/ DYNJ51199D,6153035,CDM,272,RC,,,Outpatient,,,456.8,456.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.76,70,,255.81,percent of total billed charges,70% of total billed charges for outpatient setting,387.73,84.88,,310.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,228.4,50,,182.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342.6,75,,274.08,percent of total billed charges,75% of total billed charges for outpatient setting,319.76,70,,255.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.44,80,,292.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,58.65,12.84,,46.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,296.92,65,,237.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.88,35,,127.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,411.12,90,,328.9,percent of total billed charges,90% of total billed charges for outpatient setting,58.65,411.12,
PACK PRE-OP CUSTOM / DYKS1045,70500015,CDM,272,RC,,,Outpatient,,,107.07,107.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.95,70,,59.96,percent of total billed charges,70% of total billed charges for outpatient setting,90.88,84.88,,72.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.54,50,,42.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.3,75,,64.24,percent of total billed charges,75% of total billed charges for outpatient setting,74.95,70,,59.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.66,80,,68.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.6,65,,55.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.47,35,,29.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.36,90,,77.09,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,96.36,
PACK ROBOT CUSTOM CARD / SBA43RPMSA,71500011,CDM,272,RC,,,Outpatient,,,510.92,510.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.64,70,,286.11,percent of total billed charges,70% of total billed charges for outpatient setting,433.67,84.88,,346.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,255.46,50,,204.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,383.19,75,,306.55,percent of total billed charges,75% of total billed charges for outpatient setting,357.64,70,,286.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.6,12.84,,52.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.74,80,,326.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.6,12.84,,52.48,percent of total billed charges,12.84% of total billed charges,65.6,12.84,,52.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,332.1,65,,265.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.82,35,,143.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,459.83,90,,367.86,percent of total billed charges,90% of total billed charges for outpatient setting,65.6,459.83,
PACK ROBOT GYN CUSTOM CARD / SMA43GRMSA,71500010,CDM,272,RC,,,Outpatient,,,659.64,659.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.75,70,,369.4,percent of total billed charges,70% of total billed charges for outpatient setting,559.9,84.88,,447.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,329.82,50,,263.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494.73,75,,395.78,percent of total billed charges,75% of total billed charges for outpatient setting,461.75,70,,369.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.7,12.84,,67.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.71,80,,422.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.7,12.84,,67.76,percent of total billed charges,12.84% of total billed charges,84.7,12.84,,67.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,428.77,65,,343.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.87,35,,184.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,593.68,90,,474.94,percent of total billed charges,90% of total billed charges for outpatient setting,84.7,593.68,
PACK SHOULDER / DYNJ51670,6152581,CDM,272,RC,,,Outpatient,,,270.29,270.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.2,70,,151.36,percent of total billed charges,70% of total billed charges for outpatient setting,229.42,84.88,,183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,135.15,50,,108.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.72,75,,162.18,percent of total billed charges,75% of total billed charges for outpatient setting,189.2,70,,151.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.71,12.84,,27.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.23,80,,172.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.71,12.84,,27.77,percent of total billed charges,12.84% of total billed charges,34.71,12.84,,27.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.69,65,,140.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.6,35,,75.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,243.26,90,,194.61,percent of total billed charges,90% of total billed charges for outpatient setting,34.71,243.26,
PACK SHOULDER CUSTOM CARD / SOP43SPMSA,71500001,CDM,272,RC,,,Outpatient,,,219.08,219.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.36,70,,122.69,percent of total billed charges,70% of total billed charges for outpatient setting,185.96,84.88,,148.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.54,50,,87.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.31,75,,131.45,percent of total billed charges,75% of total billed charges for outpatient setting,153.36,70,,122.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,12.84,,22.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.26,80,,140.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,12.84,,22.5,percent of total billed charges,12.84% of total billed charges,28.13,12.84,,22.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.4,65,,113.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,35,,61.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,197.17,90,,157.74,percent of total billed charges,90% of total billed charges for outpatient setting,28.13,197.17,
PACK SHOULDER W/ DRAPE / 29367,565851,CDM,272,RC,,,Outpatient,,,131.58,131.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.11,70,,73.69,percent of total billed charges,70% of total billed charges for outpatient setting,111.69,84.88,,89.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.79,50,,52.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.69,75,,78.95,percent of total billed charges,75% of total billed charges for outpatient setting,92.11,70,,73.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.89,12.84,,13.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.26,80,,84.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.89,12.84,,13.51,percent of total billed charges,12.84% of total billed charges,16.89,12.84,,13.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.53,65,,68.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.05,35,,36.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.42,90,,94.74,percent of total billed charges,90% of total billed charges for outpatient setting,16.89,118.42,
PACK T & A / DYNJ51671,69159028,CDM,272,RC,,,Outpatient,,,79.87,79.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.91,70,,44.73,percent of total billed charges,70% of total billed charges for outpatient setting,67.79,84.88,,54.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.94,50,,31.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.9,75,,47.92,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,70,,44.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.26,12.84,,8.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.9,80,,51.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.26,12.84,,8.21,percent of total billed charges,12.84% of total billed charges,10.26,12.84,,8.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.92,65,,41.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.95,35,,22.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.88,90,,57.5,percent of total billed charges,90% of total billed charges for outpatient setting,10.26,71.88,
PACK T AND A CUSTOM CARD / SEN43TAMSA,71500014,CDM,272,RC,,,Outpatient,,,106.56,106.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.59,70,,59.67,percent of total billed charges,70% of total billed charges for outpatient setting,90.45,84.88,,72.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.28,50,,42.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.92,75,,63.94,percent of total billed charges,75% of total billed charges for outpatient setting,74.59,70,,59.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,12.84,,10.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.25,80,,68.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,12.84,,10.94,percent of total billed charges,12.84% of total billed charges,13.68,12.84,,10.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.26,65,,55.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.3,35,,29.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.9,90,,76.72,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,95.9,
PACK UPPER EXTREMITY CARD / SOP43UPMSA,71500009,CDM,272,RC,,,Outpatient,,,223.56,223.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.49,70,,125.19,percent of total billed charges,70% of total billed charges for outpatient setting,189.76,84.88,,151.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,111.78,50,,89.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.67,75,,134.14,percent of total billed charges,75% of total billed charges for outpatient setting,156.49,70,,125.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.71,12.84,,22.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.85,80,,143.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.71,12.84,,22.97,percent of total billed charges,12.84% of total billed charges,28.71,12.84,,22.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.31,65,,116.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.25,35,,62.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,201.2,90,,160.96,percent of total billed charges,90% of total billed charges for outpatient setting,28.71,201.2,
PACKING IODOFORM 1/2IN / NON256125H,6150475,CDM,272,RC,,,Outpatient,,,15.75,15.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,13.37,84.88,,10.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.88,50,,6.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.81,75,,9.45,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,80,,10.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.24,65,,8.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,35,,4.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.18,90,,11.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.18,
PACKING IODOFORM 1/4 IN // NON256145H,6150474,CDM,272,RC,A6266,HCPCS,Outpatient,,,21.15,21.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,70,,11.85,percent of total billed charges,70% of total billed charges for outpatient setting,17.95,84.88,,14.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,75,,12.69,percent of total billed charges,75% of total billed charges for outpatient setting,14.81,70,,11.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,80,,13.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.75,65,,11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,90,,15.23,percent of total billed charges,90% of total billed charges for outpatient setting,2.72,19.04,
PACKS SINUS KENNEDY/400422,6150686,CDM,272,RC,,,Outpatient,,,277.24,277.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.07,70,,155.26,percent of total billed charges,70% of total billed charges for outpatient setting,235.32,84.88,,188.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,138.62,50,,110.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.93,75,,166.34,percent of total billed charges,75% of total billed charges for outpatient setting,194.07,70,,155.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.6,12.84,,28.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.79,80,,177.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.6,12.84,,28.48,percent of total billed charges,12.84% of total billed charges,35.6,12.84,,28.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.21,65,,144.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.03,35,,77.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.52,90,,199.62,percent of total billed charges,90% of total billed charges for outpatient setting,35.6,249.52,
PACKS SINUS TOFFELL/400423,6150687,CDM,272,RC,,,Outpatient,,,174.42,174.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.09,70,,97.67,percent of total billed charges,70% of total billed charges for outpatient setting,148.05,84.88,,118.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,87.21,50,,69.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.82,75,,104.66,percent of total billed charges,75% of total billed charges for outpatient setting,122.09,70,,97.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.4,12.84,,17.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.54,80,,111.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.4,12.84,,17.92,percent of total billed charges,12.84% of total billed charges,22.4,12.84,,17.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,113.37,65,,90.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,35,,48.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,156.98,90,,125.58,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,156.98,
PACLITAXEL TUBING/2C8858,69169068,CDM,272,RC,,,Outpatient,,,81.84,81.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.29,70,,45.83,percent of total billed charges,70% of total billed charges for outpatient setting,69.47,84.88,,55.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.92,50,,32.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.38,75,,49.1,percent of total billed charges,75% of total billed charges for outpatient setting,57.29,70,,45.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.51,12.84,,8.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.47,80,,52.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.51,12.84,,8.41,percent of total billed charges,12.84% of total billed charges,10.51,12.84,,8.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.2,65,,42.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.64,35,,22.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.66,90,,58.93,percent of total billed charges,90% of total billed charges for outpatient setting,10.51,73.66,
PAD 5X9IN ABD / 9190A,6150883,CDM,272,RC,,,Outpatient,,,1.32,1.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,70,,0.74,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,84.88,,0.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.66,50,,0.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.99,75,,0.79,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,70,,0.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,12.84,,0.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,80,,0.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,0.17,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.86,65,,0.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,35,,0.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.19,90,,0.95,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,1.19,
PAD ADHESIVE TRACKER / 9732500,2452068,CDM,272,RC,,,Outpatient,,,34.96,34.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.47,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,29.67,84.88,,23.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.48,50,,13.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.22,75,,20.98,percent of total billed charges,75% of total billed charges for outpatient setting,24.47,70,,19.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,80,,22.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.72,65,,18.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,35,,9.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.46,90,,25.17,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.46,
PAD ADULT BOVIE VLAB / E7507,300120,CDM,272,RC,,,Outpatient,,,28.96,28.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.27,70,,16.22,percent of total billed charges,70% of total billed charges for outpatient setting,24.58,84.88,,19.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.48,50,,11.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.72,75,,17.38,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,70,,16.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,12.84,,2.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.17,80,,18.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,3.72,12.84,,2.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.82,65,,15.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.14,35,,8.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.06,90,,20.85,percent of total billed charges,90% of total billed charges for outpatient setting,3.72,26.06,
PAD ANKLE WRAP  POLAR CARE / 04730,69162754,CDM,270,RC,,,Outpatient,,,206.8,206.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.76,70,,115.81,percent of total billed charges,70% of total billed charges for outpatient setting,175.53,84.88,,140.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.4,50,,82.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.1,75,,124.08,percent of total billed charges,75% of total billed charges for outpatient setting,144.76,70,,115.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,12.84,,21.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.44,80,,132.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,12.84,,21.24,percent of total billed charges,12.84% of total billed charges,26.55,12.84,,21.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.42,65,,107.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.38,35,,57.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,186.12,90,,148.9,percent of total billed charges,90% of total billed charges for outpatient setting,26.55,186.12,
PAD BOOT/ WRAP/ DEMAYO / 803-GP-10,69162688,CDM,272,RC,,,Outpatient,,,186.56,186.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.59,70,,104.47,percent of total billed charges,70% of total billed charges for outpatient setting,158.35,84.88,,126.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,93.28,50,,74.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.92,75,,111.94,percent of total billed charges,75% of total billed charges for outpatient setting,130.59,70,,104.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.95,12.84,,19.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.25,80,,119.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.95,12.84,,19.16,percent of total billed charges,12.84% of total billed charges,23.95,12.84,,19.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,121.26,65,,97.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,35,,52.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.9,90,,134.32,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,167.9,
PAD BOVIE ARTHREX / AR-9610SGP,71000230,CDM,272,RC,,,Outpatient,,,49,49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,41.59,84.88,,33.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,75,,29.4,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,80,,31.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.85,65,,25.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.1,90,,35.28,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.1,
PAD DEFIB ORANGE 4.5 X 4.5/M2345N,5150141,CDM,270,RC,,,Outpatient,,,39.95,39.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,70,,22.38,percent of total billed charges,70% of total billed charges for outpatient setting,33.91,84.88,,27.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.98,50,,15.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.96,75,,23.97,percent of total billed charges,75% of total billed charges for outpatient setting,27.97,70,,22.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,12.84,,4.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.96,80,,25.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,5.13,12.84,,4.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.97,65,,20.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.98,35,,11.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.96,90,,28.77,percent of total billed charges,90% of total billed charges for outpatient setting,5.13,35.96,
PAD FLYTE HELMET NS / 0408-210-000,10649,CDM,272,RC,,,Outpatient,,,76.09,76.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.26,70,,42.61,percent of total billed charges,70% of total billed charges for outpatient setting,64.59,84.88,,51.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.05,50,,30.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.07,75,,45.66,percent of total billed charges,75% of total billed charges for outpatient setting,53.26,70,,42.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,12.84,,7.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.87,80,,48.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,12.84,,7.82,percent of total billed charges,12.84% of total billed charges,9.77,12.84,,7.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.46,65,,39.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.63,35,,21.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.48,90,,54.78,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,68.48,
PAD FOOT REGULAR AV IMPULSE / 5065,70000098,CDM,270,RC,,,Outpatient,,,308.88,308.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.22,70,,172.98,percent of total billed charges,70% of total billed charges for outpatient setting,262.18,84.88,,209.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,154.44,50,,123.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.66,75,,185.33,percent of total billed charges,75% of total billed charges for outpatient setting,216.22,70,,172.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.66,12.84,,31.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.1,80,,197.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.66,12.84,,31.73,percent of total billed charges,12.84% of total billed charges,39.66,12.84,,31.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,200.77,65,,160.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.11,35,,86.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,277.99,90,,222.39,percent of total billed charges,90% of total billed charges for outpatient setting,39.66,277.99,
PAD HEEL FOAM / NON081440PH,70000432,CDM,270,RC,,,Outpatient,,,26.82,26.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,22.76,84.88,,18.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.41,50,,10.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.12,75,,16.1,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,70,,15.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.46,80,,17.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,3.44,12.84,,2.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.43,65,,13.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,35,,7.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.14,90,,19.31,percent of total billed charges,90% of total billed charges for outpatient setting,3.44,24.14,
PAD KNEE WRAP POLAR CARE / 04790,69162402,CDM,270,RC,,,Outpatient,,,124.65,124.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.26,70,,69.81,percent of total billed charges,70% of total billed charges for outpatient setting,105.8,84.88,,84.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.33,50,,49.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.49,75,,74.79,percent of total billed charges,75% of total billed charges for outpatient setting,87.26,70,,69.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.01,12.84,,12.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.72,80,,79.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.01,12.84,,12.81,percent of total billed charges,12.84% of total billed charges,16.01,12.84,,12.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.02,65,,64.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.63,35,,34.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.19,90,,89.75,percent of total billed charges,90% of total billed charges for outpatient setting,16.01,112.19,
PAD SHOULDER  XL POLAR CARE / 04905,69161476,CDM,270,RC,,,Outpatient,,,198.85,198.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,70,,111.36,percent of total billed charges,70% of total billed charges for outpatient setting,168.78,84.88,,135.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.43,50,,79.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.14,75,,119.31,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,70,,111.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.53,12.84,,20.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.08,80,,127.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.53,12.84,,20.42,percent of total billed charges,12.84% of total billed charges,25.53,12.84,,20.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.25,65,,103.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.6,35,,55.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,178.97,90,,143.18,percent of total billed charges,90% of total billed charges for outpatient setting,25.53,178.97,
PAD SHUREFOOT POSITIONER / 508-0111,69169724,CDM,271,RC,,,Outpatient,,,82.1,82.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.47,70,,45.98,percent of total billed charges,70% of total billed charges for outpatient setting,69.69,84.88,,55.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.05,50,,32.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.58,75,,49.26,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,70,,45.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.54,12.84,,8.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.68,80,,52.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.54,12.84,,8.43,percent of total billed charges,12.84% of total billed charges,10.54,12.84,,8.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.37,65,,42.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,35,,22.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.89,90,,59.11,percent of total billed charges,90% of total billed charges for outpatient setting,10.54,73.89,
PAD TEMP THERAPY DISPO W/,5150134,CDM,270,RC,,,Outpatient,,,36.87,36.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,70,,20.65,percent of total billed charges,70% of total billed charges for outpatient setting,31.3,84.88,,25.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,50,,14.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.65,75,,22.12,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,70,,20.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.5,80,,23.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.73,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.97,65,,19.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,35,,10.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.18,90,,26.54,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,33.18,
PAD ULNAR NERVE PROTECTOR / FP-UN1,6150128,CDM,272,RC,,,Outpatient,,,16.1,16.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,13.67,84.88,,10.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.05,50,,6.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.08,75,,9.66,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,80,,10.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.07,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.47,65,,8.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,35,,4.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.49,90,,11.59,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,14.49,
PADDLE BLANK COVEREDGE 32 / SC-4231-36,70000139,CDM,272,RC,,,Outpatient,,,202.79,202.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,172.13,84.88,,137.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.4,50,,81.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.09,75,,121.67,percent of total billed charges,75% of total billed charges for outpatient setting,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,80,,129.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.81,65,,105.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.98,35,,56.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.51,90,,146.01,percent of total billed charges,90% of total billed charges for outpatient setting,26.04,182.51,
PAD-PERI,5150183,CDM,270,RC,,,Outpatient,,,8.6,8.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,84.88,,5.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.3,50,,3.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.45,75,,5.16,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,80,,5.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.59,65,,4.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,35,,2.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.74,90,,6.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.74,
PAD-PERI/KC1380,7651118,CDM,270,RC,,,Outpatient,,,8.6,8.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,84.88,,5.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.3,50,,3.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.45,75,,5.16,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,80,,5.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.59,65,,4.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,35,,2.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.74,90,,6.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.74,
PADS BOVIE XODUS / 20240,71000249,CDM,272,RC,,,Outpatient,,,29.76,29.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,25.26,84.88,,20.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.88,50,,11.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.32,75,,17.86,percent of total billed charges,75% of total billed charges for outpatient setting,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,12.84,,3.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.81,80,,19.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,3.82,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.34,65,,15.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,35,,8.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.78,90,,21.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.82,26.78,
"PAIN CONTROL PUMP, LMA  550ML /1-14ML/HR",69162044,CDM,272,RC,,,Outpatient,,,1445.15,1445.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.61,70,,809.29,percent of total billed charges,70% of total billed charges for outpatient setting,1226.64,84.88,,981.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,722.58,50,,578.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083.86,75,,867.09,percent of total billed charges,75% of total billed charges for outpatient setting,1011.61,70,,809.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.56,12.84,,148.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.12,80,,924.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.56,12.84,,148.45,percent of total billed charges,12.84% of total billed charges,185.56,12.84,,148.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,939.35,65,,751.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.8,35,,404.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1300.64,90,,1040.51,percent of total billed charges,90% of total billed charges for outpatient setting,185.56,1300.64,
PAIN REL (TYL ARTHRITIS) 650MG TAB:,3301914,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PALIPERIDONE (INVEGA) 3MG: TAB,3303252,CDM,259,RC,,,Outpatient,,,38.77,38.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,32.91,84.88,,26.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.39,50,,15.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.08,75,,23.26,percent of total billed charges,75% of total billed charges for outpatient setting,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.2,65,,20.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,35,,10.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.89,90,,27.91,percent of total billed charges,90% of total billed charges for outpatient setting,4.98,34.89,
PAMIDRONATE (AREDIA) INJ : 30 MG,3301745,CDM,636,RC,J2430,HCPCS,Outpatient,,,846.52,846.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.56,70,,474.05,percent of total billed charges,70% of total billed charges for outpatient setting,718.53,84.88,,574.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,634.89,75,,507.91,percent of total billed charges,75% of total billed charges for outpatient setting,592.56,70,,474.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.69,12.84,,86.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.22,80,,541.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.69,12.84,,86.95,percent of total billed charges,12.84% of total billed charges,108.69,12.84,,86.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,550.24,65,,440.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of Custom Fee Schedule,761.87,90,,609.5,percent of total billed charges,90% of total billed charges for outpatient setting,11.17,761.87,
PAMIDRONATE: 30 MG VIAL,3303278,CDM,636,RC,J2430,HCPCS,Outpatient,,,310.18,310.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.13,70,,173.7,percent of total billed charges,70% of total billed charges for outpatient setting,263.28,84.88,,210.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,232.64,75,,186.11,percent of total billed charges,75% of total billed charges for outpatient setting,217.13,70,,173.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,12.84,,31.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.14,80,,198.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,12.84,,31.86,percent of total billed charges,12.84% of total billed charges,39.83,12.84,,31.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,201.62,65,,161.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of Custom Fee Schedule,279.16,90,,223.33,percent of total billed charges,90% of total billed charges for outpatient setting,11.17,279.16,
PANCREATIC POLYPEPTIDE,201433,CDM,301,RC,83519,HCPCS,Outpatient,,,82.8,74.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,70.28,84.88,,56.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.1,75,,49.68,percent of total billed charges,75% of total billed charges for outpatient setting,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,80,,52.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,100,,,Fee Schedule,100% of Custom Fee Schedule,74.52,90,,59.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,74.52,
PANCURONIUM (PAVULON) 1MG/ML INJ :10ML,3301746,CDM,250,RC,,,Outpatient,,,5.29,5.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,70,,2.96,percent of total billed charges,70% of total billed charges for outpatient setting,4.49,84.88,,3.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.65,50,,2.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.97,75,,3.18,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,70,,2.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,80,,3.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.44,65,,2.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,35,,1.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.76,90,,3.81,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.76,
PANCURONIUM (PAVULON) 2MG INJ :2ML,3301747,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PANFIL G: SOLN 60 ML,3302935,CDM,259,RC,,,Outpatient,,,22.44,22.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.71,70,,12.57,percent of total billed charges,70% of total billed charges for outpatient setting,19.05,84.88,,15.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.22,50,,8.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.83,75,,13.46,percent of total billed charges,75% of total billed charges for outpatient setting,15.71,70,,12.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,80,,14.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,2.88,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.59,65,,11.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.85,35,,6.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.2,90,,16.16,percent of total billed charges,90% of total billed charges for outpatient setting,2.88,20.2,
PANTOPRAZOLE (genericPROTONIX) TAB 40MG,3301748,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PANTOPRAZOLE (PROTONIX) ORALSUSP,3303775,CDM,259,RC,,,Outpatient,,,12.47,12.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,10.58,84.88,,8.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.35,75,,7.48,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,35,,3.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.22,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.22,
PANTOPRAZOLE(PROTONIX GEN)INJ 40 MG,3302795,CDM,636,RC,C9113,HCPCS,Outpatient,,,26.63,26.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.64,70,,14.91,percent of total billed charges,70% of total billed charges for outpatient setting,22.6,84.88,,18.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.97,75,,15.98,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,70,,14.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.42,12.84,,2.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.3,80,,17.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.42,12.84,,2.74,percent of total billed charges,12.84% of total billed charges,3.42,12.84,,2.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.31,65,,13.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,35,,7.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.97,90,,19.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.42,23.97,
PANTY MESH L/XL / MSC76400,5150277,CDM,270,RC,,,Outpatient,,,3.31,3.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,70,,1.86,percent of total billed charges,70% of total billed charges for outpatient setting,2.81,84.88,,2.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.66,50,,1.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.48,75,,1.98,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,70,,1.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,80,,2.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.15,65,,1.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,35,,0.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.98,90,,2.38,percent of total billed charges,90% of total billed charges for outpatient setting,0.43,2.98,
PAPAIN UREA (PANAFIL) OINT :30GM,3301749,CDM,259,RC,,,Outpatient,,,266.18,266.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.33,70,,149.06,percent of total billed charges,70% of total billed charges for outpatient setting,225.93,84.88,,180.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.09,50,,106.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.64,75,,159.71,percent of total billed charges,75% of total billed charges for outpatient setting,186.33,70,,149.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.18,12.84,,27.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.94,80,,170.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.18,12.84,,27.34,percent of total billed charges,12.84% of total billed charges,34.18,12.84,,27.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,173.02,65,,138.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.16,35,,74.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,239.56,90,,191.65,percent of total billed charges,90% of total billed charges for outpatient setting,34.18,239.56,
PAPAIN/UREA (ACCUZYME)OINT :6 GM,3303154,CDM,259,RC,,,Outpatient,,,63.59,63.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.51,70,,35.61,percent of total billed charges,70% of total billed charges for outpatient setting,53.98,84.88,,43.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.8,50,,25.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.69,75,,38.15,percent of total billed charges,75% of total billed charges for outpatient setting,44.51,70,,35.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,12.84,,6.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.87,80,,40.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,12.84,,6.53,percent of total billed charges,12.84% of total billed charges,8.16,12.84,,6.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.33,65,,33.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.26,35,,17.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.23,90,,45.78,percent of total billed charges,90% of total billed charges for outpatient setting,8.16,57.23,
PAPAVERINE (PAVABID) CAP : 150 MG,3301750,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PAPAVERINE 30MG/ML  2ML,3302703,CDM,636,RC,J2440,HCPCS,Outpatient,,,23.45,23.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.42,70,,13.14,percent of total billed charges,70% of total billed charges for outpatient setting,19.9,84.88,,15.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.59,75,,14.07,percent of total billed charges,75% of total billed charges for outpatient setting,16.42,70,,13.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,12.84,,2.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.76,80,,15.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,12.84,,2.41,percent of total billed charges,12.84% of total billed charges,3.01,12.84,,2.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.24,65,,12.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,90,,16.89,percent of total billed charges,90% of total billed charges for outpatient setting,3.01,42.75,
PARICALCITOL (ZEMPLAR) 1 MICROGM : CAP,3309857,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PAROXETINE (PAXIL) TAB : 20 MG,3301751,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PAROXETINE ER:25MG (PAXIL CR),3302927,CDM,259,RC,,,Outpatient,,,13.06,13.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,11.09,84.88,,8.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.53,50,,5.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.8,75,,7.84,percent of total billed charges,75% of total billed charges for outpatient setting,9.14,70,,7.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.45,80,,8.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.68,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.49,65,,6.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,35,,3.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.75,90,,9.4,percent of total billed charges,90% of total billed charges for outpatient setting,1.68,11.75,
PARVOVIRUS,220916,CDM,302,RC,86747,HCPCS,Outpatient,,,67.64,60.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.35,70,,37.88,percent of total billed charges,70% of total billed charges for outpatient setting,57.41,84.88,,45.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.81,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.73,75,,40.58,percent of total billed charges,75% of total billed charges for outpatient setting,47.35,70,,37.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.11,80,,43.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.95,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.51,100,,,Fee Schedule,100% of Custom Fee Schedule,60.88,90,,48.7,percent of total billed charges,90% of total billed charges for outpatient setting,15.03,60.88,
PASSER SUTURE LOOP N TACK / AR-4068LNT,71000802,CDM,272,RC,,,Outpatient,,,1008,1008,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.6,70,,564.48,percent of total billed charges,70% of total billed charges for outpatient setting,855.59,84.88,,684.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,504,50,,403.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,756,75,,604.8,percent of total billed charges,75% of total billed charges for outpatient setting,705.6,70,,564.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,80,,645.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,655.2,65,,524.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,35,,282.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,907.2,90,,725.76,percent of total billed charges,90% of total billed charges for outpatient setting,129.43,907.2,
PATELLA 10MM A32 TRIATH / 5551-G-320-E,71000127,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 10MM A32 TRIATH / 5551-G-370-E,71000955,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 11MM A32 TRIATH / 551-G-320-E,71000121,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 11MM ASYMMETRIC / 5551-G-381-E,71000376,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 26MM / 42-5400-000-26,69169437,CDM,278,RC,C1776,HCPCS,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,60,,907.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1890,65,,1512,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1134,60,,907.2,percent of total billed charges,60% of total billed charges for outpatient setting,242.68,1890,
PATELLA 29MM / 42-5400-000-29,69169417,CDM,278,RC,C1776,HCPCS,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,60,,907.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1890,65,,1512,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1134,60,,907.2,percent of total billed charges,60% of total billed charges for outpatient setting,242.68,1890,
PATELLA 29MM NEXGEN / 00-5972-065-29,71000200,CDM,278,RC,C1776,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,60,,864,percent of total billed charges,60% of total Billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,60,,864,percent of total billed charges,60% of total billed charges for outpatient setting,231.12,1800,
PATELLA 29X9MM TRIATHLON / 5552-L-299,71000365,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 32MM / 42-5400-000-32,69169371,CDM,278,RC,C1776,HCPCS,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,60,,907.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,945,50,,756,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1890,65,,1512,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1134,60,,907.2,percent of total billed charges,60% of total billed charges for outpatient setting,242.68,1890,
PATELLA 32MM NEXGEN / 00-5972-065-32,71000441,CDM,278,RC,C1776,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,60,,864,percent of total billed charges,60% of total Billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,60,,864,percent of total billed charges,60% of total billed charges for outpatient setting,231.12,1800,
PATELLA 32X10MM TRIATHLON / 5552-L-320,71000119,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 34X8.5MM STD / 184766,71000387,CDM,278,RC,C1713,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,60,,864,percent of total billed charges,60% of total Billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,60,,864,percent of total billed charges,60% of total billed charges for outpatient setting,231.12,1800,
PATELLA 35MM  98-6037,69162543,CDM,278,RC,C1776,HCPCS,Outpatient,,,1591.97,1591.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.18,60,,764.14,percent of total billed charges,60% of total Billed charges for outpatient setting,1351.26,84.88,,1081.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.98,75,,955.18,percent of total billed charges,75% of total billed charges for outpatient setting,795.99,50,,636.79,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.58,80,,1018.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1591.97,65,,1273.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.19,35,,445.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,955.18,60,,764.14,percent of total billed charges,60% of total billed charges for outpatient setting,204.41,1591.97,
PATELLA 35MM / 42-5400-000-35,69169222,CDM,272,RC,C1776,HCPCS,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1228.5,65,,982.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,90,,1360.8,percent of total billed charges,90% of total billed charges for outpatient setting,242.68,1701,
PATELLA 35MM NEXGEN / 00-5972-065-35,71000590,CDM,278,RC,C1776,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,60,,864,percent of total billed charges,60% of total Billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,60,,864,percent of total billed charges,60% of total billed charges for outpatient setting,231.12,1800,
PATELLA 35MM OVAL DOME / 96-0101,69169647,CDM,278,RC,C1776,HCPCS,Outpatient,,,1092,1092,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,60,,524.16,percent of total billed charges,60% of total Billed charges for outpatient setting,926.89,84.88,,741.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,75,,655.2,percent of total billed charges,75% of total billed charges for outpatient setting,546,50,,436.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.21,12.84,,112.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.6,80,,698.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.21,12.84,,112.17,percent of total billed charges,12.84% of total billed charges,140.21,12.84,,112.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1092,65,,873.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.2,35,,305.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,655.2,60,,524.16,percent of total billed charges,60% of total billed charges for outpatient setting,140.21,1092,
PATELLA 35X10MM TRIATHLON / 5552-L-350,71000239,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 36X10MM TRIATH TIT / 5556-L-360,71000618,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 38MM  98-6038,69162111,CDM,278,RC,C1776,HCPCS,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.68,60,,622.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1297.8,65,,1038.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,60,,622.94,percent of total billed charges,60% of total billed charges for outpatient setting,166.64,1297.8,
PATELLA 38MM / 42-5400-000-38,69169824,CDM,272,RC,C1776,HCPCS,Outpatient,,,1890,1890,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,1604.23,84.88,,1283.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,75,,1134,percent of total billed charges,75% of total billed charges for outpatient setting,1323,70,,1058.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,80,,1209.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,242.68,12.84,,194.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1228.5,65,,982.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.5,35,,529.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1701,90,,1360.8,percent of total billed charges,90% of total billed charges for outpatient setting,242.68,1701,
PATELLA 38X11MM TRIATHLON / 5551-G-350-E,69169767,CDM,278,RC,C1776,HCPCS,Outpatient,,,2024.19,2024.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1214.51,60,,971.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1718.13,84.88,,1374.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.14,75,,1214.51,percent of total billed charges,75% of total billed charges for outpatient setting,1012.1,50,,809.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.35,80,,1295.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2024.19,65,,1619.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.47,35,,566.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1214.51,60,,971.61,percent of total billed charges,60% of total billed charges for outpatient setting,259.91,2024.19,
PATELLA 38X11MM TRIATHLON / 5552-L-381,69169742,CDM,278,RC,C1776,HCPCS,Outpatient,,,2024.19,2024.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1214.51,60,,971.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1718.13,84.88,,1374.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.14,75,,1214.51,percent of total billed charges,75% of total billed charges for outpatient setting,1012.1,50,,809.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.35,80,,1295.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2024.19,65,,1619.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.47,35,,566.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1214.51,60,,971.61,percent of total billed charges,60% of total billed charges for outpatient setting,259.91,2024.19,
PATELLA 40X11MM TRIATHLON / 5551-G-401-E,69169803,CDM,278,RC,C1776,HCPCS,Outpatient,,,2024.19,2024.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1214.51,60,,971.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1718.13,84.88,,1374.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.14,75,,1214.51,percent of total billed charges,75% of total billed charges for outpatient setting,1012.1,50,,809.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.35,80,,1295.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,259.91,12.84,,207.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2024.19,65,,1619.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.47,35,,566.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1214.51,60,,971.61,percent of total billed charges,60% of total billed charges for outpatient setting,259.91,2024.19,
PATELLA 40X11MM TRIATHLON / 5552-L-401,71000573,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA 9MM A29 TRIATH / 5551-G-299-E,71000075,CDM,278,RC,C1776,HCPCS,Outpatient,,,1927.8,1927.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.68,60,,925.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1636.32,84.88,,1309.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.85,75,,1156.68,percent of total billed charges,75% of total billed charges for outpatient setting,963.9,50,,771.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.24,80,,1233.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,247.53,12.84,,198.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1927.8,65,,1542.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.73,35,,539.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1156.68,60,,925.34,percent of total billed charges,60% of total billed charges for outpatient setting,247.53,1927.8,
PATELLA REAMER BLD 41MM / 5979-95-41,69162067,CDM,272,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,90,,622.94,percent of total billed charges,90% of total billed charges for outpatient setting,111.09,778.68,
PATELLAR COMP 32MM / 71420576,69161177,CDM,278,RC,C1776,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
PATELLAR COMP 38MM / 71926225,69161093,CDM,278,RC,C1776,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
PATELLAR COMP. 29MM  71420574,69162202,CDM,278,RC,C1776,HCPCS,Outpatient,,,1390.24,1390.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.14,60,,667.31,percent of total billed charges,60% of total Billed charges for outpatient setting,1180.04,84.88,,944.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1042.68,75,,834.14,percent of total billed charges,75% of total billed charges for outpatient setting,695.12,50,,556.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.51,12.84,,142.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.19,80,,889.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.51,12.84,,142.81,percent of total billed charges,12.84% of total billed charges,178.51,12.84,,142.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1390.24,65,,1112.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.58,35,,389.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,834.14,60,,667.31,percent of total billed charges,60% of total billed charges for outpatient setting,178.51,1390.24,
PATELLAR COMP. 41MM 71926226,69161127,CDM,278,RC,C1776,HCPCS,Outpatient,,,2175.03,2175.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305.02,60,,1044.02,percent of total billed charges,60% of total Billed charges for outpatient setting,1846.17,84.88,,1476.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631.27,75,,1305.02,percent of total billed charges,75% of total billed charges for outpatient setting,1087.52,50,,870.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.27,12.84,,223.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1740.02,80,,1392.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.27,12.84,,223.42,percent of total billed charges,12.84% of total billed charges,279.27,12.84,,223.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2283.78,105,,1827.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.26,35,,609.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1305.02,60,,1044.02,percent of total billed charges,60% of total billed charges for outpatient setting,279.27,2283.78,
PATH SURG CONSULT FROZEN SEC 1ST TISSUE,900033,CDM,310,RC,88331,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,42.47,535.12,
"PATH SURG CONSULT,FROZEN SEC,ADDT'L TISS",900034,CDM,310,RC,88332,HCPCS,Outpatient,,,30.27,27.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.19,70,,16.95,percent of total billed charges,70% of total billed charges for outpatient setting,25.69,84.88,,20.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.7,75,,18.16,percent of total billed charges,75% of total billed charges for outpatient setting,21.19,70,,16.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,80,,19.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,90,,21.79,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,27.24,
PATHOLOGY CONSULTATION DURING SURGERY,900039,CDM,310,RC,88329,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,28.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,28.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,23.6,121.4,
PATIENT TRACKER / 97323534,71000285,CDM,272,RC,,,Outpatient,,,692.68,692.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.88,70,,387.9,percent of total billed charges,70% of total billed charges for outpatient setting,587.95,84.88,,470.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.34,50,,277.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.51,75,,415.61,percent of total billed charges,75% of total billed charges for outpatient setting,484.88,70,,387.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.94,12.84,,71.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.14,80,,443.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.94,12.84,,71.15,percent of total billed charges,12.84% of total billed charges,88.94,12.84,,71.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,450.24,65,,360.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.44,35,,193.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,623.41,90,,498.73,percent of total billed charges,90% of total billed charges for outpatient setting,88.94,623.41,
PATIENT TRACKER FUSION / 9734887XOM,69161834,CDM,272,RC,,,Outpatient,,,780.04,780.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.03,70,,436.82,percent of total billed charges,70% of total billed charges for outpatient setting,662.1,84.88,,529.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,390.02,50,,312.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585.03,75,,468.02,percent of total billed charges,75% of total billed charges for outpatient setting,546.03,70,,436.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.16,12.84,,80.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.03,80,,499.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.16,12.84,,80.13,percent of total billed charges,12.84% of total billed charges,100.16,12.84,,80.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,507.03,65,,405.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.01,35,,218.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,702.04,90,,561.63,percent of total billed charges,90% of total billed charges for outpatient setting,100.16,702.04,
PAXIL CR (PAROXETINE):12.5 MG,3302802,CDM,259,RC,,,Outpatient,,,12.69,12.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,10.77,84.88,,8.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.35,50,,5.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.52,75,,7.62,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,70,,7.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.15,80,,8.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.63,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.25,65,,6.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,35,,3.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.42,90,,9.14,percent of total billed charges,90% of total billed charges for outpatient setting,1.63,11.42,
PAXIL CR 37.5 MG: TAB,3303032,CDM,259,RC,,,Outpatient,,,10.63,10.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,70,,5.95,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,84.88,,7.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.32,50,,4.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.97,75,,6.38,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,70,,5.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,80,,6.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.91,65,,5.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,35,,2.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.57,90,,7.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.36,9.57,
PCMX SCRB SOLN 3.3%-4OZ / 29902-004,69161034,CDM,272,RC,,,Outpatient,,,19.27,19.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.49,70,,10.79,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,84.88,,13.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.64,50,,7.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.45,75,,11.56,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,70,,10.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,80,,12.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.53,65,,10.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,35,,5.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.34,90,,13.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,17.34,
PCR,201511,CDM,301,RC,81220,HCPCS,Outpatient,,,1391.5,1252.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,1181.11,84.88,,944.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,774.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1043.63,75,,834.9,percent of total billed charges,75% of total billed charges for outpatient setting,974.05,70,,779.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.2,80,,890.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,556.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.11,100,,,Fee Schedule,100% of Custom Fee Schedule,1252.35,90,,1001.88,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,1252.35,
"PEANUT ALLERGEN,IGE WITH COMPONENTS",220923,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
PEANUT PUSHER / 30-106,6150052,CDM,272,RC,,,Outpatient,,,7.69,7.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.53,84.88,,5.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.85,50,,3.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.77,75,,4.62,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.15,80,,4.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5,65,,4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,35,,2.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.92,90,,5.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.92,
PEDI BREATHING CIRCUIT / ANE4366266,6122005,CDM,270,RC,,,Outpatient,,,47.46,47.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,70,,26.58,percent of total billed charges,70% of total billed charges for outpatient setting,40.28,84.88,,32.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.73,50,,18.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.6,75,,28.48,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,70,,26.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.97,80,,30.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.85,65,,24.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,35,,13.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.71,90,,34.17,percent of total billed charges,90% of total billed charges for outpatient setting,6.09,42.71,
PEDIALYTE SOLN: 8OZ,3302820,CDM,259,RC,,,Outpatient,,,13.77,13.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.64,70,,7.71,percent of total billed charges,70% of total billed charges for outpatient setting,11.69,84.88,,9.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.89,50,,5.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.33,75,,8.26,percent of total billed charges,75% of total billed charges for outpatient setting,9.64,70,,7.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.02,80,,8.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.95,65,,7.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,35,,3.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.39,90,,9.91,percent of total billed charges,90% of total billed charges for outpatient setting,1.77,12.39,
PEDI-CIRCUIT W/FILTER/8005255,6152342,CDM,270,RC,,,Outpatient,,,78.07,78.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.65,70,,43.72,percent of total billed charges,70% of total billed charges for outpatient setting,66.27,84.88,,53.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.04,50,,31.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.55,75,,46.84,percent of total billed charges,75% of total billed charges for outpatient setting,54.65,70,,43.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,12.84,,8.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.46,80,,49.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,12.84,,8.02,percent of total billed charges,12.84% of total billed charges,10.02,12.84,,8.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.75,65,,40.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.32,35,,21.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.26,90,,56.21,percent of total billed charges,90% of total billed charges for outpatient setting,10.02,70.26,
PEG 2.2X14MM SMOOTH LOCK / 131227014,69169658,CDM,278,RC,,,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.2X16MM SMOOTH LOCK / 131227016,69169573,CDM,278,RC,,,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.2X18MM SMOOTH LOCK / 131227018,69169568,CDM,278,RC,,,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.2X20MM SMOOTH LOCK / 131227020,69169567,CDM,278,RC,C1713,HCPCS,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.2X22MM SMOOTH LOCK / 131227022,69169569,CDM,278,RC,C1713,HCPCS,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.2X24MM SMOOTH LOCK / 131227024,69169744,CDM,278,RC,C1713,HCPCS,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
PEG 2.3X14MM TIT CORT / CO-S2314,691875,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,60,,240,percent of total billed charges,60% of total Billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,35,,140,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300,60,,240,percent of total billed charges,60% of total billed charges for outpatient setting,64.2,500,
PEG 2.3X16MM TIT CORT / CO-S2316,733684,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,60,,240,percent of total billed charges,60% of total Billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,35,,140,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300,60,,240,percent of total billed charges,60% of total billed charges for outpatient setting,64.2,500,
PEG 2.3X18MM TIT CORT / CO-S2318,733685,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,60,,240,percent of total billed charges,60% of total Billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,35,,140,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300,60,,240,percent of total billed charges,60% of total billed charges for outpatient setting,64.2,500,
PEG 2.3X20MM TIT CORT / CO-S2320,696997,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,60,,240,percent of total billed charges,60% of total Billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,35,,140,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300,60,,240,percent of total billed charges,60% of total billed charges for outpatient setting,64.2,500,
PEG 2.3X22MM TIT CORT / CO-S2322,696998,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,60,,240,percent of total billed charges,60% of total Billed charges for outpatient setting,424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375,75,,300,percent of total billed charges,75% of total billed charges for outpatient setting,250,50,,200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400,80,,320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,64.2,12.84,,51.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,500,65,,400,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,35,,140,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300,60,,240,percent of total billed charges,60% of total billed charges for outpatient setting,64.2,500,
PELVIMETRY WITH OR W/O PLACENTAL LOCALIZ,2400800,CDM,320,RC,74710,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
PELVIS,2100140,CDM,320,RC,72170,HCPCS,Outpatient,,,193.06,144.8,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,163.87,84.88,,131.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,144.8,75,,115.84,percent of total billed charges,75% of total billed charges for outpatient setting,135.14,70,,108.11,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,24.79,12.84,,19.832,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,154.45,80,,123.56,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,24.79,12.84,,19.83,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,173.75,90,,139,percent of total billed charges,90% of total billed charges for outpatient setting,24.79,209.75,
PELVIS,2400141,CDM,320,RC,72170,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
PELVIS AND HIPS INFANT OR CHILD,2400330,CDM,320,RC,73502,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,40.28,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
PENCIL 70MM SMOKE NEPTUNE / 0703-047-000,1665580,CDM,272,RC,,,Outpatient,,,138,138,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.6,70,,77.28,percent of total billed charges,70% of total billed charges for outpatient setting,117.13,84.88,,93.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,69,50,,55.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,75,,82.8,percent of total billed charges,75% of total billed charges for outpatient setting,96.6,70,,77.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,12.84,,14.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,80,,88.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,12.84,,14.18,percent of total billed charges,12.84% of total billed charges,17.72,12.84,,14.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.7,65,,71.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.3,35,,38.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.2,90,,99.36,percent of total billed charges,90% of total billed charges for outpatient setting,17.72,124.2,
PENCIL CAUTERY LOW TEMP / 65410-010,71000289,CDM,272,RC,,,Outpatient,,,44.17,44.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.92,70,,24.74,percent of total billed charges,70% of total billed charges for outpatient setting,37.49,84.88,,29.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.09,50,,17.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.13,75,,26.5,percent of total billed charges,75% of total billed charges for outpatient setting,30.92,70,,24.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.34,80,,28.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,5.67,12.84,,4.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.71,65,,22.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,35,,12.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.75,90,,31.8,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,39.75,
PENICILLIN (PERMAPEN)INJ 1.2MM :2ML,3301752,CDM,250,RC,,,Outpatient,,,15.91,15.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,84.88,,10.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.96,50,,6.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,75,,9.54,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,80,,10.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.34,65,,8.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.32,90,,11.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.04,14.32,
PENICILLIN G (PFIZERPEN) INJ 20MMU :,3301753,CDM,250,RC,,,Outpatient,,,27.04,27.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,70,,15.14,percent of total billed charges,70% of total billed charges for outpatient setting,22.95,84.88,,18.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.52,50,,10.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.28,75,,16.22,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,70,,15.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,12.84,,2.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,80,,17.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,12.84,,2.78,percent of total billed charges,12.84% of total billed charges,3.47,12.84,,2.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.58,65,,14.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,35,,7.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.34,90,,19.47,percent of total billed charges,90% of total billed charges for outpatient setting,3.47,24.34,
PENICILLIN G (WYCILLIN)1.2MMU INJ:2ML,3301754,CDM,250,RC,,,Outpatient,,,29.45,29.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.62,70,,16.5,percent of total billed charges,70% of total billed charges for outpatient setting,25,84.88,,20,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.73,50,,11.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.09,75,,17.67,percent of total billed charges,75% of total billed charges for outpatient setting,20.62,70,,16.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.56,80,,18.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.14,65,,15.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,35,,8.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.51,90,,21.21,percent of total billed charges,90% of total billed charges for outpatient setting,3.78,26.51,
PENICILLIN V 250 MG TAB :,3301758,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PENICILLIN V SUSP 250MG/5ML : 100ML,3301755,CDM,259,RC,,,Outpatient,,,8.93,8.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,70,,5,percent of total billed charges,70% of total billed charges for outpatient setting,7.58,84.88,,6.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.47,50,,3.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.7,75,,5.36,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,70,,5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.14,80,,5.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.8,65,,4.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.04,90,,6.43,percent of total billed charges,90% of total billed charges for outpatient setting,1.15,8.04,
PENICILLIN VK (PENNICILLN) 250 MG TAB :,3301756,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PENICILLIN VK (VEETIDS) 250 MG TAB :,3301757,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PENICILLIN VK (VEETIDS)500 MG:TAB,3303241,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
PENTAZOCINE/NALOX 50/0.5MG(TALWIN NX)TAB,3302989,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PENTOTHAL 500M:SYR,3302741,CDM,250,RC,,,Outpatient,,,215.44,215.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.81,70,,120.65,percent of total billed charges,70% of total billed charges for outpatient setting,182.87,84.88,,146.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.72,50,,86.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.58,75,,129.26,percent of total billed charges,75% of total billed charges for outpatient setting,150.81,70,,120.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,12.84,,22.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.35,80,,137.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,12.84,,22.13,percent of total billed charges,12.84% of total billed charges,27.66,12.84,,22.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.04,65,,112.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.4,35,,60.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.9,90,,155.12,percent of total billed charges,90% of total billed charges for outpatient setting,27.66,193.9,
PENTOXIFYLLINE (TRENTAL) TAB: 400MG,3301759,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS T,2400720,CDM,320,RC,74355,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
PERCUTANEOUS PLACEMENT OF GASTROSTOMY TU,2400715,CDM,320,RC,49440,HCPCS,Outpatient,,,2273.15,1704.86,,2328.75,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1591.21,70,,1272.97,percent of total billed charges,70% of total billed charges for outpatient setting,1929.45,84.88,,1543.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,1945.51,50,,1556.41,percent of total billed charges,50% of total Billed charges for outpatient setting,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1704.86,75,,1363.89,percent of total billed charges,75% of total billed charges for outpatient setting,1591.21,70,,1272.97,percent of total billed charges,70% of total billed charges for outpatient setting,2474.29,170,,,Fee Schedule,170% of Medicare OPPS rate,3129.26,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,291.87,12.84,,233.496,percent of total billed charges,12.84% of total billed charges,2547.07,175,,,Fee Schedule,175% of Medicare OPPS rate,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1818.52,80,,1454.82,percent of total billed charges,80% of total billed charges for outpatient setting,2037.66,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1819.34,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,291.87,12.84,,233.5,percent of total billed charges,12.84% of total billed charges,291.87,12.84,,233.5,percent of total billed charges,12.84% of total billed charges,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1455.47,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1205.11,100,,,Fee Schedule,100% of Custom Fee Schedule,2045.84,90,,1636.67,percent of total billed charges,90% of total billed charges for outpatient setting,128,3129.26,
PERCUTANEOUS TRANSHEPATIC DILATION OF BI,2400730,CDM,320,RC,74363,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
PERFUSE DISP INSTR SET / 800-0541,69162472,CDM,272,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1560,65,,1248,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,90,,1728,percent of total billed charges,90% of total billed charges for outpatient setting,308.16,2160,
PERI C0LACE SYRUP 15ML:UD,3302588,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PERI COLACE (DOK PLUS)CAP:100/30 UD,3300762,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PERI COLACE SYRUP: UD,3302542,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PERI GYN PACK / 9274,6150211,CDM,272,RC,,,Outpatient,,,37.8,37.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,70,,21.17,percent of total billed charges,70% of total billed charges for outpatient setting,32.08,84.88,,25.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.9,50,,15.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,75,,22.68,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,70,,21.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,80,,24.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.57,65,,19.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,35,,10.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.02,90,,27.22,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,34.02,
PERINDOPRIL (ACEON) 4MG: TAB,3303316,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
PERITONEAL DIALYSIS CATH 8888413807,6152732,CDM,272,RC,,,Outpatient,,,905.51,905.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.86,70,,507.09,percent of total billed charges,70% of total billed charges for outpatient setting,768.6,84.88,,614.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,452.76,50,,362.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,679.13,75,,543.3,percent of total billed charges,75% of total billed charges for outpatient setting,633.86,70,,507.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.27,12.84,,93.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.41,80,,579.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.27,12.84,,93.02,percent of total billed charges,12.84% of total billed charges,116.27,12.84,,93.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588.58,65,,470.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.93,35,,253.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,814.96,90,,651.97,percent of total billed charges,90% of total billed charges for outpatient setting,116.27,814.96,
PERMETHRIN (ACTICIN) CRM: 60 GM,3301762,CDM,259,RC,,,Outpatient,,,75.62,75.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.19,84.88,,51.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.81,50,,30.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.72,75,,45.38,percent of total billed charges,75% of total billed charges for outpatient setting,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.5,80,,48.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.15,65,,39.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,35,,21.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.06,90,,54.45,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,68.06,
PERMETHRIN (ELIMITE) CRM: 60 GM,3301763,CDM,259,RC,,,Outpatient,,,94.36,94.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,80.09,84.88,,64.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.18,50,,37.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.77,75,,56.62,percent of total billed charges,75% of total billed charges for outpatient setting,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.12,12.84,,9.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.49,80,,60.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.12,12.84,,9.7,percent of total billed charges,12.84% of total billed charges,12.12,12.84,,9.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.33,65,,49.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.03,35,,26.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.92,90,,67.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.12,84.92,
PERPHENAZINE (TRILAFON) 250 MG TAB :,3301765,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PERPHENAZINE (TRILAFON) 2MG TAB:UD,3301764,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PERSONA +0 TASP RT EF / 42-5270-005-05,71000168,CDM,271,RC,C1776,HCPCS,Outpatient,,,1760,1760,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1232,70,,985.6,percent of total billed charges,70% of total billed charges for outpatient setting,1493.89,84.88,,1195.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,75,,1056,percent of total billed charges,75% of total billed charges for outpatient setting,1232,70,,985.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.98,12.84,,180.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1408,80,,1126.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.98,12.84,,180.78,percent of total billed charges,12.84% of total billed charges,225.98,12.84,,180.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1144,65,,915.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616,35,,492.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1584,90,,1267.2,percent of total billed charges,90% of total billed charges for outpatient setting,225.98,1584,
PETROLATUM WHITE (VASELINE) LIP 10GM,3301766,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PETROLATUM WHITE 5G (genVASELINE) OINT,3313304,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
"PH, FLUID",201071,CDM,301,RC,83986,HCPCS,Outpatient,,,16.11,14.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,13.67,84.88,,10.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.08,75,,9.66,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,80,,10.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.78,100,,,Fee Schedule,100% of Custom Fee Schedule,14.5,90,,11.6,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,14.5,
PHARMACY SUPPLIES (OB) AMBR CLICAP 20Z:,3301771,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHARMACY SUPPLIES (OB) OINT 16OZ:WHT PLS,3301769,CDM,271,RC,,,Outpatient,,,5.8,5.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.06,70,,3.25,percent of total billed charges,70% of total billed charges for outpatient setting,4.92,84.88,,3.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.9,50,,2.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.35,75,,3.48,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,70,,3.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,80,,3.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.77,65,,3.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,35,,1.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.22,90,,4.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.22,
PHARMACY SUPPLIES (OB) OINT 4OZ:WHT PLST,3301768,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHARMACY SUPPLIES (OB) PRECPK CLR-VU :,3301770,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHARMACY SUPPLIES (OB) PRECPK SRLC:13-16,3301767,CDM,271,RC,,,Outpatient,,,20.76,20.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.53,70,,11.62,percent of total billed charges,70% of total billed charges for outpatient setting,17.62,84.88,,14.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.38,50,,8.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.57,75,,12.46,percent of total billed charges,75% of total billed charges for outpatient setting,14.53,70,,11.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.67,12.84,,2.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,80,,13.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.67,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,2.67,12.84,,2.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.49,65,,10.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,35,,5.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.67,18.68,
PHARMACY SUPPLIES (OB) VIAL PL AMBR:BULK,3301774,CDM,271,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHARYNX AND/OR CERVICAL ESOPHAGUS,2400580,CDM,320,RC,74210,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
PHARYNX OR LARYNX INCLUDING FLUROSCOPY A,2400125,CDM,320,RC,70370,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
PHAZYME QUICK DISSOLVE TAB: 125MG,3302720,CDM,259,RC,,,Outpatient,,,9.83,9.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,8.34,84.88,,6.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.92,50,,3.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.37,75,,5.9,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,80,,6.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.39,65,,5.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,35,,2.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.85,90,,7.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.26,8.85,
PHENAZOPYRIDINE (genPYRIDIUM) TAB 95MG,3301775,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PHENAZOPYRIDINE (PYRIDIUM) TAB : 100 MG,3301776,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHENAZOPYRIDINE (PYRIDIUM)TAB: 200 MG,3302754,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
PHENOBARBITAL,220342,CDM,300,RC,80184,HCPCS,Outpatient,,,68.85,61.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,58.44,84.88,,46.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.64,75,,41.31,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,70,,38.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.08,80,,44.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.72,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,100,,,Fee Schedule,100% of Custom Fee Schedule,61.97,90,,49.58,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,61.97,
PHENOBARBITAL (PHENOBARB) SDV : 65 MG,3301781,CDM,250,RC,,,Outpatient,,,19.7,19.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,70,,11.03,percent of total billed charges,70% of total billed charges for outpatient setting,16.72,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.85,50,,7.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,70,,11.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.76,80,,12.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.81,65,,10.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,35,,5.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.73,90,,14.18,percent of total billed charges,90% of total billed charges for outpatient setting,2.53,17.73,
PHENOBARBITAL (PHENOBARB) TAB: 100 MG,3301780,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PHENOBARBITAL (PHENOBARB) TAB: 30 MG,3301777,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PHENOBARBITAL (PHENOBARB) TAB: 30 MG U/D,3301779,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHENOBARBITAL TAB :30MG UD,3301778,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PHENOL SOD (CHLORASEPTIC) LOZ:,3301783,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PHENOL SOD (PHENASEPTIC) CHERRY:180ML,3301782,CDM,259,RC,,,Outpatient,,,7.95,7.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,84.88,,5.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.98,50,,3.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.96,75,,4.77,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.36,80,,5.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.17,65,,4.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,35,,2.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.16,90,,5.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,7.16,
PHENTOLAMINE MESY (REGITINE) INJ :5MG,3301784,CDM,250,RC,,,Outpatient,,,101.63,101.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.14,70,,56.91,percent of total billed charges,70% of total billed charges for outpatient setting,86.26,84.88,,69.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.82,50,,40.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.22,75,,60.98,percent of total billed charges,75% of total billed charges for outpatient setting,71.14,70,,56.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,12.84,,10.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.3,80,,65.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,12.84,,10.44,percent of total billed charges,12.84% of total billed charges,13.05,12.84,,10.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.06,65,,52.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.57,35,,28.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.47,90,,73.18,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,91.47,
PHENYLEPH (NEO SYNEPHRINE) 100mcg/ml 5ml,3313699,CDM,636,RC,J2371,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PHENYLEPHRINE (NEO SYN) 2.5% DROP  2 ML,3310329,CDM,259,RC,,,Outpatient,,,138.1,138.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.67,70,,77.34,percent of total billed charges,70% of total billed charges for outpatient setting,117.22,84.88,,93.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.05,50,,55.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.58,75,,82.86,percent of total billed charges,75% of total billed charges for outpatient setting,96.67,70,,77.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,12.84,,14.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.48,80,,88.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.73,12.84,,14.18,percent of total billed charges,12.84% of total billed charges,17.73,12.84,,14.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.77,65,,71.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.34,35,,38.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.29,90,,99.43,percent of total billed charges,90% of total billed charges for outpatient setting,17.73,124.29,
PHENYLEPHRINE (NEO SYN) 2.5% DROP : 5 ML,3301788,CDM,259,RC,,,Outpatient,,,72.18,72.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.53,70,,40.42,percent of total billed charges,70% of total billed charges for outpatient setting,61.27,84.88,,49.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.09,50,,28.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.14,75,,43.31,percent of total billed charges,75% of total billed charges for outpatient setting,50.53,70,,40.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,12.84,,7.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.74,80,,46.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,12.84,,7.42,percent of total billed charges,12.84% of total billed charges,9.27,12.84,,7.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.92,65,,37.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.26,35,,20.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.96,90,,51.97,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,64.96,
PHENYLEPHRINE (NEO SYN) 2.5% OPHT DR:15M,3301786,CDM,259,RC,,,Outpatient,,,14.83,14.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,12.59,84.88,,10.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.42,50,,5.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.12,75,,8.9,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,70,,8.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.86,80,,9.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,1.9,12.84,,1.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.64,65,,7.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,35,,4.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.35,90,,10.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.9,13.35,
PHENYLEPHRINE (NEO SYN) SPY 0.5 OZ :,3301789,CDM,259,RC,,,Outpatient,,,11.04,11.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.73,70,,6.18,percent of total billed charges,70% of total billed charges for outpatient setting,9.37,84.88,,7.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.52,50,,4.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.28,75,,6.62,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,70,,6.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,80,,7.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.18,65,,5.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,35,,3.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.94,90,,7.95,percent of total billed charges,90% of total billed charges for outpatient setting,1.42,9.94,
PHENYLEPHRINE (NEO SYN)DROPS 2.5% : 3ML,3301787,CDM,259,RC,,,Outpatient,,,11.36,11.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.95,70,,6.36,percent of total billed charges,70% of total billed charges for outpatient setting,9.64,84.88,,7.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.68,50,,4.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.52,75,,6.82,percent of total billed charges,75% of total billed charges for outpatient setting,7.95,70,,6.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,80,,7.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.38,65,,5.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,35,,3.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.22,90,,8.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.46,10.22,
PHENYLEPHRINE (PHENYLEPH) SDV : 10MG/ML,3301790,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PHENYLEPHRINE 10% genAKDILATE ophth  5ml,3301791,CDM,250,RC,,,Outpatient,,,169.6,169.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.72,70,,94.98,percent of total billed charges,70% of total billed charges for outpatient setting,143.96,84.88,,115.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.8,50,,67.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.2,75,,101.76,percent of total billed charges,75% of total billed charges for outpatient setting,118.72,70,,94.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.78,12.84,,17.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.68,80,,108.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.78,12.84,,17.42,percent of total billed charges,12.84% of total billed charges,21.78,12.84,,17.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.24,65,,88.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.36,35,,47.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.64,90,,122.11,percent of total billed charges,90% of total billed charges for outpatient setting,21.78,152.64,
PHENYLEPHRINE 100mcg/ml INJ 5ml AMP,3313683,CDM,250,RC,,,Outpatient,,,23.76,23.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.63,70,,13.3,percent of total billed charges,70% of total billed charges for outpatient setting,20.17,84.88,,16.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.88,50,,9.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.82,75,,14.26,percent of total billed charges,75% of total billed charges for outpatient setting,16.63,70,,13.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,80,,15.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.44,65,,12.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.32,35,,6.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.38,90,,17.1,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,21.38,
PHENYLEPHRINE 10MG/ML INJ 1ML,3301785,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
PHENYLEPHRINE NASAL SPR: 0.125% 15ML,3307048,CDM,259,RC,,,Outpatient,,,22.69,22.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,19.26,84.88,,15.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.35,50,,9.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.02,75,,13.62,percent of total billed charges,75% of total billed charges for outpatient setting,15.88,70,,12.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,80,,14.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.75,65,,11.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,35,,6.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.42,90,,16.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.91,20.42,
PHENYLEPHRINE/ KETOROLAC 1%/0.3%OMIDRIA,3310239,CDM,636,RC,J1097,HCPCS,Outpatient,,,2014.4,2014.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410.08,70,,1128.06,percent of total billed charges,70% of total billed charges for outpatient setting,1709.82,84.88,,1367.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1510.8,75,,1208.64,percent of total billed charges,75% of total billed charges for outpatient setting,1410.08,70,,1128.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.52,80,,1289.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,258.65,12.84,,206.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1309.36,65,,1047.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.97,100,,,Fee Schedule,100% of Custom Fee Schedule,1812.96,90,,1450.37,percent of total billed charges,90% of total billed charges for outpatient setting,117.97,1812.96,
PHENYTOIN,220881,CDM,300,RC,80185,HCPCS,Outpatient,,,59.63,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,50.61,84.88,,40.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.72,75,,35.78,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,70,,33.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,80,,38.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.36,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,Fee Schedule,100% of Custom Fee Schedule,53.67,90,,42.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,53.67,
PHENYTOIN (DILANTIN) 125MG/5ML LIQ:4ML,3301792,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PHENYTOIN (DILANTIN) 50/ML INJ  2 ML,3301796,CDM,636,RC,J1165,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PHENYTOIN (DILANTIN) 50/ML INJ : 5 ML,3301797,CDM,250,RC,,,Outpatient,,,25.25,25.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,70,,14.14,percent of total billed charges,70% of total billed charges for outpatient setting,21.43,84.88,,17.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.63,50,,10.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.94,75,,15.15,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,70,,14.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.2,80,,16.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.41,65,,13.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,35,,7.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.73,90,,18.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.24,22.73,
PHENYTOIN (DILANTIN) CHEW: 50 MG,3301793,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PHENYTOIN EXT (DILANTIN) 100 MG CAP,3301794,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PHENYTOIN EXT (DILANTIN) 100 MG CAP :,3301795,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
"PHENYTOIN, FREE",220649,CDM,300,RC,80186,HCPCS,Outpatient,,,61.92,55.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.34,70,,34.67,percent of total billed charges,70% of total billed charges for outpatient setting,52.56,84.88,,42.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.44,75,,37.15,percent of total billed charges,75% of total billed charges for outpatient setting,43.34,70,,34.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.54,80,,39.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,100,,,Fee Schedule,100% of Custom Fee Schedule,55.73,90,,44.58,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,55.73,
PHISODERM CLEANSER: UD,3303001,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
PHISOHEX 3% LIQ 480ML: BOTTLE,3302610,CDM,259,RC,,,Outpatient,,,17.19,17.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,14.59,84.88,,11.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.6,50,,6.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.89,75,,10.31,percent of total billed charges,75% of total billed charges for outpatient setting,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,80,,11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.17,65,,8.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,35,,4.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.47,90,,12.38,percent of total billed charges,90% of total billed charges for outpatient setting,2.21,15.47,
PHOSLO 667 MG: CAP,3303264,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
PHOSPHATIDYLSERINE ANTIBODIES IgG IgM Ig,201319,CDM,300,RC,86148,HCPCS,Outpatient,,,72.32,65.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,61.39,84.88,,49.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.24,75,,43.39,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,70,,40.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.86,80,,46.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,100% of Custom Fee Schedule,65.09,90,,52.07,percent of total billed charges,90% of total billed charges for outpatient setting,15.65,65.09,
PHOSPHOLINE IODIDE OPTH SOL 0.125% :5ML,3300996,CDM,259,RC,,,Outpatient,,,107.15,107.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.01,70,,60.01,percent of total billed charges,70% of total billed charges for outpatient setting,90.95,84.88,,72.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.58,50,,42.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.36,75,,64.29,percent of total billed charges,75% of total billed charges for outpatient setting,75.01,70,,60.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,12.84,,11.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.72,80,,68.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,12.84,,11.01,percent of total billed charges,12.84% of total billed charges,13.76,12.84,,11.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.65,65,,55.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.5,35,,30,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.44,90,,77.15,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,96.44,
PHOSPHORUS,200705,CDM,300,RC,84100,HCPCS,Outpatient,,,21.33,19.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.93,70,,11.94,percent of total billed charges,70% of total billed charges for outpatient setting,18.1,84.88,,14.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16,75,,12.8,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,70,,11.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.06,80,,13.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.98,100,,,Fee Schedule,100% of Custom Fee Schedule,19.2,90,,15.36,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,19.2,
"PHOSPHORUS, URINE",200706,CDM,300,RC,84105,HCPCS,Outpatient,,,26.01,23.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,22.08,84.88,,17.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.51,75,,15.61,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,70,,14.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,80,,16.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,23.41,90,,18.73,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,23.41,
PHSOPHA 250 NEUTRAL: TAB,3303190,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
PHYSOSTIGMINE (ANTILIRIUM) 1MG/ML INJ:2M,3301799,CDM,250,RC,,,Outpatient,,,18.9,18.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,16.04,84.88,,12.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.45,50,,7.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.18,75,,11.34,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,70,,10.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,80,,12.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,2.43,12.84,,1.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.29,65,,9.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,35,,5.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.01,90,,13.61,percent of total billed charges,90% of total billed charges for outpatient setting,2.43,17.01,
PHYSOSTIGMINE (ANTILIRIUM) 1MG/ML INJ:2M,3301798,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,70,,16.8,percent of total billed charges,70% of total billed charges for outpatient setting,25.46,84.88,,20.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,15,50,,12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,75,,18,percent of total billed charges,75% of total billed charges for outpatient setting,21,70,,16.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,12.84,,3.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,80,,19.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,12.84,,3.08,percent of total billed charges,12.84% of total billed charges,3.85,12.84,,3.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.5,65,,15.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,35,,8.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27,90,,21.6,percent of total billed charges,90% of total billed charges for outpatient setting,3.85,27,
PHYTONADIONE (AQUA-MEPHYT) 10MG/ML INJ:1,3301800,CDM,250,RC,,,Outpatient,,,15.97,15.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,13.56,84.88,,10.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.99,50,,6.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.98,75,,9.58,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.78,80,,10.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.38,65,,8.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,35,,4.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.37,90,,11.5,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.37,
PHYTONADIONE (AQUA-MEPHYTN) 10MG AMP:1ML,3301803,CDM,250,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
PHYTONADIONE (MEPHYTON) TAB: 5 MG,3301801,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PHYTONADIONE (VITAMIN K) AMP: 10 MG/ML,3301802,CDM,636,RC,J3430,HCPCS,Outpatient,,,242.31,242.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.62,70,,135.7,percent of total billed charges,70% of total billed charges for outpatient setting,205.67,84.88,,164.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,181.73,75,,145.38,percent of total billed charges,75% of total billed charges for outpatient setting,169.62,70,,135.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.11,12.84,,24.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.85,80,,155.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.11,12.84,,24.89,percent of total billed charges,12.84% of total billed charges,31.11,12.84,,24.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.5,65,,126,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,100,,,Fee Schedule,100% of Custom Fee Schedule,218.08,90,,174.46,percent of total billed charges,90% of total billed charges for outpatient setting,3.84,218.08,
PICC CATHETER DECLOTTING,5100133,CDM,272,RC,,,Outpatient,,,137.9,137.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,117.05,84.88,,93.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.95,50,,55.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.43,75,,82.74,percent of total billed charges,75% of total billed charges for outpatient setting,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.32,80,,88.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.64,65,,71.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.27,35,,38.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.11,90,,99.29,percent of total billed charges,90% of total billed charges for outpatient setting,17.71,124.11,
PICC INSERT MIDL WO IMG GUID > 5YRS OLD,5100134,CDM,260,RC,36569,HCPCS,Outpatient,,,2286.18,2286.18,,2016.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,1940.51,84.88,,1552.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1367.11,50,,1093.69,percent of total billed charges,50% of total Billed charges for outpatient setting,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1714.64,75,,1371.71,percent of total billed charges,75% of total billed charges for outpatient setting,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,2142.19,170,,,Fee Schedule,170% of Medicare OPPS rate,2709.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,2205.19,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1828.94,80,,1463.15,percent of total billed charges,80% of total billed charges for outpatient setting,1764.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1575.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1010.8,100,,,Fee Schedule,100% of Custom Fee Schedule,2057.56,90,,1646.05,percent of total billed charges,90% of total billed charges for outpatient setting,128,2709.24,
PICC INSERT TRIPLE LUMEN PT > 5 YRS OLD,5100135,CDM,760,RC,36556,HCPCS,Outpatient,,,2286.18,2286.18,,4104.39,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,1940.51,84.88,,1552.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1367.11,50,,1093.69,percent of total billed charges,50% of total Billed charges for outpatient setting,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1714.64,75,,1371.71,percent of total billed charges,75% of total billed charges for outpatient setting,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,4360.92,170,,,Fee Schedule,170% of Medicare OPPS rate,5515.28,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,4489.18,175,,,Fee Schedule,175% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1828.94,80,,1463.15,percent of total billed charges,80% of total billed charges for outpatient setting,3591.35,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,3206.55,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1486.02,65,,1188.82,percent of total billed charges,65% of total billed charges for outpatient setting,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1010.8,100,,,Fee Schedule,100% of Custom Fee Schedule,2057.56,90,,1646.05,percent of total billed charges,90% of total billed charges for outpatient setting,293.55,5515.28,
PICC INSERTION WO IMG GUID>5 YRS OLD,5100130,CDM,260,RC,36569,HCPCS,Outpatient,,,2286.18,2286.18,,2016.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,1940.51,84.88,,1552.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1367.11,50,,1093.69,percent of total billed charges,50% of total Billed charges for outpatient setting,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1714.64,75,,1371.71,percent of total billed charges,75% of total billed charges for outpatient setting,1600.33,70,,1280.26,percent of total billed charges,70% of total billed charges for outpatient setting,2142.19,170,,,Fee Schedule,170% of Medicare OPPS rate,2709.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,2205.19,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1828.94,80,,1463.15,percent of total billed charges,80% of total billed charges for outpatient setting,1764.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1575.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,293.55,12.84,,234.84,percent of total billed charges,12.84% of total billed charges,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1010.8,100,,,Fee Schedule,100% of Custom Fee Schedule,2057.56,90,,1646.05,percent of total billed charges,90% of total billed charges for outpatient setting,128,2709.24,
PICC OTHER IV ACCESS,5100132,CDM,272,RC,,,Outpatient,,,137.9,137.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,117.05,84.88,,93.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.95,50,,55.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.43,75,,82.74,percent of total billed charges,75% of total billed charges for outpatient setting,96.53,70,,77.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.32,80,,88.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,17.71,12.84,,14.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.64,65,,71.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.27,35,,38.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.11,90,,99.29,percent of total billed charges,90% of total billed charges for outpatient setting,17.71,124.11,
PICC TIP LOCATION SYSTEM,5100131,CDM,272,RC,,,Outpatient,,,81.11,81.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,70,,45.42,percent of total billed charges,70% of total billed charges for outpatient setting,68.85,84.88,,55.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.56,50,,32.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.83,75,,48.66,percent of total billed charges,75% of total billed charges for outpatient setting,56.78,70,,45.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.41,12.84,,8.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.89,80,,51.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.41,12.84,,8.33,percent of total billed charges,12.84% of total billed charges,10.41,12.84,,8.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.72,65,,42.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.39,35,,22.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73,90,,58.4,percent of total billed charges,90% of total billed charges for outpatient setting,10.41,73,
PILGRIM CAPS / 2500SA,5150192,CDM,270,RC,,,Outpatient,,,5.31,5.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,84.88,,3.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.66,50,,2.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.98,75,,3.18,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,80,,3.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.45,65,,2.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,35,,1.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.78,90,,3.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.78,
PILLOW ABDUCTION  MEDIUM / FP-ABDUCTM,69162320,CDM,270,RC,,,Outpatient,,,99.19,99.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.43,70,,55.54,percent of total billed charges,70% of total billed charges for outpatient setting,84.19,84.88,,67.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.6,50,,39.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.39,75,,59.51,percent of total billed charges,75% of total billed charges for outpatient setting,69.43,70,,55.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,12.84,,10.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.35,80,,63.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,12.84,,10.19,percent of total billed charges,12.84% of total billed charges,12.74,12.84,,10.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.47,65,,51.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.72,35,,27.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,89.27,90,,71.42,percent of total billed charges,90% of total billed charges for outpatient setting,12.74,89.27,
PILOCARPINE (PILOSTAT) 0.5% 15ML DROP:,3301805,CDM,259,RC,,,Outpatient,,,17.87,17.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.51,70,,10.01,percent of total billed charges,70% of total billed charges for outpatient setting,15.17,84.88,,12.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.94,50,,7.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.4,75,,10.72,percent of total billed charges,75% of total billed charges for outpatient setting,12.51,70,,10.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.3,80,,11.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.62,65,,9.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,35,,5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.08,90,,12.86,percent of total billed charges,90% of total billed charges for outpatient setting,2.29,16.08,
PILOCARPINE (PILOSTAT) 2% 15ML OPH DROP:,3301806,CDM,259,RC,,,Outpatient,,,35.7,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,84.88,,24.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.85,50,,14.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,75,,21.42,percent of total billed charges,75% of total billed charges for outpatient setting,24.99,70,,19.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,80,,22.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.58,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.21,65,,18.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,35,,10,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.13,90,,25.7,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,32.13,
PILOCARPINE (PILOSTAT) 2% 2ML DROP :,3301810,CDM,259,RC,,,Outpatient,,,14.61,14.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,12.4,84.88,,9.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.31,50,,5.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.96,75,,8.77,percent of total billed charges,75% of total billed charges for outpatient setting,10.23,70,,8.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.69,80,,9.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.5,65,,7.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.11,35,,4.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.15,90,,10.52,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.15,
PILOCARPINE (PILOSTAT) 4% 1ML DROP:,3301808,CDM,259,RC,,,Outpatient,,,8.62,8.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.32,84.88,,5.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.31,50,,3.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.47,75,,5.18,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,80,,5.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.6,65,,4.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,35,,2.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.76,90,,6.21,percent of total billed charges,90% of total billed charges for outpatient setting,1.11,7.76,
PILOCARPINE (PILOSTAT) GEL: 4GM,3301809,CDM,259,RC,,,Outpatient,,,119.32,119.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.52,70,,66.82,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,84.88,,81.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,59.66,50,,47.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.49,75,,71.59,percent of total billed charges,75% of total billed charges for outpatient setting,83.52,70,,66.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.46,80,,76.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,15.32,12.84,,12.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.56,65,,62.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,35,,33.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,107.39,90,,85.91,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,107.39,
PILOCARPINE (PILOSTAT)1% 15ML OPH DROP:,3301804,CDM,259,RC,,,Outpatient,,,27.9,27.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.53,70,,15.62,percent of total billed charges,70% of total billed charges for outpatient setting,23.68,84.88,,18.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.95,50,,11.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.93,75,,16.74,percent of total billed charges,75% of total billed charges for outpatient setting,19.53,70,,15.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.32,80,,17.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.14,65,,14.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,35,,7.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.11,90,,20.09,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,25.11,
PILOCARPINE (PILOSTAT)3%OPHT 15ML DROP:,3301807,CDM,259,RC,,,Outpatient,,,32.36,32.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.65,70,,18.12,percent of total billed charges,70% of total billed charges for outpatient setting,27.47,84.88,,21.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.18,50,,12.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.27,75,,19.42,percent of total billed charges,75% of total billed charges for outpatient setting,22.65,70,,18.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,80,,20.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.03,65,,16.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.33,35,,9.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.12,90,,23.3,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,29.12,
PIN 1.4X150MM GUIDE THRD / 702459S,69161563,CDM,278,RC,C1713,HCPCS,Outpatient,,,316,316,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.6,60,,151.68,percent of total billed charges,60% of total Billed charges for outpatient setting,268.22,84.88,,214.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237,75,,189.6,percent of total billed charges,75% of total billed charges for outpatient setting,158,50,,126.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,12.84,,32.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.8,80,,202.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,12.84,,32.46,percent of total billed charges,12.84% of total billed charges,40.57,12.84,,32.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316,65,,252.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.6,35,,88.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.6,60,,151.68,percent of total billed charges,60% of total billed charges for outpatient setting,40.57,316,
PIN 100X4MM DRILL VELYS / 451570004,71000427,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,161.27,84.88,,129.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,95,50,,76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,75,,114,percent of total billed charges,75% of total billed charges for outpatient setting,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152,80,,121.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.5,65,,98.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.5,35,,53.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171,90,,136.8,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,171,
PIN 125X4MM DRILL VELYS / 451570005,71000428,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,161.27,84.88,,129.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,95,50,,76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,75,,114,percent of total billed charges,75% of total billed charges for outpatient setting,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152,80,,121.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.5,65,,98.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.5,35,,53.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171,90,,136.8,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,171,
PIN 175X4MM DRILL VELYS / 451570006,71000429,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,161.27,84.88,,129.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,95,50,,76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,75,,114,percent of total billed charges,75% of total billed charges for outpatient setting,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152,80,,121.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.5,65,,98.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.5,35,,53.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171,90,,136.8,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,171,
PIN 3.20X150MM FLUTED / 20-8000-000-10,71000350,CDM,278,RC,C1713,HCPCS,Outpatient,,,532,532,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.2,60,,255.36,percent of total billed charges,60% of total Billed charges for outpatient setting,451.56,84.88,,361.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,75,,319.2,percent of total billed charges,75% of total billed charges for outpatient setting,266,50,,212.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,12.84,,54.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.6,80,,340.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,12.84,,54.65,percent of total billed charges,12.84% of total billed charges,68.31,12.84,,54.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,532,65,,425.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,35,,148.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,319.2,60,,255.36,percent of total billed charges,60% of total billed charges for outpatient setting,68.31,532,
PIN 3.20X80MM FLUTED / 20-8000-000-11,71000340,CDM,278,RC,C1713,HCPCS,Outpatient,,,532,532,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.2,60,,255.36,percent of total billed charges,60% of total Billed charges for outpatient setting,451.56,84.88,,361.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,75,,319.2,percent of total billed charges,75% of total billed charges for outpatient setting,266,50,,212.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,12.84,,54.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.6,80,,340.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,12.84,,54.65,percent of total billed charges,12.84% of total billed charges,68.31,12.84,,54.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,532,65,,425.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,35,,148.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,319.2,60,,255.36,percent of total billed charges,60% of total billed charges for outpatient setting,68.31,532,
PIN 3.20X89MM FLUTED / 7650-2038A,71000568,CDM,278,RC,C1713,HCPCS,Outpatient,,,473.84,473.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.3,60,,227.44,percent of total billed charges,60% of total Billed charges for outpatient setting,402.2,84.88,,321.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.38,75,,284.3,percent of total billed charges,75% of total billed charges for outpatient setting,236.92,50,,189.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.84,12.84,,48.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.07,80,,303.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.84,12.84,,48.67,percent of total billed charges,12.84% of total billed charges,60.84,12.84,,48.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,473.84,65,,379.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.84,35,,132.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,284.3,60,,227.44,percent of total billed charges,60% of total billed charges for outpatient setting,60.84,473.84,
PIN 3.2MM 9IN STEINMAN SMTH / KM168-19-1,71000311,CDM,278,RC,C1713,HCPCS,Outpatient,,,44.66,44.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.8,60,,21.44,percent of total billed charges,60% of total Billed charges for outpatient setting,37.91,84.88,,30.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.5,75,,26.8,percent of total billed charges,75% of total billed charges for outpatient setting,22.33,50,,17.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,12.84,,4.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,80,,28.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.73,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,5.73,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.66,65,,35.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.63,35,,12.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.8,60,,21.44,percent of total billed charges,60% of total billed charges for outpatient setting,5.73,44.66,
PIN 3.5X150MM STEINMANN / 293.36,415596,CDM,278,RC,C1713,HCPCS,Outpatient,,,228.75,228.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.25,60,,109.8,percent of total billed charges,60% of total Billed charges for outpatient setting,194.16,84.88,,155.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.56,75,,137.25,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,50,,91.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,12.84,,23.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183,80,,146.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,29.37,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,228.75,65,,183,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.06,35,,64.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.25,60,,109.8,percent of total billed charges,60% of total billed charges for outpatient setting,29.37,228.75,
PIN 3.6MM 9IN STEINMAN SMTH / KM168-19-9,71000312,CDM,278,RC,C1713,HCPCS,Outpatient,,,43.89,43.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.33,60,,21.06,percent of total billed charges,60% of total Billed charges for outpatient setting,37.25,84.88,,29.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.92,75,,26.34,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,50,,17.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.11,80,,28.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.89,65,,35.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,35,,12.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.33,60,,21.06,percent of total billed charges,60% of total billed charges for outpatient setting,5.64,43.89,
PIN 4.0MM 9IN STEINMAN SMTH / KM168-19-5,71000313,CDM,278,RC,C1713,HCPCS,Outpatient,,,54.97,54.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.98,60,,26.38,percent of total billed charges,60% of total Billed charges for outpatient setting,46.66,84.88,,37.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.23,75,,32.98,percent of total billed charges,75% of total billed charges for outpatient setting,27.49,50,,21.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,12.84,,5.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.98,80,,35.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,7.06,12.84,,5.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.97,65,,43.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.24,35,,15.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.98,60,,26.38,percent of total billed charges,60% of total billed charges for outpatient setting,7.06,54.97,
PIN 4.0X180MM STEINMANN / 293.41,415598,CDM,278,RC,C1713,HCPCS,Outpatient,,,228.75,228.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.25,60,,109.8,percent of total billed charges,60% of total Billed charges for outpatient setting,194.16,84.88,,155.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.56,75,,137.25,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,50,,91.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,12.84,,23.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183,80,,146.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,29.37,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,228.75,65,,183,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.06,35,,64.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.25,60,,109.8,percent of total billed charges,60% of total billed charges for outpatient setting,29.37,228.75,
PIN 4MM TIGHTRPE ACL DRILL CLSD / AR-159,69161669,CDM,272,RC,,,Outpatient,,,525,525,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,70,,294,percent of total billed charges,70% of total billed charges for outpatient setting,445.62,84.88,,356.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,262.5,50,,210,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.75,75,,315,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,70,,294,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.41,12.84,,53.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,80,,336,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.41,12.84,,53.93,percent of total billed charges,12.84% of total billed charges,67.41,12.84,,53.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,341.25,65,,273,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.75,35,,147,percent of total billed charges,35% of total Billed charges for Outpatient Setting,472.5,90,,378,percent of total billed charges,90% of total billed charges for outpatient setting,67.41,472.5,
PIN 80/30 CRTCL 4.5/3.5 TAPER / A4508030,70000391,CDM,272,RC,C1713,HCPCS,Outpatient,,,670.53,670.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.37,70,,375.5,percent of total billed charges,70% of total billed charges for outpatient setting,569.15,84.88,,455.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.9,75,,402.32,percent of total billed charges,75% of total billed charges for outpatient setting,469.37,70,,375.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.42,80,,429.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,435.84,65,,348.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.69,35,,187.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,603.48,90,,482.78,percent of total billed charges,90% of total billed charges for outpatient setting,86.1,603.48,
PIN APEX HALF 5X150MM / 5018-5-150,70000778,CDM,278,RC,C1713,HCPCS,Outpatient,,,253.07,253.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.84,60,,121.47,percent of total billed charges,60% of total Billed charges for outpatient setting,214.81,84.88,,171.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.8,75,,151.84,percent of total billed charges,75% of total billed charges for outpatient setting,126.54,50,,101.23,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.49,12.84,,25.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.46,80,,161.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.49,12.84,,25.99,percent of total billed charges,12.84% of total billed charges,32.49,12.84,,25.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.57,35,,70.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.84,60,,121.47,percent of total billed charges,60% of total billed charges for outpatient setting,32.49,253.07,
PIN APEX HALF 5X200MM / 5018-6-200,70000779,CDM,278,RC,C1713,HCPCS,Outpatient,,,253.07,253.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.84,60,,121.47,percent of total billed charges,60% of total Billed charges for outpatient setting,214.81,84.88,,171.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.8,75,,151.84,percent of total billed charges,75% of total billed charges for outpatient setting,126.54,50,,101.23,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.49,12.84,,25.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.46,80,,161.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.49,12.84,,25.99,percent of total billed charges,12.84% of total billed charges,32.49,12.84,,25.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.57,35,,70.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.84,60,,121.47,percent of total billed charges,60% of total billed charges for outpatient setting,32.49,253.07,
PIN FIXATION AXSOS AO TEMP / 705019,1701294,CDM,278,RC,C1713,HCPCS,Outpatient,,,994.4,994.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.64,60,,477.31,percent of total billed charges,60% of total Billed charges for outpatient setting,844.05,84.88,,675.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.8,75,,596.64,percent of total billed charges,75% of total billed charges for outpatient setting,497.2,50,,397.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.68,12.84,,102.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.52,80,,636.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.68,12.84,,102.14,percent of total billed charges,12.84% of total billed charges,127.68,12.84,,102.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,994.4,65,,795.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.04,35,,278.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,596.64,60,,477.31,percent of total billed charges,60% of total billed charges for outpatient setting,127.68,994.4,
PIN FIXATION PROV SPINE / 650.010,40021,CDM,278,RC,C1713,HCPCS,Outpatient,,,468,468,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.8,60,,224.64,percent of total billed charges,60% of total Billed charges for outpatient setting,397.24,84.88,,317.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,75,,280.8,percent of total billed charges,75% of total billed charges for outpatient setting,234,50,,187.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,80,,299.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,468,65,,374.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,35,,131.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,280.8,60,,224.64,percent of total billed charges,60% of total billed charges for outpatient setting,60.09,468,
PIN GUIDES PT SPECIFIC /00-5970-0000-36,69169406,CDM,272,RC,,,Outpatient,,,2304,2304,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1612.8,70,,1290.24,percent of total billed charges,70% of total billed charges for outpatient setting,1955.64,84.88,,1564.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,1152,50,,921.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1728,75,,1382.4,percent of total billed charges,75% of total billed charges for outpatient setting,1612.8,70,,1290.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.83,12.84,,236.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1843.2,80,,1474.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.83,12.84,,236.66,percent of total billed charges,12.84% of total billed charges,295.83,12.84,,236.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1497.6,65,,1198.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,35,,645.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2073.6,90,,1658.88,percent of total billed charges,90% of total billed charges for outpatient setting,295.83,2073.6,
PIN GUIDES PT SPECIFIC /00-5970-0000-48,69169511,CDM,272,RC,,,Outpatient,,,2304,2304,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1612.8,70,,1290.24,percent of total billed charges,70% of total billed charges for outpatient setting,1955.64,84.88,,1564.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,1152,50,,921.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1728,75,,1382.4,percent of total billed charges,75% of total billed charges for outpatient setting,1612.8,70,,1290.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.83,12.84,,236.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1843.2,80,,1474.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.83,12.84,,236.66,percent of total billed charges,12.84% of total billed charges,295.83,12.84,,236.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1497.6,65,,1198.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,35,,645.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2073.6,90,,1658.88,percent of total billed charges,90% of total billed charges for outpatient setting,295.83,2073.6,
PIN GUIDES PT SPECIFIC /00-5970-000-67,69169732,CDM,272,RC,,,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2058,70,,1646.4,percent of total billed charges,70% of total billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1911,65,,1528.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2646,90,,2116.8,percent of total billed charges,90% of total billed charges for outpatient setting,377.5,2646,
PIN GUIDES PT SPECIFIC /00-5970-000-68,69169667,CDM,272,RC,,,Outpatient,,,3242,3242,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2269.4,70,,1815.52,percent of total billed charges,70% of total billed charges for outpatient setting,2751.81,84.88,,2201.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1621,50,,1296.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2431.5,75,,1945.2,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.27,12.84,,333.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2593.6,80,,2074.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.27,12.84,,333.02,percent of total billed charges,12.84% of total billed charges,416.27,12.84,,333.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2107.3,65,,1685.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.7,35,,907.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2917.8,90,,2334.24,percent of total billed charges,90% of total billed charges for outpatient setting,416.27,2917.8,
PIN GUIDES PT SPECIFIC /00-5970-000-83,69169579,CDM,272,RC,,,Outpatient,,,3242,3242,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2269.4,70,,1815.52,percent of total billed charges,70% of total billed charges for outpatient setting,2751.81,84.88,,2201.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1621,50,,1296.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2431.5,75,,1945.2,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.27,12.84,,333.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2593.6,80,,2074.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.27,12.84,,333.02,percent of total billed charges,12.84% of total billed charges,416.27,12.84,,333.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2107.3,65,,1685.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.7,35,,907.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2917.8,90,,2334.24,percent of total billed charges,90% of total billed charges for outpatient setting,416.27,2917.8,
PIN HALF MOD 4X120MM / 5023-5-120,70000777,CDM,278,RC,C1713,HCPCS,Outpatient,,,241.4,241.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.84,60,,115.87,percent of total billed charges,60% of total Billed charges for outpatient setting,204.9,84.88,,163.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.05,75,,144.84,percent of total billed charges,75% of total billed charges for outpatient setting,120.7,50,,96.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.12,80,,154.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,241.4,65,,193.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.49,35,,67.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144.84,60,,115.87,percent of total billed charges,60% of total billed charges for outpatient setting,31,241.4,
PIN PERC TERM THRD 2.8MM / AR-2521,70000250,CDM,272,RC,,,Outpatient,,,259.56,259.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.69,70,,145.35,percent of total billed charges,70% of total billed charges for outpatient setting,220.31,84.88,,176.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.67,75,,155.74,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,70,,145.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,80,,166.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.71,65,,134.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,35,,72.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.6,90,,186.88,percent of total billed charges,90% of total billed charges for outpatient setting,33.33,233.6,
PIN RIMMED SPEED 45MM TK / 74013471,61590163,CDM,272,RC,,,Outpatient,,,264.43,264.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.1,70,,148.08,percent of total billed charges,70% of total billed charges for outpatient setting,224.45,84.88,,179.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,132.22,50,,105.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.32,75,,158.66,percent of total billed charges,75% of total billed charges for outpatient setting,185.1,70,,148.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.95,12.84,,27.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.54,80,,169.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.95,12.84,,27.16,percent of total billed charges,12.84% of total billed charges,33.95,12.84,,27.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,171.88,65,,137.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.55,35,,74.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,237.99,90,,190.39,percent of total billed charges,90% of total billed charges for outpatient setting,33.95,237.99,
PIN RIMMED SPEED 65MM TK / 74013472,69162261,CDM,272,RC,,,Outpatient,,,233.6,233.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.52,70,,130.82,percent of total billed charges,70% of total billed charges for outpatient setting,198.28,84.88,,158.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.8,50,,93.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.2,75,,140.16,percent of total billed charges,75% of total billed charges for outpatient setting,163.52,70,,130.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,12.84,,23.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.88,80,,149.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,12.84,,23.99,percent of total billed charges,12.84% of total billed charges,29.99,12.84,,23.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.84,65,,121.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.76,35,,65.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.24,90,,168.19,percent of total billed charges,90% of total billed charges for outpatient setting,29.99,210.24,
PIN SKY THREADED TEMP FIX / 2868-50-200,70000354,CDM,272,RC,,,Outpatient,,,294.17,294.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,70,,164.74,percent of total billed charges,70% of total billed charges for outpatient setting,249.69,84.88,,199.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,147.09,50,,117.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.63,75,,176.5,percent of total billed charges,75% of total billed charges for outpatient setting,205.92,70,,164.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.34,80,,188.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,37.77,12.84,,30.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,191.21,65,,152.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.96,35,,82.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,264.75,90,,211.8,percent of total billed charges,90% of total billed charges for outpatient setting,37.77,264.75,
PIN SPEED NON-RIMMED 65MM / 74013480,61590164,CDM,272,RC,,,Outpatient,,,233.6,233.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.52,70,,130.82,percent of total billed charges,70% of total billed charges for outpatient setting,198.28,84.88,,158.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.8,50,,93.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.2,75,,140.16,percent of total billed charges,75% of total billed charges for outpatient setting,163.52,70,,130.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,12.84,,23.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.88,80,,149.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,12.84,,23.99,percent of total billed charges,12.84% of total billed charges,29.99,12.84,,23.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.84,65,,121.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.76,35,,65.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.24,90,,168.19,percent of total billed charges,90% of total billed charges for outpatient setting,29.99,210.24,
PIN STEINMANN SMOOTH 2.5X100 / 45-80300,70000461,CDM,272,RC,,,Outpatient,,,235.23,235.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.66,70,,131.73,percent of total billed charges,70% of total billed charges for outpatient setting,199.66,84.88,,159.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.62,50,,94.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.42,75,,141.14,percent of total billed charges,75% of total billed charges for outpatient setting,164.66,70,,131.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.2,12.84,,24.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.18,80,,150.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.2,12.84,,24.16,percent of total billed charges,12.84% of total billed charges,30.2,12.84,,24.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.9,65,,122.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.33,35,,65.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.71,90,,169.37,percent of total billed charges,90% of total billed charges for outpatient setting,30.2,211.71,
PIN TEMP FIXATION / 13-90-003,69169304,CDM,272,RC,,,Outpatient,,,286.65,286.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.66,70,,160.53,percent of total billed charges,70% of total billed charges for outpatient setting,243.31,84.88,,194.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,143.33,50,,114.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.99,75,,171.99,percent of total billed charges,75% of total billed charges for outpatient setting,200.66,70,,160.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.81,12.84,,29.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.32,80,,183.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.81,12.84,,29.45,percent of total billed charges,12.84% of total billed charges,36.81,12.84,,29.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,186.32,65,,149.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.33,35,,80.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,257.99,90,,206.39,percent of total billed charges,90% of total billed charges for outpatient setting,36.81,257.99,
PIN TRIM-IT DRILL 1.5X100MM / AR-4151DS,69162166,CDM,278,RC,,,Outpatient,,,908.46,908.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.08,60,,436.06,percent of total billed charges,60% of total Billed charges for outpatient setting,771.1,84.88,,616.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,454.23,50,,363.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,681.35,75,,545.08,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,50,,363.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,12.84,,93.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.77,80,,581.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,12.84,,93.32,percent of total billed charges,12.84% of total billed charges,116.65,12.84,,93.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,908.46,65,,726.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.96,35,,254.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,60,,436.06,percent of total billed charges,60% of total billed charges for outpatient setting,116.65,908.46,
PINK PAD XL KIT ARM CRDL HEAD RST /40595,69162870,CDM,271,RC,,,Outpatient,,,464,464,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.8,70,,259.84,percent of total billed charges,70% of total billed charges for outpatient setting,393.84,84.88,,315.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,232,50,,185.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348,75,,278.4,percent of total billed charges,75% of total billed charges for outpatient setting,324.8,70,,259.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.58,12.84,,47.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.2,80,,296.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.58,12.84,,47.66,percent of total billed charges,12.84% of total billed charges,59.58,12.84,,47.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.6,65,,241.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.4,35,,129.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,417.6,90,,334.08,percent of total billed charges,90% of total billed charges for outpatient setting,59.58,417.6,
PINK PAD XL KIT HEAD REST / 40597,69169226,CDM,271,RC,,,Outpatient,,,384,384,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.8,70,,215.04,percent of total billed charges,70% of total billed charges for outpatient setting,325.94,84.88,,260.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,192,50,,153.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288,75,,230.4,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,70,,215.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.31,12.84,,39.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.2,80,,245.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.31,12.84,,39.45,percent of total billed charges,12.84% of total billed charges,49.31,12.84,,39.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,249.6,65,,199.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,35,,107.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,345.6,90,,276.48,percent of total billed charges,90% of total billed charges for outpatient setting,49.31,345.6,
PINNING SYSTEM ATTUNE TK / 2544-00-111,69169646,CDM,272,RC,,,Outpatient,,,1497,1497,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.9,70,,838.32,percent of total billed charges,70% of total billed charges for outpatient setting,1270.65,84.88,,1016.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,748.5,50,,598.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1122.75,75,,898.2,percent of total billed charges,75% of total billed charges for outpatient setting,1047.9,70,,838.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.21,12.84,,153.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1197.6,80,,958.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.21,12.84,,153.77,percent of total billed charges,12.84% of total billed charges,192.21,12.84,,153.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,973.05,65,,778.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.95,35,,419.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1347.3,90,,1077.84,percent of total billed charges,90% of total billed charges for outpatient setting,192.21,1347.3,
PINS 12MM DISTRACTION / DP-12-TB,69162793,CDM,272,RC,,,Outpatient,,,155.74,155.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,132.19,84.88,,105.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.87,50,,62.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.81,75,,93.45,percent of total billed charges,75% of total billed charges for outpatient setting,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.59,80,,99.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.23,65,,80.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,35,,43.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.17,90,,112.14,percent of total billed charges,90% of total billed charges for outpatient setting,20,140.17,
PINS 14MM DISTRACTION / DP-14-TY,69169153,CDM,272,RC,,,Outpatient,,,155.74,155.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,132.19,84.88,,105.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.87,50,,62.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.81,75,,93.45,percent of total billed charges,75% of total billed charges for outpatient setting,109.02,70,,87.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.59,80,,99.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,20,12.84,,16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.23,65,,80.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,35,,43.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.17,90,,112.14,percent of total billed charges,90% of total billed charges for outpatient setting,20,140.17,
PIOGLITAZONE (ACTOS) TAB : 45 MG,3301812,CDM,259,RC,,,Outpatient,,,16.49,16.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.54,70,,9.23,percent of total billed charges,70% of total billed charges for outpatient setting,14,84.88,,11.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.25,50,,6.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.37,75,,9.9,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,70,,9.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,12.84,,1.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.19,80,,10.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.12,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.72,65,,8.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,35,,4.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.84,90,,11.87,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,14.84,
PIOGLITAZONE (genericACTOS) 30 MG TAB,3301811,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PIPERACIL/TAZO (genZOSYN)  4.5 GM VIAL,3301817,CDM,636,RC,J2543,HCPCS,Outpatient,,,22.63,22.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,70,,12.67,percent of total billed charges,70% of total billed charges for outpatient setting,19.21,84.88,,15.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.97,75,,13.58,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,70,,12.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,80,,14.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,2.91,12.84,,2.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.71,65,,11.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,100,,,Fee Schedule,100% of Custom Fee Schedule,20.37,90,,16.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,20.37,
PIPERACIL/TAZO (genZOSYN) 3.375 GM VIAL,3301816,CDM,636,RC,J2543,HCPCS,Outpatient,,,28.6,28.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.02,70,,16.02,percent of total billed charges,70% of total billed charges for outpatient setting,24.28,84.88,,19.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.45,75,,17.16,percent of total billed charges,75% of total billed charges for outpatient setting,20.02,70,,16.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.88,80,,18.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,3.67,12.84,,2.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.59,65,,14.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,100,,,Fee Schedule,100% of Custom Fee Schedule,25.74,90,,20.59,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,25.74,
PIPERACILLIN (PIPRACIL) 2 GM INJ :,3301813,CDM,250,RC,,,Outpatient,,,437.39,437.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.17,70,,244.94,percent of total billed charges,70% of total billed charges for outpatient setting,371.26,84.88,,297.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,218.7,50,,174.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.04,75,,262.43,percent of total billed charges,75% of total billed charges for outpatient setting,306.17,70,,244.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,12.84,,44.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.91,80,,279.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,12.84,,44.93,percent of total billed charges,12.84% of total billed charges,56.16,12.84,,44.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,284.3,65,,227.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.09,35,,122.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,393.65,90,,314.92,percent of total billed charges,90% of total billed charges for outpatient setting,56.16,393.65,
PIPERACILLIN (PIPRACIL) 3 GM: INJ,3302677,CDM,250,RC,,,Outpatient,,,87.72,87.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.4,70,,49.12,percent of total billed charges,70% of total billed charges for outpatient setting,74.46,84.88,,59.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.86,50,,35.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,75,,52.63,percent of total billed charges,75% of total billed charges for outpatient setting,61.4,70,,49.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,12.84,,9.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.18,80,,56.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,12.84,,9.01,percent of total billed charges,12.84% of total billed charges,11.26,12.84,,9.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.02,65,,45.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.7,35,,24.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.95,90,,63.16,percent of total billed charges,90% of total billed charges for outpatient setting,11.26,78.95,
PIPERACILLIN (PIPRACIL) 4 GM INJ :,3301814,CDM,250,RC,,,Outpatient,,,87.49,87.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.24,70,,48.99,percent of total billed charges,70% of total billed charges for outpatient setting,74.26,84.88,,59.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.75,50,,35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.62,75,,52.5,percent of total billed charges,75% of total billed charges for outpatient setting,61.24,70,,48.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.99,80,,55.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.87,65,,45.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,35,,24.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,90,,62.99,percent of total billed charges,90% of total billed charges for outpatient setting,11.23,78.74,
PIPERACILLIN (ZOSYN) 2.25GM INJ :,3301815,CDM,250,RC,,,Outpatient,,,32.75,32.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.93,70,,18.34,percent of total billed charges,70% of total billed charges for outpatient setting,27.8,84.88,,22.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.38,50,,13.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.56,75,,19.65,percent of total billed charges,75% of total billed charges for outpatient setting,22.93,70,,18.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.2,80,,20.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.29,65,,17.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,35,,9.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.48,90,,23.58,percent of total billed charges,90% of total billed charges for outpatient setting,4.21,29.48,
PIROXICAM (FELDENE) CAP : 10 MG,3301820,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PITAVASTATIN (LIVALO) TAB: 4MG,3304196,CDM,259,RC,,,Outpatient,,,13.42,13.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.39,70,,7.51,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,84.88,,9.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.71,50,,5.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.07,75,,8.06,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,70,,7.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,80,,8.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.72,65,,6.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,35,,3.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.08,90,,9.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.08,
PKA CUT GUIDE/MDL  42 411573,69162278,CDM,272,RC,,,Outpatient,,,2460.41,2460.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1722.29,70,,1377.83,percent of total billed charges,70% of total billed charges for outpatient setting,2088.4,84.88,,1670.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1230.21,50,,984.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1845.31,75,,1476.25,percent of total billed charges,75% of total billed charges for outpatient setting,1722.29,70,,1377.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.92,12.84,,252.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968.33,80,,1574.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.92,12.84,,252.74,percent of total billed charges,12.84% of total billed charges,315.92,12.84,,252.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1599.27,65,,1279.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,861.14,35,,688.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2214.37,90,,1771.5,percent of total billed charges,90% of total billed charges for outpatient setting,315.92,2214.37,
PKA POST CUT SML,69161900,CDM,272,RC,,,Outpatient,,,2084,2084,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1458.8,70,,1167.04,percent of total billed charges,70% of total billed charges for outpatient setting,1768.9,84.88,,1415.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,1042,50,,833.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1563,75,,1250.4,percent of total billed charges,75% of total billed charges for outpatient setting,1458.8,70,,1167.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.59,12.84,,214.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1667.2,80,,1333.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.59,12.84,,214.07,percent of total billed charges,12.84% of total billed charges,267.59,12.84,,214.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1354.6,65,,1083.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.4,35,,583.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1875.6,90,,1500.48,percent of total billed charges,90% of total billed charges for outpatient setting,267.59,1875.6,
PLAC,200912,CDM,300,RC,83698,HCPCS,Outpatient,,,208.4,187.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.88,70,,116.7,percent of total billed charges,70% of total billed charges for outpatient setting,176.89,84.88,,141.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,156.3,75,,125.04,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,70,,116.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.72,80,,133.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,49.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of Custom Fee Schedule,187.56,90,,150.05,percent of total billed charges,90% of total billed charges for outpatient setting,45.76,187.56,
PLACEMENT OF RADIOThx EXPANDABLE CATH,69160906,CDM,360,RC,,,Outpatient,,,11930.35,11930.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8351.25,70,,6681,percent of total billed charges,70% of total billed charges for outpatient setting,10126.48,84.88,,8101.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,5965.18,50,,4772.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8947.76,75,,7158.21,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.86,12.84,,1225.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9544.28,80,,7635.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.86,12.84,,1225.49,percent of total billed charges,12.84% of total billed charges,1531.86,12.84,,1225.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4175.62,35,,3340.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10737.32,90,,8589.86,percent of total billed charges,90% of total billed charges for outpatient setting,1531.86,10737.32,
PLASMA BLADE 3.0S / PS210-030S,69162271,CDM,272,RC,,,Outpatient,,,1199.02,1199.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.31,70,,671.45,percent of total billed charges,70% of total billed charges for outpatient setting,1017.73,84.88,,814.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,599.51,50,,479.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,899.27,75,,719.42,percent of total billed charges,75% of total billed charges for outpatient setting,839.31,70,,671.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.95,12.84,,123.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,959.22,80,,767.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.95,12.84,,123.16,percent of total billed charges,12.84% of total billed charges,153.95,12.84,,123.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,779.36,65,,623.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.66,35,,335.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1079.12,90,,863.3,percent of total billed charges,90% of total billed charges for outpatient setting,153.95,1079.12,
PLASMA BLD 3.0S LIGHT / PS210-030S-LIGHT,69169549,CDM,272,RC,,,Outpatient,,,1255.8,1255.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.06,70,,703.25,percent of total billed charges,70% of total billed charges for outpatient setting,1065.92,84.88,,852.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,627.9,50,,502.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,941.85,75,,753.48,percent of total billed charges,75% of total billed charges for outpatient setting,879.06,70,,703.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.24,12.84,,128.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.64,80,,803.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.24,12.84,,128.99,percent of total billed charges,12.84% of total billed charges,161.24,12.84,,128.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,816.27,65,,653.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.53,35,,351.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1130.22,90,,904.18,percent of total billed charges,90% of total billed charges for outpatient setting,161.24,1130.22,
PLASMA VOLUME RADIOPHARMACEUTICAL VOLUME,3000170,CDM,341,RC,78110,HCPCS,Outpatient,,,811.23,608.42,,1873.63,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,688.57,84.88,,550.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,1672.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,608.42,75,,486.74,percent of total billed charges,75% of total billed charges for outpatient setting,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,1990.73,170,,,Fee Schedule,170% of Medicare OPPS rate,2517.69,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,104.16,12.84,,83.328,percent of total billed charges,12.84% of total billed charges,2049.28,175,,,Fee Schedule,175% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,648.98,80,,519.18,percent of total billed charges,80% of total billed charges for outpatient setting,1639.42,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1463.77,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1171.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,673.24,100,,,Fee Schedule,100% of Custom Fee Schedule,730.11,90,,584.09,percent of total billed charges,90% of total billed charges for outpatient setting,104.16,2517.69,
PLASMINOGEN,202560,CDM,310,RC,85420,HCPCS,Outpatient,,,63.13,56.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.19,70,,35.35,percent of total billed charges,70% of total billed charges for outpatient setting,53.58,84.88,,42.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.35,75,,37.88,percent of total billed charges,75% of total billed charges for outpatient setting,44.19,70,,35.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.5,80,,40.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.4,100,,,Fee Schedule,100% of Custom Fee Schedule,56.82,90,,45.46,percent of total billed charges,90% of total billed charges for outpatient setting,6.53,56.82,
PLASMINOGEN ACTIVATOR INHIBITOR 1,202559,CDM,305,RC,85415,HCPCS,Outpatient,,,77.36,69.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.15,70,,43.32,percent of total billed charges,70% of total billed charges for outpatient setting,65.66,84.88,,52.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.02,75,,46.42,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,70,,43.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.89,80,,49.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.61,100,,,Fee Schedule,100% of Custom Fee Schedule,69.62,90,,55.7,percent of total billed charges,90% of total billed charges for outpatient setting,17.19,69.62,
PLATE  6 HOLE CURVED / 40-15014,69162876,CDM,278,RC,C1713,HCPCS,Outpatient,,,2375.44,2375.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.26,60,,1140.21,percent of total billed charges,60% of total Billed charges for outpatient setting,2016.27,84.88,,1613.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1781.58,75,,1425.26,percent of total billed charges,75% of total billed charges for outpatient setting,1187.72,50,,950.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.01,12.84,,244.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1900.35,80,,1520.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.01,12.84,,244.01,percent of total billed charges,12.84% of total billed charges,305.01,12.84,,244.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2494.21,105,,1995.37,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.4,35,,665.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1425.26,60,,1140.21,percent of total billed charges,60% of total billed charges for outpatient setting,305.01,2494.21,
PLATE 0D 2.4/2.7MM RT / 02.211.230,742876,CDM,278,RC,C1776,HCPCS,Outpatient,,,2526.2,2526.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1515.72,60,,1212.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2144.24,84.88,,1715.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.65,75,,1515.72,percent of total billed charges,75% of total billed charges for outpatient setting,1263.1,50,,1010.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.36,12.84,,259.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2020.96,80,,1616.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.36,12.84,,259.49,percent of total billed charges,12.84% of total billed charges,324.36,12.84,,259.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2652.51,105,,2122.01,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.17,35,,707.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1515.72,60,,1212.58,percent of total billed charges,60% of total billed charges for outpatient setting,324.36,2652.51,
PLATE 1.5MM CONDYLR 2X6H / 02.130.255,69169251,CDM,278,RC,C1713,HCPCS,Outpatient,,,2344.8,2344.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1406.88,60,,1125.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1990.27,84.88,,1592.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1758.6,75,,1406.88,percent of total billed charges,75% of total billed charges for outpatient setting,1172.4,50,,937.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.07,12.84,,240.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1875.84,80,,1500.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.07,12.84,,240.86,percent of total billed charges,12.84% of total billed charges,301.07,12.84,,240.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2462.04,105,,1969.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.68,35,,656.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1406.88,60,,1125.5,percent of total billed charges,60% of total billed charges for outpatient setting,301.07,2462.04,
PLATE 10 HOLE 121MM 1/3 TUBULR / 241.40,6152874,CDM,278,RC,,,Outpatient,,,218.57,218.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.14,60,,104.91,percent of total billed charges,60% of total Billed charges for outpatient setting,185.52,84.88,,148.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.29,50,,87.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.93,75,,131.14,percent of total billed charges,75% of total billed charges for outpatient setting,109.29,50,,87.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.06,12.84,,22.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.86,80,,139.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.06,12.84,,22.45,percent of total billed charges,12.84% of total billed charges,28.06,12.84,,22.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,218.57,65,,174.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,35,,61.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.14,60,,104.91,percent of total billed charges,60% of total billed charges for outpatient setting,28.06,218.57,
PLATE 10 HOLE 122MM VARIAX / 628030,1152907,CDM,278,RC,C1713,HCPCS,Outpatient,,,3437.28,3437.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2062.37,60,,1649.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2917.56,84.88,,2334.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2577.96,75,,2062.37,percent of total billed charges,75% of total billed charges for outpatient setting,1718.64,50,,1374.91,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2749.82,80,,2199.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3609.14,105,,2887.31,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.05,35,,962.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2062.37,60,,1649.9,percent of total billed charges,60% of total billed charges for outpatient setting,441.35,3609.14,
PLATE 10H LOCKING STRT / AR-8943BRS-10,71000587,CDM,278,RC,C1776,HCPCS,Outpatient,,,3123.75,3123.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.25,60,,1499.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2651.44,84.88,,2121.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2342.81,75,,1874.25,percent of total billed charges,75% of total billed charges for outpatient setting,1561.88,50,,1249.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.09,12.84,,320.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2499,80,,1999.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.09,12.84,,320.87,percent of total billed charges,12.84% of total billed charges,401.09,12.84,,320.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3279.94,105,,2623.95,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.31,35,,874.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.25,60,,1499.4,percent of total billed charges,60% of total billed charges for outpatient setting,401.09,3279.94,
PLATE 10H LOCKING STRT / AR-9943C-10,71000930,CDM,278,RC,C1776,HCPCS,Outpatient,,,2186.62,2186.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.97,60,,1049.58,percent of total billed charges,60% of total Billed charges for outpatient setting,1856,84.88,,1484.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.97,75,,1311.98,percent of total billed charges,75% of total billed charges for outpatient setting,1093.31,50,,874.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.76,12.84,,224.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.3,80,,1399.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.76,12.84,,224.61,percent of total billed charges,12.84% of total billed charges,280.76,12.84,,224.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2295.95,105,,1836.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.32,35,,612.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1311.97,60,,1049.58,percent of total billed charges,60% of total billed charges for outpatient setting,280.76,2295.95,
PLATE 10H VOLAR RT INTMDT / 54-25684,70000606,CDM,278,RC,C1713,HCPCS,Outpatient,,,2478,2478,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.8,60,,1189.44,percent of total billed charges,60% of total Billed charges for outpatient setting,2103.33,84.88,,1682.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1858.5,75,,1486.8,percent of total billed charges,75% of total billed charges for outpatient setting,1239,50,,991.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.18,12.84,,254.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1982.4,80,,1585.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.18,12.84,,254.54,percent of total billed charges,12.84% of total billed charges,318.18,12.84,,254.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2601.9,105,,2081.52,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.3,35,,693.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1486.8,60,,1189.44,percent of total billed charges,60% of total billed charges for outpatient setting,318.18,2601.9,
PLATE 11 HOLE VARIAX COMP CRV / 629561,70000642,CDM,278,RC,C1713,HCPCS,Outpatient,,,2404.57,2404.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1442.74,60,,1154.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2041,84.88,,1632.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1803.43,75,,1442.74,percent of total billed charges,75% of total billed charges for outpatient setting,1202.29,50,,961.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.75,12.84,,247,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1923.66,80,,1538.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.75,12.84,,247,percent of total billed charges,12.84% of total billed charges,308.75,12.84,,247,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2524.8,105,,2019.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.6,35,,673.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1442.74,60,,1154.19,percent of total billed charges,60% of total billed charges for outpatient setting,308.75,2524.8,
PLATE 12 HOLE HUMERUS STRAIGHT / 627512,69169778,CDM,278,RC,C1713,HCPCS,Outpatient,,,2808.32,2808.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1684.99,60,,1347.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2383.7,84.88,,1906.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2106.24,75,,1684.99,percent of total billed charges,75% of total billed charges for outpatient setting,1404.16,50,,1123.33,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.59,12.84,,288.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2246.66,80,,1797.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.59,12.84,,288.47,percent of total billed charges,12.84% of total billed charges,360.59,12.84,,288.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2948.74,105,,2358.99,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.91,35,,786.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1684.99,60,,1347.99,percent of total billed charges,60% of total billed charges for outpatient setting,360.59,2948.74,
PLATE 12 HOLE STR / 626682,69162587,CDM,278,RC,,,Outpatient,,,2585.33,2585.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1551.2,60,,1240.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2194.43,84.88,,1755.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1292.67,50,,1034.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1939,75,,1551.2,percent of total billed charges,75% of total billed charges for outpatient setting,1292.67,50,,1034.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.96,12.84,,265.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2068.26,80,,1654.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.96,12.84,,265.57,percent of total billed charges,12.84% of total billed charges,331.96,12.84,,265.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2714.6,105,,2171.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,904.87,35,,723.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1551.2,60,,1240.96,percent of total billed charges,60% of total billed charges for outpatient setting,331.96,2714.6,
PLATE 12H 151MM VARIAX / 629562,1612644,CDM,278,RC,C1713,HCPCS,Outpatient,,,2099.02,2099.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1259.41,60,,1007.53,percent of total billed charges,60% of total Billed charges for outpatient setting,1781.65,84.88,,1425.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1574.27,75,,1259.42,percent of total billed charges,75% of total billed charges for outpatient setting,1049.51,50,,839.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.51,12.84,,215.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1679.22,80,,1343.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.51,12.84,,215.61,percent of total billed charges,12.84% of total billed charges,269.51,12.84,,215.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2099.02,65,,1679.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.66,35,,587.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1259.41,60,,1007.53,percent of total billed charges,60% of total billed charges for outpatient setting,269.51,2099.02,
PLATE 12H LOCKING STRT / AR-8943C-12,71000834,CDM,278,RC,C1776,HCPCS,Outpatient,,,2554.12,2554.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.47,60,,1225.98,percent of total billed charges,60% of total Billed charges for outpatient setting,2167.94,84.88,,1734.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.59,75,,1532.47,percent of total billed charges,75% of total billed charges for outpatient setting,1277.06,50,,1021.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2043.3,80,,1634.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2681.83,105,,2145.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.94,35,,715.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1532.47,60,,1225.98,percent of total billed charges,60% of total billed charges for outpatient setting,327.95,2681.83,
PLATE 14MM CERVICAL  UM102-01-14,69169384,CDM,278,RC,C1713,HCPCS,Outpatient,,,3307.5,3307.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,60,,1587.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2807.41,84.88,,2245.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2480.63,75,,1984.5,percent of total billed charges,75% of total billed charges for outpatient setting,1653.75,50,,1323,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2646,80,,2116.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3472.88,105,,2778.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.63,35,,926.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1984.5,60,,1587.6,percent of total billed charges,60% of total billed charges for outpatient setting,424.68,3472.88,
PLATE 14MM FORTOX C / 13-01-014,69169317,CDM,278,RC,C1713,HCPCS,Outpatient,,,3307.5,3307.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,60,,1587.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2807.41,84.88,,2245.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2480.63,75,,1984.5,percent of total billed charges,75% of total billed charges for outpatient setting,1653.75,50,,1323,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2646,80,,2116.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3472.88,105,,2778.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.63,35,,926.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1984.5,60,,1587.6,percent of total billed charges,60% of total billed charges for outpatient setting,424.68,3472.88,
PLATE 14MM SKYLINE 1 LVL / 1868-01-014,70000479,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805,35,,644,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
PLATE 14MM XTEND AC / 161.114,69161701,CDM,278,RC,C1713,HCPCS,Outpatient,,,2134,2134,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.4,60,,1024.32,percent of total billed charges,60% of total Billed charges for outpatient setting,1811.34,84.88,,1449.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600.5,75,,1280.4,percent of total billed charges,75% of total billed charges for outpatient setting,1067,50,,853.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.2,80,,1365.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2240.7,105,,1792.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.9,35,,597.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1280.4,60,,1024.32,percent of total billed charges,60% of total billed charges for outpatient setting,274.01,2240.7,
PLATE 16MM FORTOX C / 13-01-016,69169301,CDM,278,RC,C1713,HCPCS,Outpatient,,,3307.5,3307.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,60,,1587.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2807.41,84.88,,2245.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2480.63,75,,1984.5,percent of total billed charges,75% of total billed charges for outpatient setting,1653.75,50,,1323,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2646,80,,2116.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,424.68,12.84,,339.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3472.88,105,,2778.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.63,35,,926.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1984.5,60,,1587.6,percent of total billed charges,60% of total billed charges for outpatient setting,424.68,3472.88,
PLATE 2 HOLE TUBULAR 1/3 / 626672,69169286,CDM,278,RC,C1713,HCPCS,Outpatient,,,977.59,977.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.55,60,,469.24,percent of total billed charges,60% of total Billed charges for outpatient setting,829.78,84.88,,663.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.19,75,,586.55,percent of total billed charges,75% of total billed charges for outpatient setting,488.8,50,,391.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.52,12.84,,100.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.07,80,,625.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.52,12.84,,100.42,percent of total billed charges,12.84% of total billed charges,125.52,12.84,,100.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,977.59,65,,782.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.16,35,,273.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,586.55,60,,469.24,percent of total billed charges,60% of total billed charges for outpatient setting,125.52,977.59,
PLATE 2.0MM Y 3/7HOLE LCP/ 247.350,69169656,CDM,278,RC,C1713,HCPCS,Outpatient,,,2086.14,2086.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1251.68,60,,1001.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1770.72,84.88,,1416.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1564.61,75,,1251.69,percent of total billed charges,75% of total billed charges for outpatient setting,1043.07,50,,834.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.86,12.84,,214.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1668.91,80,,1335.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.86,12.84,,214.29,percent of total billed charges,12.84% of total billed charges,267.86,12.84,,214.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2086.14,65,,1668.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.15,35,,584.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1251.68,60,,1001.34,percent of total billed charges,60% of total billed charges for outpatient setting,267.86,2086.14,
PLATE 2.0X31MM LCP 4 HOLE / 247.344,69169400,CDM,278,RC,C1713,HCPCS,Outpatient,,,1282.56,1282.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.54,60,,615.63,percent of total billed charges,60% of total Billed charges for outpatient setting,1088.64,84.88,,870.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.92,75,,769.54,percent of total billed charges,75% of total billed charges for outpatient setting,641.28,50,,513.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.68,12.84,,131.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1026.05,80,,820.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.68,12.84,,131.74,percent of total billed charges,12.84% of total billed charges,164.68,12.84,,131.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1282.56,65,,1026.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.9,35,,359.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,769.54,60,,615.63,percent of total billed charges,60% of total billed charges for outpatient setting,164.68,1282.56,
PLATE 2.0X38MM LCP 5 HOLE / 247.345,69169305,CDM,278,RC,C1713,HCPCS,Outpatient,,,981,981,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.6,60,,470.88,percent of total billed charges,60% of total Billed charges for outpatient setting,832.67,84.88,,666.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.75,75,,588.6,percent of total billed charges,75% of total billed charges for outpatient setting,490.5,50,,392.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.96,12.84,,100.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,80,,627.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.96,12.84,,100.77,percent of total billed charges,12.84% of total billed charges,125.96,12.84,,100.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,981,65,,784.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.35,35,,274.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,588.6,60,,470.88,percent of total billed charges,60% of total billed charges for outpatient setting,125.96,981,
PLATE 2.0X45MM LCP 6 HOLE / 247.346,69162729,CDM,278,RC,C1713,HCPCS,Outpatient,,,1370.25,1370.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.15,60,,657.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1163.07,84.88,,930.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.69,75,,822.15,percent of total billed charges,75% of total billed charges for outpatient setting,685.13,50,,548.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.94,12.84,,140.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.2,80,,876.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.94,12.84,,140.75,percent of total billed charges,12.84% of total billed charges,175.94,12.84,,140.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1370.25,65,,1096.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.59,35,,383.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,822.15,60,,657.72,percent of total billed charges,60% of total billed charges for outpatient setting,175.94,1370.25,
PLATE 2.0X52MM LCP 7 HOLE / 247.347,69162709,CDM,278,RC,C1713,HCPCS,Outpatient,,,1046.81,1046.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.09,60,,502.47,percent of total billed charges,60% of total Billed charges for outpatient setting,888.53,84.88,,710.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.11,75,,628.09,percent of total billed charges,75% of total billed charges for outpatient setting,523.41,50,,418.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.41,12.84,,107.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.45,80,,669.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.41,12.84,,107.53,percent of total billed charges,12.84% of total billed charges,134.41,12.84,,107.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1046.81,65,,837.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.38,35,,293.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.09,60,,502.47,percent of total billed charges,60% of total billed charges for outpatient setting,134.41,1046.81,
PLATE 2.4/7.2MM CLVR LF / 02.211.251,69169177,CDM,278,RC,C1713,HCPCS,Outpatient,,,2480.4,2480.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488.24,60,,1190.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2105.36,84.88,,1684.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1860.3,75,,1488.24,percent of total billed charges,75% of total billed charges for outpatient setting,1240.2,50,,992.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.48,12.84,,254.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.32,80,,1587.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.48,12.84,,254.78,percent of total billed charges,12.84% of total billed charges,318.48,12.84,,254.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2604.42,105,,2083.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.14,35,,694.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1488.24,60,,1190.59,percent of total billed charges,60% of total billed charges for outpatient setting,318.48,2604.42,
PLATE 2.4/7.2MM VA-LCP RIGHT/ 02.211.238,69169448,CDM,278,RC,C1713,HCPCS,Outpatient,,,2795.52,2795.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1677.31,60,,1341.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2372.84,84.88,,1898.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096.64,75,,1677.31,percent of total billed charges,75% of total billed charges for outpatient setting,1397.76,50,,1118.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.94,12.84,,287.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2236.42,80,,1789.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.94,12.84,,287.15,percent of total billed charges,12.84% of total billed charges,358.94,12.84,,287.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2935.3,105,,2348.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.43,35,,782.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.31,60,,1341.85,percent of total billed charges,60% of total billed charges for outpatient setting,358.94,2935.3,
PLATE 2.4MM /6X4HL LEFT / 04.111.541,69162574,CDM,278,RC,C1713,HCPCS,Outpatient,,,15670.94,15670.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9402.56,60,,7522.05,percent of total billed charges,60% of total Billed charges for outpatient setting,13301.49,84.88,,10641.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11753.21,75,,9402.57,percent of total billed charges,75% of total billed charges for outpatient setting,7835.47,50,,6268.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2012.15,12.84,,1609.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12536.75,80,,10029.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2012.15,12.84,,1609.72,percent of total billed charges,12.84% of total billed charges,2012.15,12.84,,1609.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16454.49,105,,13163.59,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5484.83,35,,4387.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9402.56,60,,7522.05,percent of total billed charges,60% of total billed charges for outpatient setting,2012.15,16454.49,
PLATE 2.4MM 4HL DSTL RAD / 242.478,662152,CDM,278,RC,C1713,HCPCS,Outpatient,,,1954.99,1954.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.99,60,,938.39,percent of total billed charges,60% of total Billed charges for outpatient setting,1659.4,84.88,,1327.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1466.24,75,,1172.99,percent of total billed charges,75% of total billed charges for outpatient setting,977.5,50,,782,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.02,12.84,,200.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1563.99,80,,1251.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.02,12.84,,200.82,percent of total billed charges,12.84% of total billed charges,251.02,12.84,,200.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1954.99,65,,1563.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.25,35,,547.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1172.99,60,,938.39,percent of total billed charges,60% of total billed charges for outpatient setting,251.02,1954.99,
PLATE 2.4MM 5HL DSTL RAD / 242.479,662153,CDM,278,RC,C1713,HCPCS,Outpatient,,,1780.55,1780.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.33,60,,854.66,percent of total billed charges,60% of total Billed charges for outpatient setting,1511.33,84.88,,1209.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1335.41,75,,1068.33,percent of total billed charges,75% of total billed charges for outpatient setting,890.28,50,,712.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.62,12.84,,182.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1424.44,80,,1139.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.62,12.84,,182.9,percent of total billed charges,12.84% of total billed charges,228.62,12.84,,182.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1780.55,65,,1424.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.19,35,,498.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1068.33,60,,854.66,percent of total billed charges,60% of total billed charges for outpatient setting,228.62,1780.55,
PLATE 2.7/3.5 2H PRX OLCRAN / 02.107.102,1164919,CDM,278,RC,C1713,HCPCS,Outpatient,,,3702.4,3702.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2221.44,60,,1777.15,percent of total billed charges,60% of total Billed charges for outpatient setting,3142.6,84.88,,2514.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2776.8,75,,2221.44,percent of total billed charges,75% of total billed charges for outpatient setting,1851.2,50,,1480.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.39,12.84,,380.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2961.92,80,,2369.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.39,12.84,,380.31,percent of total billed charges,12.84% of total billed charges,475.39,12.84,,380.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3887.52,105,,3110.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295.84,35,,1036.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2221.44,60,,1777.15,percent of total billed charges,60% of total billed charges for outpatient setting,475.39,3887.52,
PLATE 2.7/3.5 2H RT OLCRAN / 02.107.202,1150703,CDM,278,RC,C1713,HCPCS,Outpatient,,,4162.58,4162.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2497.55,60,,1998.04,percent of total billed charges,60% of total Billed charges for outpatient setting,3533.2,84.88,,2826.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3121.94,75,,2497.55,percent of total billed charges,75% of total billed charges for outpatient setting,2081.29,50,,1665.03,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.48,12.84,,427.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3330.06,80,,2664.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.48,12.84,,427.58,percent of total billed charges,12.84% of total billed charges,534.48,12.84,,427.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4370.71,105,,3496.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456.9,35,,1165.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2497.55,60,,1998.04,percent of total billed charges,60% of total billed charges for outpatient setting,534.48,4370.71,
PLATE 2.7/3.5 X90MM LT OLCRAN 02.107.302,69169429,CDM,278,RC,,,Outpatient,,,2115.66,2115.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1269.4,60,,1015.52,percent of total billed charges,60% of total Billed charges for outpatient setting,1795.77,84.88,,1436.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,1057.83,50,,846.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1586.75,75,,1269.4,percent of total billed charges,75% of total billed charges for outpatient setting,1057.83,50,,846.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.65,12.84,,217.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1692.53,80,,1354.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.65,12.84,,217.32,percent of total billed charges,12.84% of total billed charges,271.65,12.84,,217.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2221.44,105,,1777.15,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.48,35,,592.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1269.4,60,,1015.52,percent of total billed charges,60% of total billed charges for outpatient setting,271.65,2221.44,
PLATE 20MM XTEND ANT / 161.120,341989,CDM,278,RC,C1713,HCPCS,Outpatient,,,3734.5,3734.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.7,60,,1792.56,percent of total billed charges,60% of total Billed charges for outpatient setting,3169.84,84.88,,2535.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800.88,75,,2240.7,percent of total billed charges,75% of total billed charges for outpatient setting,1867.25,50,,1493.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.51,12.84,,383.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2987.6,80,,2390.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.51,12.84,,383.61,percent of total billed charges,12.84% of total billed charges,479.51,12.84,,383.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3921.23,105,,3136.98,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.08,35,,1045.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2240.7,60,,1792.56,percent of total billed charges,60% of total billed charges for outpatient setting,479.51,3921.23,
PLATE 20X9MM 0 DEG INTERCON / 187.009,69162375,CDM,278,RC,,,Outpatient,,,2134,2134,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.4,60,,1024.32,percent of total billed charges,60% of total Billed charges for outpatient setting,1811.34,84.88,,1449.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,1067,50,,853.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1600.5,75,,1280.4,percent of total billed charges,75% of total billed charges for outpatient setting,1067,50,,853.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.2,80,,1365.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2240.7,105,,1792.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.9,35,,597.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1280.4,60,,1024.32,percent of total billed charges,60% of total billed charges for outpatient setting,274.01,2240.7,
PLATE 2H 2.7MM DIST HUM L / 02.117.902,1163001,CDM,278,RC,C1713,HCPCS,Outpatient,,,2898.42,2898.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1739.05,60,,1391.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2460.18,84.88,,1968.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2173.82,75,,1739.06,percent of total billed charges,75% of total billed charges for outpatient setting,1449.21,50,,1159.37,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.16,12.84,,297.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2318.74,80,,1854.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.16,12.84,,297.73,percent of total billed charges,12.84% of total billed charges,372.16,12.84,,297.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3043.34,105,,2434.67,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.45,35,,811.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1739.05,60,,1391.24,percent of total billed charges,60% of total billed charges for outpatient setting,372.16,3043.34,
PLATE 2H SYNDESMOSIS DUAL  AR-8958TDS,69162767,CDM,278,RC,C1713,HCPCS,Outpatient,,,4700,4700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2820,60,,2256,percent of total billed charges,60% of total Billed charges for outpatient setting,3989.36,84.88,,3191.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3525,75,,2820,percent of total billed charges,75% of total billed charges for outpatient setting,2350,50,,1880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.48,12.84,,482.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3760,80,,3008,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.48,12.84,,482.78,percent of total billed charges,12.84% of total billed charges,603.48,12.84,,482.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4935,105,,3948,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1645,35,,1316,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2820,60,,2256,percent of total billed charges,60% of total billed charges for outpatient setting,603.48,4935,
PLATE 2H T VARIAX / 629782,7233952,CDM,278,RC,C1713,HCPCS,Outpatient,,,2654.4,2654.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1592.64,60,,1274.11,percent of total billed charges,60% of total Billed charges for outpatient setting,2253.05,84.88,,1802.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1990.8,75,,1592.64,percent of total billed charges,75% of total billed charges for outpatient setting,1327.2,50,,1061.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.82,12.84,,272.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2123.52,80,,1698.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.82,12.84,,272.66,percent of total billed charges,12.84% of total billed charges,340.82,12.84,,272.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2787.12,105,,2229.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.04,35,,743.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1592.64,60,,1274.11,percent of total billed charges,60% of total billed charges for outpatient setting,340.82,2787.12,
PLATE 3 HOLE TUBULAR 1/3 / 626673,2050564,CDM,278,RC,C1713,HCPCS,Outpatient,,,971.52,971.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.91,60,,466.33,percent of total billed charges,60% of total Billed charges for outpatient setting,824.63,84.88,,659.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.64,75,,582.91,percent of total billed charges,75% of total billed charges for outpatient setting,485.76,50,,388.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,12.84,,99.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.22,80,,621.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,12.84,,99.79,percent of total billed charges,12.84% of total billed charges,124.74,12.84,,99.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,971.52,65,,777.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.03,35,,272.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,582.91,60,,466.33,percent of total billed charges,60% of total billed charges for outpatient setting,124.74,971.52,
PLATE 3.5 X194MM LT DIST HM/ 02.104.028S,69169794,CDM,278,RC,C1713,HCPCS,Outpatient,,,3514.64,3514.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2108.78,60,,1687.02,percent of total billed charges,60% of total Billed charges for outpatient setting,2983.23,84.88,,2386.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2635.98,75,,2108.78,percent of total billed charges,75% of total billed charges for outpatient setting,1757.32,50,,1405.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.28,12.84,,361.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2811.71,80,,2249.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.28,12.84,,361.02,percent of total billed charges,12.84% of total billed charges,451.28,12.84,,361.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3690.37,105,,2952.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1230.12,35,,984.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2108.78,60,,1687.02,percent of total billed charges,60% of total billed charges for outpatient setting,451.28,3690.37,
PLATE 3.5 X230MM LT DIST HM/ 02.104.030S,69169793,CDM,278,RC,C1713,HCPCS,Outpatient,,,3714.02,3714.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2228.41,60,,1782.73,percent of total billed charges,60% of total Billed charges for outpatient setting,3152.46,84.88,,2521.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2785.52,75,,2228.42,percent of total billed charges,75% of total billed charges for outpatient setting,1857.01,50,,1485.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.88,12.84,,381.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2971.22,80,,2376.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.88,12.84,,381.5,percent of total billed charges,12.84% of total billed charges,476.88,12.84,,381.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3899.72,105,,3119.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1299.91,35,,1039.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2228.41,60,,1782.73,percent of total billed charges,60% of total billed charges for outpatient setting,476.88,3899.72,
PLATE 3.5MM 10H RT BEND / 02.127.240,1178761,CDM,278,RC,C1713,HCPCS,Outpatient,,,6239.62,6239.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3743.77,60,,2995.02,percent of total billed charges,60% of total Billed charges for outpatient setting,5296.19,84.88,,4236.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4679.72,75,,3743.78,percent of total billed charges,75% of total billed charges for outpatient setting,3119.81,50,,2495.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.17,12.84,,640.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.7,80,,3993.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.17,12.84,,640.94,percent of total billed charges,12.84% of total billed charges,801.17,12.84,,640.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6551.6,105,,5241.28,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2183.87,35,,1747.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3743.77,60,,2995.02,percent of total billed charges,60% of total billed charges for outpatient setting,801.17,6551.6,
PLATE 3.5MM CLAVICLE 6H RT / 02.112.080,69169634,CDM,278,RC,C1713,HCPCS,Outpatient,,,3565.5,3565.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2139.3,60,,1711.44,percent of total billed charges,60% of total Billed charges for outpatient setting,3026.4,84.88,,2421.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2674.13,75,,2139.3,percent of total billed charges,75% of total billed charges for outpatient setting,1782.75,50,,1426.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.81,12.84,,366.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2852.4,80,,2281.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.81,12.84,,366.25,percent of total billed charges,12.84% of total billed charges,457.81,12.84,,366.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3743.78,105,,2995.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.93,35,,998.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2139.3,60,,1711.44,percent of total billed charges,60% of total billed charges for outpatient setting,457.81,3743.78,
PLATE 3.5MM LCP PERIARTICLR / 02.123.020,70000397,CDM,278,RC,C1713,HCPCS,Outpatient,,,3008.84,3008.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1805.3,60,,1444.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2553.9,84.88,,2043.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2256.63,75,,1805.3,percent of total billed charges,75% of total billed charges for outpatient setting,1504.42,50,,1203.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.34,12.84,,309.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2407.07,80,,1925.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.34,12.84,,309.07,percent of total billed charges,12.84% of total billed charges,386.34,12.84,,309.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3159.28,105,,2527.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.09,35,,842.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1805.3,60,,1444.24,percent of total billed charges,60% of total billed charges for outpatient setting,386.34,3159.28,
PLATE 3.5X103MM LC-DCP 223.58,6152862,CDM,278,RC,,,Outpatient,,,455.93,455.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.56,60,,218.85,percent of total billed charges,60% of total Billed charges for outpatient setting,386.99,84.88,,309.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,227.97,50,,182.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.95,75,,273.56,percent of total billed charges,75% of total billed charges for outpatient setting,227.97,50,,182.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.54,12.84,,46.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.74,80,,291.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.54,12.84,,46.83,percent of total billed charges,12.84% of total billed charges,58.54,12.84,,46.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,455.93,65,,364.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.58,35,,127.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,273.56,60,,218.85,percent of total billed charges,60% of total billed charges for outpatient setting,58.54,455.93,
PLATE 3.5X116MM LC-DCP  223.59,6152863,CDM,278,RC,,,Outpatient,,,474.71,474.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.83,60,,227.86,percent of total billed charges,60% of total Billed charges for outpatient setting,402.93,84.88,,322.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,237.36,50,,189.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.03,75,,284.82,percent of total billed charges,75% of total billed charges for outpatient setting,237.36,50,,189.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.95,12.84,,48.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.77,80,,303.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.95,12.84,,48.76,percent of total billed charges,12.84% of total billed charges,60.95,12.84,,48.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,474.71,65,,379.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.15,35,,132.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,284.83,60,,227.86,percent of total billed charges,60% of total billed charges for outpatient setting,60.95,474.71,
PLATE 3.5X129MM  LC-DCP 223.60,6152864,CDM,278,RC,,,Outpatient,,,483.23,483.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.94,60,,231.95,percent of total billed charges,60% of total Billed charges for outpatient setting,410.17,84.88,,328.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,241.62,50,,193.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,362.42,75,,289.94,percent of total billed charges,75% of total billed charges for outpatient setting,241.62,50,,193.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,12.84,,49.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.58,80,,309.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,12.84,,49.64,percent of total billed charges,12.84% of total billed charges,62.05,12.84,,49.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483.23,65,,386.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.13,35,,135.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.94,60,,231.95,percent of total billed charges,60% of total billed charges for outpatient setting,62.05,483.23,
PLATE 3.5X64MM LC-DCP 223.55,6152875,CDM,278,RC,,,Outpatient,,,389.31,389.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.59,60,,186.87,percent of total billed charges,60% of total Billed charges for outpatient setting,330.45,84.88,,264.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.66,50,,155.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.98,75,,233.58,percent of total billed charges,75% of total billed charges for outpatient setting,194.66,50,,155.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.45,80,,249.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,389.31,65,,311.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.26,35,,109.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.59,60,,186.87,percent of total billed charges,60% of total billed charges for outpatient setting,49.99,389.31,
PLATE 3.5X77MM LC-DCP / 223.56,6152860,CDM,278,RC,C1776,HCPCS,Outpatient,,,585,585,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,60,,280.8,percent of total billed charges,60% of total Billed charges for outpatient setting,496.55,84.88,,397.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,75,,351,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,50,,234,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.11,12.84,,60.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,80,,374.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.11,12.84,,60.09,percent of total billed charges,12.84% of total billed charges,75.11,12.84,,60.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,585,65,,468,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,35,,163.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,351,60,,280.8,percent of total billed charges,60% of total billed charges for outpatient setting,75.11,585,
PLATE 3.5X81MM 4H CLAVICLE / 02.122.010,69169248,CDM,278,RC,C1713,HCPCS,Outpatient,,,2286,2286,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1371.6,60,,1097.28,percent of total billed charges,60% of total Billed charges for outpatient setting,1940.36,84.88,,1552.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1714.5,75,,1371.6,percent of total billed charges,75% of total billed charges for outpatient setting,1143,50,,914.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.52,12.84,,234.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1828.8,80,,1463.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.52,12.84,,234.82,percent of total billed charges,12.84% of total billed charges,293.52,12.84,,234.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2400.3,105,,1920.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.1,35,,640.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1371.6,60,,1097.28,percent of total billed charges,60% of total billed charges for outpatient setting,293.52,2400.3,
PLATE 3.5X85MM LC-DCP 223.561,69169527,CDM,278,RC,C1713,HCPCS,Outpatient,,,1669.5,1669.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.7,60,,801.36,percent of total billed charges,60% of total Billed charges for outpatient setting,1417.07,84.88,,1133.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.13,75,,1001.7,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,50,,667.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.36,12.84,,171.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1335.6,80,,1068.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.36,12.84,,171.49,percent of total billed charges,12.84% of total billed charges,214.36,12.84,,171.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1669.5,65,,1335.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.33,35,,467.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1001.7,60,,801.36,percent of total billed charges,60% of total billed charges for outpatient setting,214.36,1669.5,
PLATE 3.5X87MM LEFT TIBIA / 0127.311,69169313,CDM,278,RC,C1713,HCPCS,Outpatient,,,4141.8,4141.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2485.08,60,,1988.06,percent of total billed charges,60% of total Billed charges for outpatient setting,3515.56,84.88,,2812.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3106.35,75,,2485.08,percent of total billed charges,75% of total billed charges for outpatient setting,2070.9,50,,1656.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.81,12.84,,425.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3313.44,80,,2650.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.81,12.84,,425.45,percent of total billed charges,12.84% of total billed charges,531.81,12.84,,425.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4348.89,105,,3479.11,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449.63,35,,1159.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2485.08,60,,1988.06,percent of total billed charges,60% of total billed charges for outpatient setting,531.81,4348.89,
PLATE 3.5X90MM LC-DCP 223.57,6152861,CDM,278,RC,,,Outpatient,,,1386.14,1386.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.68,60,,665.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1176.56,84.88,,941.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,693.07,50,,554.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1039.61,75,,831.69,percent of total billed charges,75% of total billed charges for outpatient setting,693.07,50,,554.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.98,12.84,,142.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.91,80,,887.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.98,12.84,,142.38,percent of total billed charges,12.84% of total billed charges,177.98,12.84,,142.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1386.14,65,,1108.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.15,35,,388.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.68,60,,665.34,percent of total billed charges,60% of total billed charges for outpatient setting,177.98,1386.14,
PLATE 30MM SKYLINE 2 LVL / 1868-02-030,70000350,CDM,278,RC,C1713,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
PLATE 32MM CERVICAL 2 LVL  UM102-02-32,69169459,CDM,278,RC,C1713,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
PLATE 36MM SKYLINE 2 LVL / 1868-02-036,69169134,CDM,278,RC,C1713,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
PLATE 3H 73MM 2.7X3.5MM LCP / 02.112.136,50395,CDM,278,RC,C1713,HCPCS,Outpatient,,,2454.23,2454.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1472.54,60,,1178.03,percent of total billed charges,60% of total Billed charges for outpatient setting,2083.15,84.88,,1666.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840.67,75,,1472.54,percent of total billed charges,75% of total billed charges for outpatient setting,1227.12,50,,981.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.12,12.84,,252.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1963.38,80,,1570.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.12,12.84,,252.1,percent of total billed charges,12.84% of total billed charges,315.12,12.84,,252.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2576.94,105,,2061.55,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.98,35,,687.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1472.54,60,,1178.03,percent of total billed charges,60% of total billed charges for outpatient setting,315.12,2576.94,
PLATE 3H CLAVICLE LT VARIAX / 628203,1152701,CDM,278,RC,C1713,HCPCS,Outpatient,,,3437.28,3437.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2062.37,60,,1649.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2917.56,84.88,,2334.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2577.96,75,,2062.37,percent of total billed charges,75% of total billed charges for outpatient setting,1718.64,50,,1374.91,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2749.82,80,,2199.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,441.35,12.84,,353.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3609.14,105,,2887.31,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.05,35,,962.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2062.37,60,,1649.9,percent of total billed charges,60% of total billed charges for outpatient setting,441.35,3609.14,
PLATE 3H SUPERIOR LTRL / 628227,1152709,CDM,278,RC,C1776,HCPCS,Outpatient,,,3150.84,3150.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890.5,60,,1512.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2674.43,84.88,,2139.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2363.13,75,,1890.5,percent of total billed charges,75% of total billed charges for outpatient setting,1575.42,50,,1260.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.57,12.84,,323.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520.67,80,,2016.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.57,12.84,,323.66,percent of total billed charges,12.84% of total billed charges,404.57,12.84,,323.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3308.38,105,,2646.7,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.79,35,,882.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1890.5,60,,1512.4,percent of total billed charges,60% of total billed charges for outpatient setting,404.57,3308.38,
PLATE 3H VLR DSTL NRRW / AR-8916VNL-03,70000539,CDM,278,RC,C1713,HCPCS,Outpatient,,,2921.62,2921.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.97,60,,1402.38,percent of total billed charges,60% of total Billed charges for outpatient setting,2479.87,84.88,,1983.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2191.22,75,,1752.98,percent of total billed charges,75% of total billed charges for outpatient setting,1460.81,50,,1168.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2337.3,80,,1869.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3067.7,105,,2454.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.57,35,,818.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.97,60,,1402.38,percent of total billed charges,60% of total billed charges for outpatient setting,375.14,3067.7,
PLATE 3H VLR DSTL NRW / AR-8916VNR-03,71000435,CDM,278,RC,C1713,HCPCS,Outpatient,,,2921.62,2921.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.97,60,,1402.38,percent of total billed charges,60% of total Billed charges for outpatient setting,2479.87,84.88,,1983.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2191.22,75,,1752.98,percent of total billed charges,75% of total billed charges for outpatient setting,1460.81,50,,1168.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2337.3,80,,1869.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3067.7,105,,2454.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.57,35,,818.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.97,60,,1402.38,percent of total billed charges,60% of total billed charges for outpatient setting,375.14,3067.7,
PLATE 3H VLR PLT DSTL / AR-8916VSL-03,71000700,CDM,278,RC,C1713,HCPCS,Outpatient,,,2921.62,2921.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.97,60,,1402.38,percent of total billed charges,60% of total Billed charges for outpatient setting,2479.87,84.88,,1983.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2191.22,75,,1752.98,percent of total billed charges,75% of total billed charges for outpatient setting,1460.81,50,,1168.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2337.3,80,,1869.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,375.14,12.84,,300.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3067.7,105,,2454.16,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022.57,35,,818.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.97,60,,1402.38,percent of total billed charges,60% of total billed charges for outpatient setting,375.14,3067.7,
PLATE 4 HOLE L HUMERUS / 627204,70000672,CDM,278,RC,C1713,HCPCS,Outpatient,,,3738.6,3738.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2243.16,60,,1794.53,percent of total billed charges,60% of total Billed charges for outpatient setting,3173.32,84.88,,2538.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2803.95,75,,2243.16,percent of total billed charges,75% of total billed charges for outpatient setting,1869.3,50,,1495.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.04,12.84,,384.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2990.88,80,,2392.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.04,12.84,,384.03,percent of total billed charges,12.84% of total billed charges,480.04,12.84,,384.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3925.53,105,,3140.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1308.51,35,,1046.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2243.16,60,,1794.53,percent of total billed charges,60% of total billed charges for outpatient setting,480.04,3925.53,
PLATE 4 HOLE OLECRANON / 629344,70000702,CDM,278,RC,C1713,HCPCS,Outpatient,,,3159.54,3159.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1895.72,60,,1516.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2681.82,84.88,,2145.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2369.66,75,,1895.73,percent of total billed charges,75% of total billed charges for outpatient setting,1579.77,50,,1263.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.68,12.84,,324.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2527.63,80,,2022.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.68,12.84,,324.54,percent of total billed charges,12.84% of total billed charges,405.68,12.84,,324.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3317.52,105,,2654.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1105.84,35,,884.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1895.72,60,,1516.58,percent of total billed charges,60% of total billed charges for outpatient setting,405.68,3317.52,
PLATE 4 HOLE TUBULAR 1/3 / 626674,69162855,CDM,278,RC,C1713,HCPCS,Outpatient,,,1078.95,1078.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.37,60,,517.9,percent of total billed charges,60% of total Billed charges for outpatient setting,915.81,84.88,,732.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.21,75,,647.37,percent of total billed charges,75% of total billed charges for outpatient setting,539.48,50,,431.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.54,12.84,,110.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.16,80,,690.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.54,12.84,,110.83,percent of total billed charges,12.84% of total billed charges,138.54,12.84,,110.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1078.95,65,,863.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.63,35,,302.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,647.37,60,,517.9,percent of total billed charges,60% of total billed charges for outpatient setting,138.54,1078.95,
PLATE 4H 2.7MM DIST FIB L / 02.118.403,70000589,CDM,278,RC,C1713,HCPCS,Outpatient,,,3148.41,3148.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1889.05,60,,1511.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2672.37,84.88,,2137.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2361.31,75,,1889.05,percent of total billed charges,75% of total billed charges for outpatient setting,1574.21,50,,1259.37,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.26,12.84,,323.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2518.73,80,,2014.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.26,12.84,,323.41,percent of total billed charges,12.84% of total billed charges,404.26,12.84,,323.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3305.83,105,,2644.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1101.94,35,,881.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1889.05,60,,1511.24,percent of total billed charges,60% of total billed charges for outpatient setting,404.26,3305.83,
PLATE 4H 86MM FIBULA LFT / 02.112.139,69169760,CDM,278,RC,C1713,HCPCS,Outpatient,,,2178.75,2178.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.25,60,,1045.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1849.32,84.88,,1479.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.06,75,,1307.25,percent of total billed charges,75% of total billed charges for outpatient setting,1089.38,50,,871.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.75,12.84,,223.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1743,80,,1394.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.75,12.84,,223.8,percent of total billed charges,12.84% of total billed charges,279.75,12.84,,223.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2287.69,105,,1830.15,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.56,35,,610.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1307.25,60,,1045.8,percent of total billed charges,60% of total billed charges for outpatient setting,279.75,2287.69,
PLATE 4H FIB DISTL LATRL / 40-20904,70000564,CDM,278,RC,C1713,HCPCS,Outpatient,,,1760.22,1760.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1056.13,60,,844.9,percent of total billed charges,60% of total Billed charges for outpatient setting,1494.07,84.88,,1195.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320.17,75,,1056.14,percent of total billed charges,75% of total billed charges for outpatient setting,880.11,50,,704.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.01,12.84,,180.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1408.18,80,,1126.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.01,12.84,,180.81,percent of total billed charges,12.84% of total billed charges,226.01,12.84,,180.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1760.22,65,,1408.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.08,35,,492.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1056.13,60,,844.9,percent of total billed charges,60% of total billed charges for outpatient setting,226.01,1760.22,
PLATE 4H TIBIAL PROX LAT / 627304,1521077,CDM,278,RC,C1713,HCPCS,Outpatient,,,3439.4,3439.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2063.64,60,,1650.91,percent of total billed charges,60% of total Billed charges for outpatient setting,2919.36,84.88,,2335.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2579.55,75,,2063.64,percent of total billed charges,75% of total billed charges for outpatient setting,1719.7,50,,1375.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.62,12.84,,353.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2751.52,80,,2201.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.62,12.84,,353.3,percent of total billed charges,12.84% of total billed charges,441.62,12.84,,353.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3611.37,105,,2889.1,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.79,35,,963.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2063.64,60,,1650.91,percent of total billed charges,60% of total billed charges for outpatient setting,441.62,3611.37,
PLATE 5 HOLE 1/3 TUBULR / 241.351,69169365,CDM,278,RC,C1713,HCPCS,Outpatient,,,904.05,904.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.43,60,,433.94,percent of total billed charges,60% of total Billed charges for outpatient setting,767.36,84.88,,613.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.04,75,,542.43,percent of total billed charges,75% of total billed charges for outpatient setting,452.03,50,,361.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.08,12.84,,92.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.24,80,,578.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.08,12.84,,92.86,percent of total billed charges,12.84% of total billed charges,116.08,12.84,,92.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,904.05,65,,723.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.42,35,,253.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,542.43,60,,433.94,percent of total billed charges,60% of total billed charges for outpatient setting,116.08,904.05,
PLATE 5 HOLE PROX HUMERUS / 627235,69169336,CDM,278,RC,C1713,HCPCS,Outpatient,,,3738.6,3738.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2243.16,60,,1794.53,percent of total billed charges,60% of total Billed charges for outpatient setting,3173.32,84.88,,2538.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2803.95,75,,2243.16,percent of total billed charges,75% of total billed charges for outpatient setting,1869.3,50,,1495.44,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.04,12.84,,384.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2990.88,80,,2392.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.04,12.84,,384.03,percent of total billed charges,12.84% of total billed charges,480.04,12.84,,384.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3925.53,105,,3140.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1308.51,35,,1046.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2243.16,60,,1794.53,percent of total billed charges,60% of total billed charges for outpatient setting,480.04,3925.53,
PLATE 5 HOLE TUBULAR 1/3 / 626675,70000617,CDM,278,RC,C1713,HCPCS,Outpatient,,,1046.4,1046.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.84,60,,502.27,percent of total billed charges,60% of total Billed charges for outpatient setting,888.18,84.88,,710.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,75,,627.84,percent of total billed charges,75% of total billed charges for outpatient setting,523.2,50,,418.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.36,12.84,,107.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.12,80,,669.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.36,12.84,,107.49,percent of total billed charges,12.84% of total billed charges,134.36,12.84,,107.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1046.4,65,,837.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.24,35,,292.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,627.84,60,,502.27,percent of total billed charges,60% of total billed charges for outpatient setting,134.36,1046.4,
PLATE 5 HOLE X61MM 1\3 TUBULAR / 241.35,6152870,CDM,278,RC,,,Outpatient,,,342.96,342.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.78,60,,164.62,percent of total billed charges,60% of total Billed charges for outpatient setting,291.1,84.88,,232.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,171.48,50,,137.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.22,75,,205.78,percent of total billed charges,75% of total billed charges for outpatient setting,171.48,50,,137.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.04,12.84,,35.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.37,80,,219.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.04,12.84,,35.23,percent of total billed charges,12.84% of total billed charges,44.04,12.84,,35.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,342.96,65,,274.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.04,35,,96.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,205.78,60,,164.62,percent of total billed charges,60% of total billed charges for outpatient setting,44.04,342.96,
PLATE 51MM XTEND AC / 161.351,69161758,CDM,278,RC,C1776,HCPCS,Outpatient,,,2204,2204,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1322.4,60,,1057.92,percent of total billed charges,60% of total Billed charges for outpatient setting,1870.76,84.88,,1496.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653,75,,1322.4,percent of total billed charges,75% of total billed charges for outpatient setting,1102,50,,881.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.99,12.84,,226.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.2,80,,1410.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.99,12.84,,226.39,percent of total billed charges,12.84% of total billed charges,282.99,12.84,,226.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2314.2,105,,1851.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.4,35,,617.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1322.4,60,,1057.92,percent of total billed charges,60% of total billed charges for outpatient setting,282.99,2314.2,
PLATE 51X25X2.3MM ACULOC / 70-0357,905212,CDM,278,RC,C1776,HCPCS,Outpatient,,,2780,2780,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1668,60,,1334.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2359.66,84.88,,1887.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2085,75,,1668,percent of total billed charges,75% of total billed charges for outpatient setting,1390,50,,1112,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.95,12.84,,285.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2224,80,,1779.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.95,12.84,,285.56,percent of total billed charges,12.84% of total billed charges,356.95,12.84,,285.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2919,105,,2335.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973,35,,778.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1668,60,,1334.4,percent of total billed charges,60% of total billed charges for outpatient setting,356.95,2919,
PLATE 5D 2.4/2.7MM LT / 02.211.243,468344,CDM,278,RC,C1713,HCPCS,Outpatient,,,4514.47,4514.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.68,60,,2166.94,percent of total billed charges,60% of total Billed charges for outpatient setting,3831.88,84.88,,3065.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3385.85,75,,2708.68,percent of total billed charges,75% of total billed charges for outpatient setting,2257.24,50,,1805.79,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.66,12.84,,463.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3611.58,80,,2889.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.66,12.84,,463.73,percent of total billed charges,12.84% of total billed charges,579.66,12.84,,463.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4740.19,105,,3792.15,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.06,35,,1264.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2708.68,60,,2166.94,percent of total billed charges,60% of total billed charges for outpatient setting,579.66,4740.19,
PLATE 5H 3.5X72MM LCP / 223.551,34514,CDM,278,RC,C1776,HCPCS,Outpatient,,,1468.2,1468.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.92,60,,704.74,percent of total billed charges,60% of total Billed charges for outpatient setting,1246.21,84.88,,996.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1101.15,75,,880.92,percent of total billed charges,75% of total billed charges for outpatient setting,734.1,50,,587.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.52,12.84,,150.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.56,80,,939.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.52,12.84,,150.82,percent of total billed charges,12.84% of total billed charges,188.52,12.84,,150.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1468.2,65,,1174.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.87,35,,411.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,880.92,60,,704.74,percent of total billed charges,60% of total billed charges for outpatient setting,188.52,1468.2,
PLATE 5H DSTL FIB LOCK LT / AR-8943DL-05,71000822,CDM,278,RC,C1713,HCPCS,Outpatient,,,2664.37,2664.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.62,60,,1278.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2261.52,84.88,,1809.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1998.28,75,,1598.62,percent of total billed charges,75% of total billed charges for outpatient setting,1332.19,50,,1065.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2131.5,80,,1705.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2797.59,105,,2238.07,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.53,35,,746.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1598.62,60,,1278.9,percent of total billed charges,60% of total billed charges for outpatient setting,342.11,2797.59,
PLATE 5H LOCK DST FIB LT / AR-8943BL-05,69162694,CDM,278,RC,C1713,HCPCS,Outpatient,,,2388.75,2388.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1433.25,60,,1146.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2027.57,84.88,,1622.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1791.56,75,,1433.25,percent of total billed charges,75% of total billed charges for outpatient setting,1194.38,50,,955.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.72,12.84,,245.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1911,80,,1528.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.72,12.84,,245.38,percent of total billed charges,12.84% of total billed charges,306.72,12.84,,245.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2508.19,105,,2006.55,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,836.06,35,,668.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1433.25,60,,1146.6,percent of total billed charges,60% of total billed charges for outpatient setting,306.72,2508.19,
PLATE 5H RT LTRL DSTL FIB / 02.112.140,50412,CDM,278,RC,C1776,HCPCS,Outpatient,,,2529.45,2529.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1517.67,60,,1214.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2147,84.88,,1717.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1897.09,75,,1517.67,percent of total billed charges,75% of total billed charges for outpatient setting,1264.73,50,,1011.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.78,12.84,,259.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2023.56,80,,1618.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.78,12.84,,259.82,percent of total billed charges,12.84% of total billed charges,324.78,12.84,,259.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2655.92,105,,2124.74,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.31,35,,708.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1517.67,60,,1214.14,percent of total billed charges,60% of total billed charges for outpatient setting,324.78,2655.92,
PLATE 5HL 44MM LCP / 247.375,116894,CDM,278,RC,C1713,HCPCS,Outpatient,,,1569,1569,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,941.4,60,,753.12,percent of total billed charges,60% of total Billed charges for outpatient setting,1331.77,84.88,,1065.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.75,75,,941.4,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,50,,627.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.46,12.84,,161.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1255.2,80,,1004.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.46,12.84,,161.17,percent of total billed charges,12.84% of total billed charges,201.46,12.84,,161.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1569,65,,1255.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.15,35,,439.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,941.4,60,,753.12,percent of total billed charges,60% of total billed charges for outpatient setting,201.46,1569,
PLATE 5TH MET HOOK / 52020400,71000355,CDM,278,RC,C1713,HCPCS,Outpatient,,,2852,2852,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1711.2,60,,1368.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2420.78,84.88,,1936.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2139,75,,1711.2,percent of total billed charges,75% of total billed charges for outpatient setting,1426,50,,1140.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.2,12.84,,292.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2281.6,80,,1825.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.2,12.84,,292.96,percent of total billed charges,12.84% of total billed charges,366.2,12.84,,292.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2994.6,105,,2395.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.2,35,,798.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1711.2,60,,1368.96,percent of total billed charges,60% of total billed charges for outpatient setting,366.2,2994.6,
PLATE 6 HL CLAVICLE VARIAX / 628026,1152904,CDM,278,RC,C1713,HCPCS,Outpatient,,,3092.88,3092.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1855.73,60,,1484.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2625.24,84.88,,2100.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2319.66,75,,1855.73,percent of total billed charges,75% of total billed charges for outpatient setting,1546.44,50,,1237.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,12.84,,317.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2474.3,80,,1979.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,12.84,,317.7,percent of total billed charges,12.84% of total billed charges,397.13,12.84,,317.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3247.52,105,,2598.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.51,35,,866.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1855.73,60,,1484.58,percent of total billed charges,60% of total billed charges for outpatient setting,397.13,3247.52,
PLATE 6 HOLE 2.4MM LCP 52MM / 249.676,70000570,CDM,278,RC,C1713,HCPCS,Outpatient,,,1887.61,1887.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1132.57,60,,906.06,percent of total billed charges,60% of total Billed charges for outpatient setting,1602.2,84.88,,1281.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.71,75,,1132.57,percent of total billed charges,75% of total billed charges for outpatient setting,943.81,50,,755.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.37,12.84,,193.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1510.09,80,,1208.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.37,12.84,,193.9,percent of total billed charges,12.84% of total billed charges,242.37,12.84,,193.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1887.61,65,,1510.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.66,35,,528.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1132.57,60,,906.06,percent of total billed charges,60% of total billed charges for outpatient setting,242.37,1887.61,
PLATE 6 HOLE TUBULAR 1/3 / 626676,70000616,CDM,278,RC,C1776,HCPCS,Outpatient,,,959.2,959.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.52,60,,460.42,percent of total billed charges,60% of total Billed charges for outpatient setting,814.17,84.88,,651.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.4,75,,575.52,percent of total billed charges,75% of total billed charges for outpatient setting,479.6,50,,383.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.16,12.84,,98.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.36,80,,613.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.16,12.84,,98.53,percent of total billed charges,12.84% of total billed charges,123.16,12.84,,98.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,959.2,65,,767.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.72,35,,268.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,575.52,60,,460.42,percent of total billed charges,60% of total billed charges for outpatient setting,123.16,959.2,
PLATE 6 HOLE VARIAX / 626762,1610551,CDM,278,RC,C1713,HCPCS,Outpatient,,,3593.52,3593.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2156.11,60,,1724.89,percent of total billed charges,60% of total Billed charges for outpatient setting,3050.18,84.88,,2440.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2695.14,75,,2156.11,percent of total billed charges,75% of total billed charges for outpatient setting,1796.76,50,,1437.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.41,12.84,,369.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2874.82,80,,2299.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.41,12.84,,369.13,percent of total billed charges,12.84% of total billed charges,461.41,12.84,,369.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3773.2,105,,3018.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.73,35,,1006.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2156.11,60,,1724.89,percent of total billed charges,60% of total billed charges for outpatient setting,461.41,3773.2,
PLATE 6 HOLE X 73MM 1\3 TUBULAR 241.36,6152871,CDM,278,RC,,,Outpatient,,,322.69,322.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.61,60,,154.89,percent of total billed charges,60% of total Billed charges for outpatient setting,273.9,84.88,,219.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,161.35,50,,129.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.02,75,,193.62,percent of total billed charges,75% of total billed charges for outpatient setting,161.35,50,,129.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.43,12.84,,33.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.15,80,,206.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.43,12.84,,33.14,percent of total billed charges,12.84% of total billed charges,41.43,12.84,,33.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,322.69,65,,258.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.94,35,,90.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.61,60,,154.89,percent of total billed charges,60% of total billed charges for outpatient setting,41.43,322.69,
PLATE 6H 69MM 1/3 TUBULAR / 241.361,69169445,CDM,278,RC,C1713,HCPCS,Outpatient,,,849.12,849.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.47,60,,407.58,percent of total billed charges,60% of total Billed charges for outpatient setting,720.73,84.88,,576.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.84,75,,509.47,percent of total billed charges,75% of total billed charges for outpatient setting,424.56,50,,339.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.03,12.84,,87.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,679.3,80,,543.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.03,12.84,,87.22,percent of total billed charges,12.84% of total billed charges,109.03,12.84,,87.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,849.12,65,,679.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.19,35,,237.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,509.47,60,,407.58,percent of total billed charges,60% of total billed charges for outpatient setting,109.03,849.12,
PLATE 6H 85MM 3.5MM L / 02.112.081,587486,CDM,278,RC,C1713,HCPCS,Outpatient,,,3165.75,3165.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1899.45,60,,1519.56,percent of total billed charges,60% of total Billed charges for outpatient setting,2687.09,84.88,,2149.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2374.31,75,,1899.45,percent of total billed charges,75% of total billed charges for outpatient setting,1582.88,50,,1266.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.48,12.84,,325.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2532.6,80,,2026.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.48,12.84,,325.18,percent of total billed charges,12.84% of total billed charges,406.48,12.84,,325.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3324.04,105,,2659.23,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.01,35,,886.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1899.45,60,,1519.56,percent of total billed charges,60% of total billed charges for outpatient setting,406.48,3324.04,
PLATE 6H DISTL LAT FIBULA / 40-20906,69162804,CDM,278,RC,C1713,HCPCS,Outpatient,,,1827.98,1827.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.79,60,,877.43,percent of total billed charges,60% of total Billed charges for outpatient setting,1551.59,84.88,,1241.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1370.99,75,,1096.79,percent of total billed charges,75% of total billed charges for outpatient setting,913.99,50,,731.19,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.71,12.84,,187.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.38,80,,1169.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.71,12.84,,187.77,percent of total billed charges,12.84% of total billed charges,234.71,12.84,,187.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1827.98,65,,1462.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.79,35,,511.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1096.79,60,,877.43,percent of total billed charges,60% of total billed charges for outpatient setting,234.71,1827.98,
PLATE 6H RIGHT VA-LCP / 04.111.630,69162460,CDM,278,RC,,,Outpatient,,,3733.84,3733.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.3,60,,1792.24,percent of total billed charges,60% of total Billed charges for outpatient setting,3169.28,84.88,,2535.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,1866.92,50,,1493.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2800.38,75,,2240.3,percent of total billed charges,75% of total billed charges for outpatient setting,1866.92,50,,1493.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.43,12.84,,383.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2987.07,80,,2389.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.43,12.84,,383.54,percent of total billed charges,12.84% of total billed charges,479.43,12.84,,383.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3920.53,105,,3136.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1306.84,35,,1045.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2240.3,60,,1792.24,percent of total billed charges,60% of total billed charges for outpatient setting,479.43,3920.53,
PLATE 6H TIB AXSOS / 627336,1574962,CDM,278,RC,C1713,HCPCS,Outpatient,,,3509,3509,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2105.4,60,,1684.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2978.44,84.88,,2382.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2631.75,75,,2105.4,percent of total billed charges,75% of total billed charges for outpatient setting,1754.5,50,,1403.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.56,12.84,,360.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2807.2,80,,2245.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.56,12.84,,360.45,percent of total billed charges,12.84% of total billed charges,450.56,12.84,,360.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3684.45,105,,2947.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.15,35,,982.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2105.4,60,,1684.32,percent of total billed charges,60% of total billed charges for outpatient setting,450.56,3684.45,
PLATE 6H TIBIAL PROX LAT / 627306,1583454,CDM,278,RC,C1776,HCPCS,Outpatient,,,3509,3509,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2105.4,60,,1684.32,percent of total billed charges,60% of total Billed charges for outpatient setting,2978.44,84.88,,2382.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2631.75,75,,2105.4,percent of total billed charges,75% of total billed charges for outpatient setting,1754.5,50,,1403.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.56,12.84,,360.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2807.2,80,,2245.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.56,12.84,,360.45,percent of total billed charges,12.84% of total billed charges,450.56,12.84,,360.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3684.45,105,,2947.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.15,35,,982.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2105.4,60,,1684.32,percent of total billed charges,60% of total billed charges for outpatient setting,450.56,3684.45,
PLATE 6H VARIAX COMPR STRT / 629546,1627025,CDM,278,RC,C1713,HCPCS,Outpatient,,,1499.52,1499.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.71,60,,719.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1272.79,84.88,,1018.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.64,75,,899.71,percent of total billed charges,75% of total billed charges for outpatient setting,749.76,50,,599.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.54,12.84,,154.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.62,80,,959.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.54,12.84,,154.03,percent of total billed charges,12.84% of total billed charges,192.54,12.84,,154.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1499.52,65,,1199.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.83,35,,419.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.71,60,,719.77,percent of total billed charges,60% of total billed charges for outpatient setting,192.54,1499.52,
PLATE 6HL CLAVICLE LT / 628046,1152680,CDM,278,RC,C1713,HCPCS,Outpatient,,,2159.04,2159.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295.42,60,,1036.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1832.59,84.88,,1466.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.28,75,,1295.42,percent of total billed charges,75% of total billed charges for outpatient setting,1079.52,50,,863.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.22,12.84,,221.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.23,80,,1381.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.22,12.84,,221.78,percent of total billed charges,12.84% of total billed charges,277.22,12.84,,221.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2266.99,105,,1813.59,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.66,35,,604.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1295.42,60,,1036.34,percent of total billed charges,60% of total billed charges for outpatient setting,277.22,2266.99,
PLATE 7 HL CLAVICLE VARIAX / 628027,1152905,CDM,278,RC,C1713,HCPCS,Outpatient,,,3092.88,3092.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1855.73,60,,1484.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2625.24,84.88,,2100.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2319.66,75,,1855.73,percent of total billed charges,75% of total billed charges for outpatient setting,1546.44,50,,1237.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,12.84,,317.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2474.3,80,,1979.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.13,12.84,,317.7,percent of total billed charges,12.84% of total billed charges,397.13,12.84,,317.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3247.52,105,,2598.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.51,35,,866.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1855.73,60,,1484.58,percent of total billed charges,60% of total billed charges for outpatient setting,397.13,3247.52,
PLATE 7 HOLE 81MM 1/3 TUBULR / 241.371,69169258,CDM,278,RC,C1713,HCPCS,Outpatient,,,864.12,864.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.47,60,,414.78,percent of total billed charges,60% of total Billed charges for outpatient setting,733.47,84.88,,586.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.09,75,,518.47,percent of total billed charges,75% of total billed charges for outpatient setting,432.06,50,,345.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.95,12.84,,88.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.3,80,,553.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.95,12.84,,88.76,percent of total billed charges,12.84% of total billed charges,110.95,12.84,,88.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,864.12,65,,691.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.44,35,,241.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,518.47,60,,414.78,percent of total billed charges,60% of total billed charges for outpatient setting,110.95,864.12,
PLATE 7 HOLE SYS 7 / 249.679,116925,CDM,278,RC,C1713,HCPCS,Outpatient,,,2568.82,2568.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1541.29,60,,1233.03,percent of total billed charges,60% of total Billed charges for outpatient setting,2180.41,84.88,,1744.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926.62,75,,1541.3,percent of total billed charges,75% of total billed charges for outpatient setting,1284.41,50,,1027.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.84,12.84,,263.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2055.06,80,,1644.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.84,12.84,,263.87,percent of total billed charges,12.84% of total billed charges,329.84,12.84,,263.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2697.26,105,,2157.81,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.09,35,,719.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1541.29,60,,1233.03,percent of total billed charges,60% of total billed charges for outpatient setting,329.84,2697.26,
PLATE 7 HOLE TUBULAR 1/3 / 626677,70000637,CDM,278,RC,C1713,HCPCS,Outpatient,,,959.2,959.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.52,60,,460.42,percent of total billed charges,60% of total Billed charges for outpatient setting,814.17,84.88,,651.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.4,75,,575.52,percent of total billed charges,75% of total billed charges for outpatient setting,479.6,50,,383.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.16,12.84,,98.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.36,80,,613.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.16,12.84,,98.53,percent of total billed charges,12.84% of total billed charges,123.16,12.84,,98.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,959.2,65,,767.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.72,35,,268.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,575.52,60,,460.42,percent of total billed charges,60% of total billed charges for outpatient setting,123.16,959.2,
PLATE 7 HOLE VARIAX COMPR STRT / 629507,69169137,CDM,278,RC,C1713,HCPCS,Outpatient,,,1499.52,1499.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.71,60,,719.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1272.79,84.88,,1018.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.64,75,,899.71,percent of total billed charges,75% of total billed charges for outpatient setting,749.76,50,,599.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.54,12.84,,154.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.62,80,,959.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.54,12.84,,154.03,percent of total billed charges,12.84% of total billed charges,192.54,12.84,,154.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1499.52,65,,1199.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.83,35,,419.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.71,60,,719.77,percent of total billed charges,60% of total billed charges for outpatient setting,192.54,1499.52,
PLATE 7 HOLE X 85MM 1\3 TUBULAR 241.37,6152872,CDM,278,RC,,,Outpatient,,,295.42,295.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.25,60,,141.8,percent of total billed charges,60% of total Billed charges for outpatient setting,250.75,84.88,,200.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,147.71,50,,118.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.57,75,,177.26,percent of total billed charges,75% of total billed charges for outpatient setting,147.71,50,,118.17,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.93,12.84,,30.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.34,80,,189.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.93,12.84,,30.34,percent of total billed charges,12.84% of total billed charges,37.93,12.84,,30.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,295.42,65,,236.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.4,35,,82.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,177.25,60,,141.8,percent of total billed charges,60% of total billed charges for outpatient setting,37.93,295.42,
PLATE 7H 100MM 35MM RT / 02.112.082,505020,CDM,278,RC,C1713,HCPCS,Outpatient,,,3249.75,3249.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1949.85,60,,1559.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2758.39,84.88,,2206.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.31,75,,1949.85,percent of total billed charges,75% of total billed charges for outpatient setting,1624.88,50,,1299.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.27,12.84,,333.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2599.8,80,,2079.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.27,12.84,,333.82,percent of total billed charges,12.84% of total billed charges,417.27,12.84,,333.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3412.24,105,,2729.79,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.41,35,,909.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1949.85,60,,1559.88,percent of total billed charges,60% of total billed charges for outpatient setting,417.27,3412.24,
PLATE 7H 2.3MM WIDE / 57-10460,697358,CDM,278,RC,C1713,HCPCS,Outpatient,,,1209.6,1209.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.76,60,,580.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1026.71,84.88,,821.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.2,75,,725.76,percent of total billed charges,75% of total billed charges for outpatient setting,604.8,50,,483.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.31,12.84,,124.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.68,80,,774.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.31,12.84,,124.25,percent of total billed charges,12.84% of total billed charges,155.31,12.84,,124.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1209.6,65,,967.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.36,35,,338.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,725.76,60,,580.61,percent of total billed charges,60% of total billed charges for outpatient setting,155.31,1209.6,
PLATE 7H DSTL FIB LAT / 40-20907,69169492,CDM,278,RC,C1776,HCPCS,Outpatient,,,1983.52,1983.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.11,60,,952.09,percent of total billed charges,60% of total Billed charges for outpatient setting,1683.61,84.88,,1346.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1487.64,75,,1190.11,percent of total billed charges,75% of total billed charges for outpatient setting,991.76,50,,793.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.68,12.84,,203.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1586.82,80,,1269.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.68,12.84,,203.74,percent of total billed charges,12.84% of total billed charges,254.68,12.84,,203.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1983.52,65,,1586.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.23,35,,555.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1190.11,60,,952.09,percent of total billed charges,60% of total billed charges for outpatient setting,254.68,1983.52,
PLATE 7H SUPERIOR LTRL / 628227,69169206,CDM,278,RC,C1776,HCPCS,Outpatient,,,2321.16,2321.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392.7,60,,1114.16,percent of total billed charges,60% of total Billed charges for outpatient setting,1970.2,84.88,,1576.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1740.87,75,,1392.7,percent of total billed charges,75% of total billed charges for outpatient setting,1160.58,50,,928.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.04,12.84,,238.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.93,80,,1485.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.04,12.84,,238.43,percent of total billed charges,12.84% of total billed charges,298.04,12.84,,238.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2437.22,105,,1949.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,812.41,35,,649.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1392.7,60,,1114.16,percent of total billed charges,60% of total billed charges for outpatient setting,298.04,2437.22,
PLATE 7HL 53MM LCP / 247.351,116880,CDM,278,RC,C1713,HCPCS,Outpatient,,,1892.52,1892.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.51,60,,908.41,percent of total billed charges,60% of total Billed charges for outpatient setting,1606.37,84.88,,1285.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1419.39,75,,1135.51,percent of total billed charges,75% of total billed charges for outpatient setting,946.26,50,,757.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243,12.84,,194.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.02,80,,1211.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243,12.84,,194.4,percent of total billed charges,12.84% of total billed charges,243,12.84,,194.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1892.52,65,,1514.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.38,35,,529.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1135.51,60,,908.41,percent of total billed charges,60% of total billed charges for outpatient setting,243,1892.52,
PLATE 8 HOLE HUMERUS 4.0 / 627508,69169786,CDM,278,RC,C1776,HCPCS,Outpatient,,,2579.7,2579.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1547.82,60,,1238.26,percent of total billed charges,60% of total Billed charges for outpatient setting,2189.65,84.88,,1751.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1934.78,75,,1547.82,percent of total billed charges,75% of total billed charges for outpatient setting,1289.85,50,,1031.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.23,12.84,,264.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2063.76,80,,1651.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.23,12.84,,264.98,percent of total billed charges,12.84% of total billed charges,331.23,12.84,,264.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2708.69,105,,2166.95,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,902.9,35,,722.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1547.82,60,,1238.26,percent of total billed charges,60% of total billed charges for outpatient setting,331.23,2708.69,
PLATE 8 HOLE TIBIA RT / 627508,1592668,CDM,278,RC,C1776,HCPCS,Outpatient,,,3579.76,3579.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2147.86,60,,1718.29,percent of total billed charges,60% of total Billed charges for outpatient setting,3038.5,84.88,,2430.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2684.82,75,,2147.86,percent of total billed charges,75% of total billed charges for outpatient setting,1789.88,50,,1431.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.64,12.84,,367.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2863.81,80,,2291.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.64,12.84,,367.71,percent of total billed charges,12.84% of total billed charges,459.64,12.84,,367.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3758.75,105,,3007,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.92,35,,1002.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2147.86,60,,1718.29,percent of total billed charges,60% of total billed charges for outpatient setting,459.64,3758.75,
PLATE 8 HOLE TUBULAR 1/3 / 626678,70000615,CDM,278,RC,C1713,HCPCS,Outpatient,,,1046.4,1046.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.84,60,,502.27,percent of total billed charges,60% of total Billed charges for outpatient setting,888.18,84.88,,710.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,75,,627.84,percent of total billed charges,75% of total billed charges for outpatient setting,523.2,50,,418.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.36,12.84,,107.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.12,80,,669.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.36,12.84,,107.49,percent of total billed charges,12.84% of total billed charges,134.36,12.84,,107.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1046.4,65,,837.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.24,35,,292.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,627.84,60,,502.27,percent of total billed charges,60% of total billed charges for outpatient setting,134.36,1046.4,
PLATE 8 HOLE X 97MM 1\3 TUBULAR 241.38,6152873,CDM,278,RC,,,Outpatient,,,369.68,369.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.81,60,,177.45,percent of total billed charges,60% of total Billed charges for outpatient setting,313.78,84.88,,251.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,184.84,50,,147.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.26,75,,221.81,percent of total billed charges,75% of total billed charges for outpatient setting,184.84,50,,147.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.47,12.84,,37.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.74,80,,236.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.47,12.84,,37.98,percent of total billed charges,12.84% of total billed charges,47.47,12.84,,37.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.68,65,,295.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.39,35,,103.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.81,60,,177.45,percent of total billed charges,60% of total billed charges for outpatient setting,47.47,369.68,
PLATE 89MM FIB LATERAL LT / 5888402L,71000565,CDM,278,RC,C1776,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
PLATE 8H 202MM TIT FEM LT / 627608,1547294,CDM,278,RC,C1713,HCPCS,Outpatient,,,4706.56,4706.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2823.94,60,,2259.15,percent of total billed charges,60% of total Billed charges for outpatient setting,3994.93,84.88,,3195.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3529.92,75,,2823.94,percent of total billed charges,75% of total billed charges for outpatient setting,2353.28,50,,1882.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.32,12.84,,483.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3765.25,80,,3012.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.32,12.84,,483.46,percent of total billed charges,12.84% of total billed charges,604.32,12.84,,483.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4941.89,105,,3953.51,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.3,35,,1317.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2823.94,60,,2259.15,percent of total billed charges,60% of total billed charges for outpatient setting,604.32,4941.89,
PLATE 8H 3.5MM LCP / 02.112.084,783059,CDM,278,RC,C1713,HCPCS,Outpatient,,,3333.75,3333.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000.25,60,,1600.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2829.69,84.88,,2263.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2500.31,75,,2000.25,percent of total billed charges,75% of total billed charges for outpatient setting,1666.88,50,,1333.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.05,12.84,,342.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2667,80,,2133.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.05,12.84,,342.44,percent of total billed charges,12.84% of total billed charges,428.05,12.84,,342.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3500.44,105,,2800.35,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.81,35,,933.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2000.25,60,,1600.2,percent of total billed charges,60% of total billed charges for outpatient setting,428.05,3500.44,
PLATE 8H CLAV RT  AR-2652CR,69169804,CDM,278,RC,C1713,HCPCS,Outpatient,,,3123.75,3123.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.25,60,,1499.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2651.44,84.88,,2121.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2342.81,75,,1874.25,percent of total billed charges,75% of total billed charges for outpatient setting,1561.88,50,,1249.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.09,12.84,,320.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2499,80,,1999.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.09,12.84,,320.87,percent of total billed charges,12.84% of total billed charges,401.09,12.84,,320.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3279.94,105,,2623.95,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.31,35,,874.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.25,60,,1499.4,percent of total billed charges,60% of total billed charges for outpatient setting,401.09,3279.94,
PLATE 8H LOCKING STRT / AR-8943C-08,71000513,CDM,278,RC,C1776,HCPCS,Outpatient,,,2021.25,2021.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.75,60,,970.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1715.64,84.88,,1372.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1515.94,75,,1212.75,percent of total billed charges,75% of total billed charges for outpatient setting,1010.63,50,,808.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.53,12.84,,207.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617,80,,1293.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.53,12.84,,207.62,percent of total billed charges,12.84% of total billed charges,259.53,12.84,,207.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2021.25,65,,1617,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.44,35,,565.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1212.75,60,,970.2,percent of total billed charges,60% of total billed charges for outpatient setting,259.53,2021.25,
PLATE 8H TIBIAL PROX LAT / 627308,1547073,CDM,278,RC,C1713,HCPCS,Outpatient,,,3579.76,3579.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2147.86,60,,1718.29,percent of total billed charges,60% of total Billed charges for outpatient setting,3038.5,84.88,,2430.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2684.82,75,,2147.86,percent of total billed charges,75% of total billed charges for outpatient setting,1789.88,50,,1431.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.64,12.84,,367.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2863.81,80,,2291.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.64,12.84,,367.71,percent of total billed charges,12.84% of total billed charges,459.64,12.84,,367.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3758.75,105,,3007,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.92,35,,1002.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2147.86,60,,1718.29,percent of total billed charges,60% of total billed charges for outpatient setting,459.64,3758.75,
PLATE 8H/3H DISTL RADIUS LT / 04.110.431,69162815,CDM,278,RC,C1713,HCPCS,Outpatient,,,3128.81,3128.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1877.29,60,,1501.83,percent of total billed charges,60% of total Billed charges for outpatient setting,2655.73,84.88,,2124.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2346.61,75,,1877.29,percent of total billed charges,75% of total billed charges for outpatient setting,1564.41,50,,1251.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2503.05,80,,2002.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3285.25,105,,2628.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.08,35,,876.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1877.29,60,,1501.83,percent of total billed charges,60% of total billed charges for outpatient setting,401.74,3285.25,
"PLATE 8X4 HOLE, DISTAL LOCK 02.110.341",69161234,CDM,278,RC,,,Outpatient,,,3905.04,3905.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.02,60,,1874.42,percent of total billed charges,60% of total Billed charges for outpatient setting,3314.6,84.88,,2651.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,1952.52,50,,1562.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2928.78,75,,2343.02,percent of total billed charges,75% of total billed charges for outpatient setting,1952.52,50,,1562.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.41,12.84,,401.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3124.03,80,,2499.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.41,12.84,,401.13,percent of total billed charges,12.84% of total billed charges,501.41,12.84,,401.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4100.29,105,,3280.23,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1366.76,35,,1093.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2343.02,60,,1874.42,percent of total billed charges,60% of total billed charges for outpatient setting,501.41,4100.29,
PLATE BASE SHLDR COMPR RVS / 115330,70000068,CDM,278,RC,C1713,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
PLATE COALITION AGX 14X6MM / 1128.1206,70000559,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
PLATE COALITION AGX 14X8MM / 1128.1208,69162810,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
PLATE COALITION AGX 14X9MM / 1128.1209,69162834,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
PLATE DIST RAD 8 HOLE LT / 02.110.431,69160443,CDM,278,RC,,,Outpatient,,,3128.81,3128.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1877.29,60,,1501.83,percent of total billed charges,60% of total Billed charges for outpatient setting,2655.73,84.88,,2124.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1564.41,50,,1251.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2346.61,75,,1877.29,percent of total billed charges,75% of total billed charges for outpatient setting,1564.41,50,,1251.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2503.05,80,,2002.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3285.25,105,,2628.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.08,35,,876.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1877.29,60,,1501.83,percent of total billed charges,60% of total billed charges for outpatient setting,401.74,3285.25,
PLATE DISTL FIBULA / 40-20905,70000084,CDM,278,RC,C1713,HCPCS,Outpatient,,,1920.24,1920.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152.14,60,,921.71,percent of total billed charges,60% of total Billed charges for outpatient setting,1629.9,84.88,,1303.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.18,75,,1152.14,percent of total billed charges,75% of total billed charges for outpatient setting,960.12,50,,768.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.56,12.84,,197.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.19,80,,1228.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.56,12.84,,197.25,percent of total billed charges,12.84% of total billed charges,246.56,12.84,,197.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1920.24,65,,1536.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.08,35,,537.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1152.14,60,,921.71,percent of total billed charges,60% of total billed charges for outpatient setting,246.56,1920.24,
PLATE DISTL LAT FIBULA 3 HOLE / 40-20903,70000378,CDM,278,RC,C1713,HCPCS,Outpatient,,,1920.24,1920.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152.14,60,,921.71,percent of total billed charges,60% of total Billed charges for outpatient setting,1629.9,84.88,,1303.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.18,75,,1152.14,percent of total billed charges,75% of total billed charges for outpatient setting,960.12,50,,768.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.56,12.84,,197.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.19,80,,1228.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.56,12.84,,197.25,percent of total billed charges,12.84% of total billed charges,246.56,12.84,,197.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1920.24,65,,1536.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.08,35,,537.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1152.14,60,,921.71,percent of total billed charges,60% of total billed charges for outpatient setting,246.56,1920.24,
PLATE DISTL RADIUS 4H LCP / 02.110.440,69169654,CDM,278,RC,C1713,HCPCS,Outpatient,,,3638.03,3638.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2182.82,60,,1746.26,percent of total billed charges,60% of total Billed charges for outpatient setting,3087.96,84.88,,2470.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728.52,75,,2182.82,percent of total billed charges,75% of total billed charges for outpatient setting,1819.02,50,,1455.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.12,12.84,,373.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2910.42,80,,2328.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.12,12.84,,373.7,percent of total billed charges,12.84% of total billed charges,467.12,12.84,,373.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3819.93,105,,3055.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.31,35,,1018.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2182.82,60,,1746.26,percent of total billed charges,60% of total billed charges for outpatient setting,467.12,3819.93,
PLATE DISTL RADIUS RIGHT / 04.110.330,69162425,CDM,278,RC,,,Outpatient,,,3128.81,3128.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1877.29,60,,1501.83,percent of total billed charges,60% of total Billed charges for outpatient setting,2655.73,84.88,,2124.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1564.41,50,,1251.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2346.61,75,,1877.29,percent of total billed charges,75% of total billed charges for outpatient setting,1564.41,50,,1251.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2503.05,80,,2002.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,401.74,12.84,,321.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3285.25,105,,2628.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.08,35,,876.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1877.29,60,,1501.83,percent of total billed charges,60% of total billed charges for outpatient setting,401.74,3285.25,
PLATE DORSAL DR LEFT / 54-25293,69162917,CDM,278,RC,C1713,HCPCS,Outpatient,,,2364,2364,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1418.4,60,,1134.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2006.56,84.88,,1605.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1773,75,,1418.4,percent of total billed charges,75% of total billed charges for outpatient setting,1182,50,,945.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.54,12.84,,242.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891.2,80,,1512.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.54,12.84,,242.83,percent of total billed charges,12.84% of total billed charges,303.54,12.84,,242.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2482.2,105,,1985.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.4,35,,661.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1418.4,60,,1134.72,percent of total billed charges,60% of total billed charges for outpatient setting,303.54,2482.2,
PLATE DORSAL DR RIGHT / 54-25292,69162934,CDM,278,RC,C1713,HCPCS,Outpatient,,,2868.84,2868.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1721.3,60,,1377.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2435.07,84.88,,1948.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.63,75,,1721.3,percent of total billed charges,75% of total billed charges for outpatient setting,1434.42,50,,1147.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.36,12.84,,294.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2295.07,80,,1836.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.36,12.84,,294.69,percent of total billed charges,12.84% of total billed charges,368.36,12.84,,294.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3012.28,105,,2409.82,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.09,35,,803.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1721.3,60,,1377.04,percent of total billed charges,60% of total billed charges for outpatient setting,368.36,3012.28,
PLATE DORSAL LEFT WRIST / 54-25295,69169507,CDM,278,RC,C1713,HCPCS,Outpatient,,,3230.55,3230.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1938.33,60,,1550.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2742.09,84.88,,2193.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.91,75,,1938.33,percent of total billed charges,75% of total billed charges for outpatient setting,1615.28,50,,1292.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.8,12.84,,331.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2584.44,80,,2067.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.8,12.84,,331.84,percent of total billed charges,12.84% of total billed charges,414.8,12.84,,331.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3392.08,105,,2713.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130.69,35,,904.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1938.33,60,,1550.66,percent of total billed charges,60% of total billed charges for outpatient setting,414.8,3392.08,
PLATE DORSAL RT SMARTLOCK / 54-25290,70000501,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.08,2782.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.25,60,,1335.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.43,84.88,,1889.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.56,75,,1669.25,percent of total billed charges,75% of total billed charges for outpatient setting,1391.04,50,,1112.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.22,12.84,,285.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2225.66,80,,1780.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.22,12.84,,285.78,percent of total billed charges,12.84% of total billed charges,357.22,12.84,,285.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.18,105,,2336.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.73,35,,778.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.25,60,,1335.4,percent of total billed charges,60% of total billed charges for outpatient setting,357.22,2921.18,
PLATE DORSAL SMARTLOCK L / 54-25291,70000697,CDM,278,RC,C1776,HCPCS,Outpatient,,,2364,2364,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1418.4,60,,1134.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2006.56,84.88,,1605.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1773,75,,1418.4,percent of total billed charges,75% of total billed charges for outpatient setting,1182,50,,945.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.54,12.84,,242.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891.2,80,,1512.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.54,12.84,,242.83,percent of total billed charges,12.84% of total billed charges,303.54,12.84,,242.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2482.2,105,,1985.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.4,35,,661.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1418.4,60,,1134.72,percent of total billed charges,60% of total billed charges for outpatient setting,303.54,2482.2,
PLATE DSTL FIB LAT 8 HOLE / 40-20908,70000168,CDM,278,RC,C1713,HCPCS,Outpatient,,,2242.68,2242.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.61,60,,1076.49,percent of total billed charges,60% of total Billed charges for outpatient setting,1903.59,84.88,,1522.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1682.01,75,,1345.61,percent of total billed charges,75% of total billed charges for outpatient setting,1121.34,50,,897.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.96,12.84,,230.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.14,80,,1435.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.96,12.84,,230.37,percent of total billed charges,12.84% of total billed charges,287.96,12.84,,230.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2354.81,105,,1883.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.94,35,,627.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1345.61,60,,1076.49,percent of total billed charges,60% of total billed charges for outpatient setting,287.96,2354.81,
PLATE DSTL MEDIAL HUMERUS / 629384,70000316,CDM,278,RC,C1713,HCPCS,Outpatient,,,3296.92,3296.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1978.15,60,,1582.52,percent of total billed charges,60% of total Billed charges for outpatient setting,2798.43,84.88,,2238.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2472.69,75,,1978.15,percent of total billed charges,75% of total billed charges for outpatient setting,1648.46,50,,1318.77,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.32,12.84,,338.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2637.54,80,,2110.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.32,12.84,,338.66,percent of total billed charges,12.84% of total billed charges,423.32,12.84,,338.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3461.77,105,,2769.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.92,35,,923.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1978.15,60,,1582.52,percent of total billed charges,60% of total billed charges for outpatient setting,423.32,3461.77,
PLATE DSTL MEDL HUMRS 3 HOLE / 629383,70000487,CDM,278,RC,C1713,HCPCS,Outpatient,,,2989.98,2989.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1793.99,60,,1435.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.9,84.88,,2030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.49,75,,1793.99,percent of total billed charges,75% of total billed charges for outpatient setting,1494.99,50,,1195.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.98,80,,1913.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.48,105,,2511.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.49,35,,837.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1793.99,60,,1435.19,percent of total billed charges,60% of total billed charges for outpatient setting,383.91,3139.48,
PLATE DSTL RADIUS 2.4MM / 02.111.631,70000302,CDM,278,RC,C1713,HCPCS,Outpatient,,,3733.84,3733.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.3,60,,1792.24,percent of total billed charges,60% of total Billed charges for outpatient setting,3169.28,84.88,,2535.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800.38,75,,2240.3,percent of total billed charges,75% of total billed charges for outpatient setting,1866.92,50,,1493.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.43,12.84,,383.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2987.07,80,,2389.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.43,12.84,,383.54,percent of total billed charges,12.84% of total billed charges,479.43,12.84,,383.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3920.53,105,,3136.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1306.84,35,,1045.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2240.3,60,,1792.24,percent of total billed charges,60% of total billed charges for outpatient setting,479.43,3920.53,
PLATE DVR LOCK STD / 131822050,69169828,CDM,278,RC,C1713,HCPCS,Outpatient,,,2943.5,2943.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1766.1,60,,1412.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2498.44,84.88,,1998.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2207.63,75,,1766.1,percent of total billed charges,75% of total billed charges for outpatient setting,1471.75,50,,1177.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.95,12.84,,302.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2354.8,80,,1883.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.95,12.84,,302.36,percent of total billed charges,12.84% of total billed charges,377.95,12.84,,302.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3090.68,105,,2472.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.23,35,,824.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1766.1,60,,1412.88,percent of total billed charges,60% of total billed charges for outpatient setting,377.95,3090.68,
PLATE HUMERAL 3 HOLE / AR-14003,70000237,CDM,278,RC,C1713,HCPCS,Outpatient,,,2990,2990,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794,60,,1435.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.91,84.88,,2030.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.5,75,,1794,percent of total billed charges,75% of total billed charges for outpatient setting,1495,50,,1196,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392,80,,1913.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.5,105,,2511.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.5,35,,837.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794,60,,1435.2,percent of total billed charges,60% of total billed charges for outpatient setting,383.92,3139.5,
PLATE INTERM LEFT 11 HOLE / 54-25674,70000678,CDM,278,RC,C1713,HCPCS,Outpatient,,,3006.24,3006.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1803.74,60,,1442.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2551.7,84.88,,2041.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2254.68,75,,1803.74,percent of total billed charges,75% of total billed charges for outpatient setting,1503.12,50,,1202.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2404.99,80,,1923.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3156.55,105,,2525.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.18,35,,841.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1803.74,60,,1442.99,percent of total billed charges,60% of total billed charges for outpatient setting,386,3156.55,
PLATE L 0.6MM 7 HOLE / 25-306-07-09,69162229,CDM,278,RC,,,Outpatient,,,1019.73,1019.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.84,60,,489.47,percent of total billed charges,60% of total Billed charges for outpatient setting,865.55,84.88,,692.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,509.87,50,,407.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,764.8,75,,611.84,percent of total billed charges,75% of total billed charges for outpatient setting,509.87,50,,407.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.93,12.84,,104.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.78,80,,652.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.93,12.84,,104.74,percent of total billed charges,12.84% of total billed charges,130.93,12.84,,104.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1019.73,65,,815.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.91,35,,285.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,611.84,60,,489.47,percent of total billed charges,60% of total billed charges for outpatient setting,130.93,1019.73,
PLATE L 0.6MM 9 HOLE / 25-306-09-09,69162230,CDM,278,RC,,,Outpatient,,,1019.73,1019.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.84,60,,489.47,percent of total billed charges,60% of total Billed charges for outpatient setting,865.55,84.88,,692.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,509.87,50,,407.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,764.8,75,,611.84,percent of total billed charges,75% of total billed charges for outpatient setting,509.87,50,,407.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.93,12.84,,104.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.78,80,,652.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.93,12.84,,104.74,percent of total billed charges,12.84% of total billed charges,130.93,12.84,,104.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1019.73,65,,815.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.91,35,,285.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,611.84,60,,489.47,percent of total billed charges,60% of total billed charges for outpatient setting,130.93,1019.73,
"PLATE L, 2.4 DIST RADIUS 20DEG / 442.508",69160881,CDM,278,RC,,,Outpatient,,,2170.23,2170.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1302.14,60,,1041.71,percent of total billed charges,60% of total Billed charges for outpatient setting,1842.09,84.88,,1473.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,1085.12,50,,868.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1627.67,75,,1302.14,percent of total billed charges,75% of total billed charges for outpatient setting,1085.12,50,,868.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.66,12.84,,222.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.18,80,,1388.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.66,12.84,,222.93,percent of total billed charges,12.84% of total billed charges,278.66,12.84,,222.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2278.74,105,,1822.99,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.58,35,,607.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1302.14,60,,1041.71,percent of total billed charges,60% of total billed charges for outpatient setting,278.66,2278.74,
PLATE LAT DST FIB 6H/112MM/ 02.112.142,69162487,CDM,278,RC,C1713,HCPCS,Outpatient,,,2392.13,2392.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435.28,60,,1148.22,percent of total billed charges,60% of total Billed charges for outpatient setting,2030.44,84.88,,1624.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.1,75,,1435.28,percent of total billed charges,75% of total billed charges for outpatient setting,1196.07,50,,956.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.15,12.84,,245.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1913.7,80,,1530.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.15,12.84,,245.72,percent of total billed charges,12.84% of total billed charges,307.15,12.84,,245.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2511.74,105,,2009.39,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.25,35,,669.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1435.28,60,,1148.22,percent of total billed charges,60% of total billed charges for outpatient setting,307.15,2511.74,
PLATE LATERAL DR SHORT / 54-25400,69162502,CDM,278,RC,,,Outpatient,,,3239.99,3239.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1943.99,60,,1555.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2750.1,84.88,,2200.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1620,50,,1296,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2429.99,75,,1943.99,percent of total billed charges,75% of total billed charges for outpatient setting,1620,50,,1296,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.01,12.84,,332.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2591.99,80,,2073.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.01,12.84,,332.81,percent of total billed charges,12.84% of total billed charges,416.01,12.84,,332.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3401.99,105,,2721.59,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,35,,907.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1943.99,60,,1555.19,percent of total billed charges,60% of total billed charges for outpatient setting,416.01,3401.99,
PLATE LCP FIBULA LFT 3H73MM / 02.112.137,69169814,CDM,278,RC,C1713,HCPCS,Outpatient,,,2621.16,2621.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572.7,60,,1258.16,percent of total billed charges,60% of total Billed charges for outpatient setting,2224.84,84.88,,1779.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965.87,75,,1572.7,percent of total billed charges,75% of total billed charges for outpatient setting,1310.58,50,,1048.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.56,12.84,,269.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096.93,80,,1677.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.56,12.84,,269.25,percent of total billed charges,12.84% of total billed charges,336.56,12.84,,269.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2752.22,105,,2201.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917.41,35,,733.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1572.7,60,,1258.16,percent of total billed charges,60% of total billed charges for outpatient setting,336.56,2752.22,
PLATE LCP FIBULA LFT 3H73MM / 02.112.137,69161798,CDM,278,RC,,,Outpatient,,,2918.87,2918.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1751.32,60,,1401.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2477.54,84.88,,1982.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1459.44,50,,1167.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2189.15,75,,1751.32,percent of total billed charges,75% of total billed charges for outpatient setting,1459.44,50,,1167.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.78,12.84,,299.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2335.1,80,,1868.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.78,12.84,,299.82,percent of total billed charges,12.84% of total billed charges,374.78,12.84,,299.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3064.81,105,,2451.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.6,35,,817.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1751.32,60,,1401.06,percent of total billed charges,60% of total billed charges for outpatient setting,374.78,3064.81,
PLATE LCP FIBULA LFT 5H99MM / 02.112.141,69161610,CDM,278,RC,C1776,HCPCS,Outpatient,,,2529.45,2529.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1517.67,60,,1214.14,percent of total billed charges,60% of total Billed charges for outpatient setting,2147,84.88,,1717.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1897.09,75,,1517.67,percent of total billed charges,75% of total billed charges for outpatient setting,1264.73,50,,1011.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.78,12.84,,259.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2023.56,80,,1618.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.78,12.84,,259.82,percent of total billed charges,12.84% of total billed charges,324.78,12.84,,259.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2655.92,105,,2124.74,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.31,35,,708.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1517.67,60,,1214.14,percent of total billed charges,60% of total billed charges for outpatient setting,324.78,2655.92,
PLATE LCP FIBULA RT 3H73MM / 02.112.136,69162035,CDM,278,RC,,,Outpatient,,,2918.87,2918.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1751.32,60,,1401.06,percent of total billed charges,60% of total Billed charges for outpatient setting,2477.54,84.88,,1982.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,1459.44,50,,1167.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2189.15,75,,1751.32,percent of total billed charges,75% of total billed charges for outpatient setting,1459.44,50,,1167.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.78,12.84,,299.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2335.1,80,,1868.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.78,12.84,,299.82,percent of total billed charges,12.84% of total billed charges,374.78,12.84,,299.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3064.81,105,,2451.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.6,35,,817.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1751.32,60,,1401.06,percent of total billed charges,60% of total billed charges for outpatient setting,374.78,3064.81,
PLATE LCP FIBULA RT 4H86MM / 02.112.138,69169818,CDM,278,RC,C1713,HCPCS,Outpatient,,,2496.34,2496.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.8,60,,1198.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2118.89,84.88,,1695.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872.26,75,,1497.81,percent of total billed charges,75% of total billed charges for outpatient setting,1248.17,50,,998.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.53,12.84,,256.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1997.07,80,,1597.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.53,12.84,,256.42,percent of total billed charges,12.84% of total billed charges,320.53,12.84,,256.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2621.16,105,,2096.93,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.72,35,,698.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1497.8,60,,1198.24,percent of total billed charges,60% of total billed charges for outpatient setting,320.53,2621.16,
PLATE LCP FIBULA RT 5H99MM / 02.112.140,69161430,CDM,278,RC,,,Outpatient,,,2903.83,2903.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1742.3,60,,1393.84,percent of total billed charges,60% of total Billed charges for outpatient setting,2464.77,84.88,,1971.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1451.92,50,,1161.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2177.87,75,,1742.3,percent of total billed charges,75% of total billed charges for outpatient setting,1451.92,50,,1161.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.85,12.84,,298.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2323.06,80,,1858.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.85,12.84,,298.28,percent of total billed charges,12.84% of total billed charges,372.85,12.84,,298.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3049.02,105,,2439.22,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1016.34,35,,813.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1742.3,60,,1393.84,percent of total billed charges,60% of total billed charges for outpatient setting,372.85,3049.02,
"PLATE LCP, FIBULA LT. 5H99mm  02.112.141",69161810,CDM,278,RC,,,Outpatient,,,3044.71,3044.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1826.83,60,,1461.46,percent of total billed charges,60% of total Billed charges for outpatient setting,2584.35,84.88,,2067.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,1522.36,50,,1217.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2283.53,75,,1826.82,percent of total billed charges,75% of total billed charges for outpatient setting,1522.36,50,,1217.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.94,12.84,,312.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2435.77,80,,1948.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.94,12.84,,312.75,percent of total billed charges,12.84% of total billed charges,390.94,12.84,,312.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3196.95,105,,2557.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.65,35,,852.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1826.83,60,,1461.46,percent of total billed charges,60% of total billed charges for outpatient setting,390.94,3196.95,
PLATE LEFT NARROW / 131821050,69169572,CDM,278,RC,C1713,HCPCS,Outpatient,,,3090.68,3090.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.41,60,,1483.53,percent of total billed charges,60% of total Billed charges for outpatient setting,2623.37,84.88,,2098.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2318.01,75,,1854.41,percent of total billed charges,75% of total billed charges for outpatient setting,1545.34,50,,1236.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.84,12.84,,317.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2472.54,80,,1978.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.84,12.84,,317.47,percent of total billed charges,12.84% of total billed charges,396.84,12.84,,317.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3245.21,105,,2596.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.74,35,,865.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1854.41,60,,1483.53,percent of total billed charges,60% of total billed charges for outpatient setting,396.84,3245.21,
PLATE LEFT STD LONG VOLAR  / 54-25377,69162758,CDM,278,RC,C1713,HCPCS,Outpatient,,,2703,2703,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1621.8,60,,1297.44,percent of total billed charges,60% of total Billed charges for outpatient setting,2294.31,84.88,,1835.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2027.25,75,,1621.8,percent of total billed charges,75% of total billed charges for outpatient setting,1351.5,50,,1081.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.07,12.84,,277.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2162.4,80,,1729.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.07,12.84,,277.66,percent of total billed charges,12.84% of total billed charges,347.07,12.84,,277.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2838.15,105,,2270.52,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,946.05,35,,756.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1621.8,60,,1297.44,percent of total billed charges,60% of total billed charges for outpatient setting,347.07,2838.15,
PLATE LOCK DST FIB LT 6H / AR-8943BL-06,70000506,CDM,278,RC,C1713,HCPCS,Outpatient,,,2744.31,2744.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.59,60,,1317.27,percent of total billed charges,60% of total Billed charges for outpatient setting,2329.37,84.88,,1863.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2058.23,75,,1646.58,percent of total billed charges,75% of total billed charges for outpatient setting,1372.16,50,,1097.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.37,12.84,,281.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2195.45,80,,1756.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.37,12.84,,281.9,percent of total billed charges,12.84% of total billed charges,352.37,12.84,,281.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2881.53,105,,2305.22,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.51,35,,768.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1646.59,60,,1317.27,percent of total billed charges,60% of total billed charges for outpatient setting,352.37,2881.53,
PLATE LOCK DST FIB RT 6H / AR-8943BR-06,69162484,CDM,278,RC,,,Outpatient,,,2744.31,2744.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.59,60,,1317.27,percent of total billed charges,60% of total Billed charges for outpatient setting,2329.37,84.88,,1863.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1372.16,50,,1097.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2058.23,75,,1646.58,percent of total billed charges,75% of total billed charges for outpatient setting,1372.16,50,,1097.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.37,12.84,,281.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2195.45,80,,1756.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.37,12.84,,281.9,percent of total billed charges,12.84% of total billed charges,352.37,12.84,,281.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2881.53,105,,2305.22,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.51,35,,768.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1646.59,60,,1317.27,percent of total billed charges,60% of total billed charges for outpatient setting,352.37,2881.53,
PLATE LOCK STRT 22/ 10 HOLE AR-8943C-10,69162330,CDM,278,RC,,,Outpatient,,,2252.23,2252.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.34,60,,1081.07,percent of total billed charges,60% of total Billed charges for outpatient setting,1911.69,84.88,,1529.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,1126.12,50,,900.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1689.17,75,,1351.34,percent of total billed charges,75% of total billed charges for outpatient setting,1126.12,50,,900.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.19,12.84,,231.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1801.78,80,,1441.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.19,12.84,,231.35,percent of total billed charges,12.84% of total billed charges,289.19,12.84,,231.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2364.84,105,,1891.87,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.28,35,,630.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1351.34,60,,1081.07,percent of total billed charges,60% of total billed charges for outpatient setting,289.19,2364.84,
PLATE MTP STD RT LOW-PROFL  AR-8944CR-S,69162346,CDM,278,RC,C1713,HCPCS,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
PLATE OLECRANON 3 HOLE LEFT /  629343,69169605,CDM,278,RC,C1713,HCPCS,Outpatient,,,2989.98,2989.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1793.99,60,,1435.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.9,84.88,,2030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.49,75,,1793.99,percent of total billed charges,75% of total billed charges for outpatient setting,1494.99,50,,1195.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.98,80,,1913.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.48,105,,2511.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.49,35,,837.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1793.99,60,,1435.19,percent of total billed charges,60% of total billed charges for outpatient setting,383.91,3139.48,
PLATE OLECRANON 6 HOLE LEFT /  629346,69162554,CDM,278,RC,,,Outpatient,,,3159.54,3159.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1895.72,60,,1516.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2681.82,84.88,,2145.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,1579.77,50,,1263.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2369.66,75,,1895.73,percent of total billed charges,75% of total billed charges for outpatient setting,1579.77,50,,1263.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.68,12.84,,324.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2527.63,80,,2022.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.68,12.84,,324.54,percent of total billed charges,12.84% of total billed charges,405.68,12.84,,324.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3317.52,105,,2654.02,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1105.84,35,,884.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1895.72,60,,1516.58,percent of total billed charges,60% of total billed charges for outpatient setting,405.68,3317.52,
PLATE POSTERIOR LTRL DISTL LT / 629243,69169601,CDM,278,RC,C1713,HCPCS,Outpatient,,,2989.98,2989.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1793.99,60,,1435.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.9,84.88,,2030.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.49,75,,1793.99,percent of total billed charges,75% of total billed charges for outpatient setting,1494.99,50,,1195.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.98,80,,1913.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,383.91,12.84,,307.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.48,105,,2511.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.49,35,,837.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1793.99,60,,1435.19,percent of total billed charges,60% of total billed charges for outpatient setting,383.91,3139.48,
PLATE POSTERIOR LTRL DISTL RT / 629264,70000317,CDM,278,RC,C1713,HCPCS,Outpatient,,,2718.3,2718.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.98,60,,1304.78,percent of total billed charges,60% of total Billed charges for outpatient setting,2307.29,84.88,,1845.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.73,75,,1630.98,percent of total billed charges,75% of total billed charges for outpatient setting,1359.15,50,,1087.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.03,12.84,,279.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2174.64,80,,1739.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.03,12.84,,279.22,percent of total billed charges,12.84% of total billed charges,349.03,12.84,,279.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2854.22,105,,2283.38,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.41,35,,761.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1630.98,60,,1304.78,percent of total billed charges,60% of total billed charges for outpatient setting,349.03,2854.22,
PLATE PROX/LAT HUM 4 HLE / 627234,70000626,CDM,278,RC,C1713,HCPCS,Outpatient,,,3859.2,3859.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.52,60,,1852.42,percent of total billed charges,60% of total Billed charges for outpatient setting,3275.69,84.88,,2620.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2894.4,75,,2315.52,percent of total billed charges,75% of total billed charges for outpatient setting,1929.6,50,,1543.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.52,12.84,,396.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3087.36,80,,2469.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.52,12.84,,396.42,percent of total billed charges,12.84% of total billed charges,495.52,12.84,,396.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4052.16,105,,3241.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350.72,35,,1080.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2315.52,60,,1852.42,percent of total billed charges,60% of total billed charges for outpatient setting,495.52,4052.16,
PLATE RIGHT NARROW / 131811050,69169607,CDM,278,RC,C1713,HCPCS,Outpatient,,,3090.68,3090.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.41,60,,1483.53,percent of total billed charges,60% of total Billed charges for outpatient setting,2623.37,84.88,,2098.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2318.01,75,,1854.41,percent of total billed charges,75% of total billed charges for outpatient setting,1545.34,50,,1236.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.84,12.84,,317.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2472.54,80,,1978.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.84,12.84,,317.47,percent of total billed charges,12.84% of total billed charges,396.84,12.84,,317.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3245.21,105,,2596.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.74,35,,865.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1854.41,60,,1483.53,percent of total billed charges,60% of total billed charges for outpatient setting,396.84,3245.21,
PLATE RIGHT NARROW VOLAR DR / 54-25384,70000172,CDM,278,RC,C1713,HCPCS,Outpatient,,,2747.06,2747.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1648.24,60,,1318.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2331.7,84.88,,1865.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2060.3,75,,1648.24,percent of total billed charges,75% of total billed charges for outpatient setting,1373.53,50,,1098.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.72,12.84,,282.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.65,80,,1758.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.72,12.84,,282.18,percent of total billed charges,12.84% of total billed charges,352.72,12.84,,282.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2884.41,105,,2307.53,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.47,35,,769.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1648.24,60,,1318.59,percent of total billed charges,60% of total billed charges for outpatient setting,352.72,2884.41,
PLATE RIGHT SHORT VOLAR DR / 54-25386,69162501,CDM,278,RC,,,Outpatient,,,2342.6,2342.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1405.56,60,,1124.45,percent of total billed charges,60% of total Billed charges for outpatient setting,1988.4,84.88,,1590.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1171.3,50,,937.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1756.95,75,,1405.56,percent of total billed charges,75% of total billed charges for outpatient setting,1171.3,50,,937.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.79,12.84,,240.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.08,80,,1499.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.79,12.84,,240.63,percent of total billed charges,12.84% of total billed charges,300.79,12.84,,240.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2459.73,105,,1967.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.91,35,,655.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1405.56,60,,1124.45,percent of total billed charges,60% of total billed charges for outpatient setting,300.79,2459.73,
PLATE STRAIGHT VARIAX 3 HOLE / 40-20807,70000554,CDM,278,RC,C1713,HCPCS,Outpatient,,,2168.57,2168.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1301.14,60,,1040.91,percent of total billed charges,60% of total Billed charges for outpatient setting,1840.68,84.88,,1472.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.43,75,,1301.14,percent of total billed charges,75% of total billed charges for outpatient setting,1084.29,50,,867.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.44,12.84,,222.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.86,80,,1387.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.44,12.84,,222.75,percent of total billed charges,12.84% of total billed charges,278.44,12.84,,222.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2277,105,,1821.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759,35,,607.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1301.14,60,,1040.91,percent of total billed charges,60% of total billed charges for outpatient setting,278.44,2277,
PLATE STRAIGHT VARIAX 7 HOLE / 40-20807,70000383,CDM,278,RC,C1713,HCPCS,Outpatient,,,2168.57,2168.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1301.14,60,,1040.91,percent of total billed charges,60% of total Billed charges for outpatient setting,1840.68,84.88,,1472.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.43,75,,1301.14,percent of total billed charges,75% of total billed charges for outpatient setting,1084.29,50,,867.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.44,12.84,,222.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.86,80,,1387.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.44,12.84,,222.75,percent of total billed charges,12.84% of total billed charges,278.44,12.84,,222.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2277,105,,1821.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759,35,,607.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1301.14,60,,1040.91,percent of total billed charges,60% of total billed charges for outpatient setting,278.44,2277,
PLATE SUP/LAT CLAVICLE5 4 HLE / 628204,69162252,CDM,278,RC,,,Outpatient,,,3013.36,3013.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.02,60,,1446.42,percent of total billed charges,60% of total Billed charges for outpatient setting,2557.74,84.88,,2046.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,1506.68,50,,1205.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2260.02,75,,1808.02,percent of total billed charges,75% of total billed charges for outpatient setting,1506.68,50,,1205.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.92,12.84,,309.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2410.69,80,,1928.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.92,12.84,,309.54,percent of total billed charges,12.84% of total billed charges,386.92,12.84,,309.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3164.03,105,,2531.22,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1054.68,35,,843.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1808.02,60,,1446.42,percent of total billed charges,60% of total billed charges for outpatient setting,386.92,3164.03,
PLATE T 3.5MM 3\5 HLE RT.ANG 241.15,6152866,CDM,278,RC,,,Outpatient,,,481.56,481.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.94,60,,231.15,percent of total billed charges,60% of total Billed charges for outpatient setting,408.75,84.88,,327,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.78,50,,192.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.17,75,,288.94,percent of total billed charges,75% of total billed charges for outpatient setting,240.78,50,,192.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.83,12.84,,49.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.25,80,,308.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.83,12.84,,49.46,percent of total billed charges,12.84% of total billed charges,61.83,12.84,,49.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.56,65,,385.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.55,35,,134.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288.94,60,,231.15,percent of total billed charges,60% of total billed charges for outpatient setting,61.83,481.56,
PLATE T 3.5MMX3\3 HOLE RT.ANG.241.13,6152865,CDM,278,RC,,,Outpatient,,,350.05,350.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.03,60,,168.02,percent of total billed charges,60% of total Billed charges for outpatient setting,297.12,84.88,,237.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,175.03,50,,140.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.54,75,,210.03,percent of total billed charges,75% of total billed charges for outpatient setting,175.03,50,,140.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.95,12.84,,35.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.04,80,,224.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.95,12.84,,35.96,percent of total billed charges,12.84% of total billed charges,44.95,12.84,,35.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,350.05,65,,280.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.52,35,,98.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.03,60,,168.02,percent of total billed charges,60% of total billed charges for outpatient setting,44.95,350.05,
PLATE T 3.5MMX3\3 OB  ANG 241.23,6152867,CDM,278,RC,,,Outpatient,,,812.64,812.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.58,60,,390.06,percent of total billed charges,60% of total Billed charges for outpatient setting,689.77,84.88,,551.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,406.32,50,,325.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,609.48,75,,487.58,percent of total billed charges,75% of total billed charges for outpatient setting,406.32,50,,325.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.34,12.84,,83.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.11,80,,520.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.34,12.84,,83.47,percent of total billed charges,12.84% of total billed charges,104.34,12.84,,83.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,812.64,65,,650.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.42,35,,227.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,487.58,60,,390.06,percent of total billed charges,60% of total billed charges for outpatient setting,104.34,812.64,
PLATE T 3.5MMX3\4OB ANG 241.24,6152868,CDM,278,RC,,,Outpatient,,,874.69,874.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.81,60,,419.85,percent of total billed charges,60% of total Billed charges for outpatient setting,742.44,84.88,,593.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,437.35,50,,349.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,656.02,75,,524.82,percent of total billed charges,75% of total billed charges for outpatient setting,437.35,50,,349.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.31,12.84,,89.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.75,80,,559.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.31,12.84,,89.85,percent of total billed charges,12.84% of total billed charges,112.31,12.84,,89.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,874.69,65,,699.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.14,35,,244.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,524.81,60,,419.85,percent of total billed charges,60% of total billed charges for outpatient setting,112.31,874.69,
PLATE T 3.5MMX3\5 HOLE OB ANG 241.25,6152869,CDM,278,RC,,,Outpatient,,,662.52,662.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.51,60,,318.01,percent of total billed charges,60% of total Billed charges for outpatient setting,562.35,84.88,,449.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,331.26,50,,265.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.89,75,,397.51,percent of total billed charges,75% of total billed charges for outpatient setting,331.26,50,,265.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.07,12.84,,68.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.02,80,,424.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.07,12.84,,68.06,percent of total billed charges,12.84% of total billed charges,85.07,12.84,,68.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,662.52,65,,530.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.88,35,,185.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.51,60,,318.01,percent of total billed charges,60% of total billed charges for outpatient setting,85.07,662.52,
PLATE TIBIAL PROX LAT 2 HOLE / 627332,69169408,CDM,278,RC,C1713,HCPCS,Outpatient,,,3715.84,3715.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2229.5,60,,1783.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3154,84.88,,2523.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786.88,75,,2229.5,percent of total billed charges,75% of total billed charges for outpatient setting,1857.92,50,,1486.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.11,12.84,,381.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2972.67,80,,2378.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.11,12.84,,381.69,percent of total billed charges,12.84% of total billed charges,477.11,12.84,,381.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3901.63,105,,3121.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.54,35,,1040.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2229.5,60,,1783.6,percent of total billed charges,60% of total billed charges for outpatient setting,477.11,3901.63,
PLATE ULNAR COLUMN LFT SHORT / 54-25403,70000453,CDM,278,RC,C1713,HCPCS,Outpatient,,,3239.97,3239.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1943.98,60,,1555.18,percent of total billed charges,60% of total Billed charges for outpatient setting,2750.09,84.88,,2200.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2429.98,75,,1943.98,percent of total billed charges,75% of total billed charges for outpatient setting,1619.99,50,,1295.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.01,12.84,,332.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2591.98,80,,2073.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.01,12.84,,332.81,percent of total billed charges,12.84% of total billed charges,416.01,12.84,,332.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3401.97,105,,2721.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.99,35,,907.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1943.98,60,,1555.18,percent of total billed charges,60% of total billed charges for outpatient setting,416.01,3401.97,
PLATE VARIAX COMPR CRVD 9 HOLE / 629559,70000346,CDM,278,RC,C1713,HCPCS,Outpatient,,,3124.15,3124.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.49,60,,1499.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2651.78,84.88,,2121.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.11,75,,1874.49,percent of total billed charges,75% of total billed charges for outpatient setting,1562.08,50,,1249.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.14,12.84,,320.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2499.32,80,,1999.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.14,12.84,,320.91,percent of total billed charges,12.84% of total billed charges,401.14,12.84,,320.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3280.36,105,,2624.29,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.45,35,,874.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.49,60,,1499.59,percent of total billed charges,60% of total billed charges for outpatient setting,401.14,3280.36,
PLATE VARIAX COMPR STRT 5 HOLE / 629545,70000614,CDM,278,RC,C1713,HCPCS,Outpatient,,,1575.09,1575.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945.05,60,,756.04,percent of total billed charges,60% of total Billed charges for outpatient setting,1336.94,84.88,,1069.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.32,75,,945.06,percent of total billed charges,75% of total billed charges for outpatient setting,787.55,50,,630.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.24,12.84,,161.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260.07,80,,1008.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.24,12.84,,161.79,percent of total billed charges,12.84% of total billed charges,202.24,12.84,,161.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1575.09,65,,1260.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.28,35,,441.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,945.05,60,,756.04,percent of total billed charges,60% of total billed charges for outpatient setting,202.24,1575.09,
PLATE VARIAX COMPR STRT 8 HOLE / 629548,70000345,CDM,278,RC,C1713,HCPCS,Outpatient,,,3124.15,3124.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.49,60,,1499.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2651.78,84.88,,2121.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.11,75,,1874.49,percent of total billed charges,75% of total billed charges for outpatient setting,1562.08,50,,1249.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.14,12.84,,320.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2499.32,80,,1999.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.14,12.84,,320.91,percent of total billed charges,12.84% of total billed charges,401.14,12.84,,320.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3280.36,105,,2624.29,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.45,35,,874.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.49,60,,1499.59,percent of total billed charges,60% of total billed charges for outpatient setting,401.14,3280.36,
PLATE VARIAX FIBULA 9 HOLE / 40-20909,70000374,CDM,278,RC,C1713,HCPCS,Outpatient,,,1046.81,1046.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.09,60,,502.47,percent of total billed charges,60% of total Billed charges for outpatient setting,888.53,84.88,,710.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.11,75,,628.09,percent of total billed charges,75% of total billed charges for outpatient setting,523.41,50,,418.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.41,12.84,,107.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.45,80,,669.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.41,12.84,,107.53,percent of total billed charges,12.84% of total billed charges,134.41,12.84,,107.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1046.81,65,,837.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.38,35,,293.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.09,60,,502.47,percent of total billed charges,60% of total billed charges for outpatient setting,134.41,1046.81,
PLATE VLR PLT RAD 3 HOLE / AR-8916VSR-03,70000548,CDM,278,RC,C1713,HCPCS,Outpatient,,,3008.73,3008.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1805.24,60,,1444.19,percent of total billed charges,60% of total Billed charges for outpatient setting,2553.81,84.88,,2043.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2256.55,75,,1805.24,percent of total billed charges,75% of total billed charges for outpatient setting,1504.37,50,,1203.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.32,12.84,,309.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2406.98,80,,1925.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.32,12.84,,309.06,percent of total billed charges,12.84% of total billed charges,386.32,12.84,,309.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3159.17,105,,2527.34,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.06,35,,842.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1805.24,60,,1444.19,percent of total billed charges,60% of total billed charges for outpatient setting,386.32,3159.17,
PLATE VOLAR LEFT / 54-25376,69161627,CDM,278,RC,,,Outpatient,,,2868.84,2868.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1721.3,60,,1377.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2435.07,84.88,,1948.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,1434.42,50,,1147.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2151.63,75,,1721.3,percent of total billed charges,75% of total billed charges for outpatient setting,1434.42,50,,1147.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.36,12.84,,294.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2295.07,80,,1836.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.36,12.84,,294.69,percent of total billed charges,12.84% of total billed charges,368.36,12.84,,294.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3012.28,105,,2409.82,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.09,35,,803.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1721.3,60,,1377.04,percent of total billed charges,60% of total billed charges for outpatient setting,368.36,3012.28,
PLATE VOLAR LEFT XSHORT/ 54-25673,69169455,CDM,278,RC,C1713,HCPCS,Outpatient,,,3006.24,3006.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1803.74,60,,1442.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2551.7,84.88,,2041.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2254.68,75,,1803.74,percent of total billed charges,75% of total billed charges for outpatient setting,1503.12,50,,1202.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2404.99,80,,1923.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3156.55,105,,2525.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.18,35,,841.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1803.74,60,,1442.99,percent of total billed charges,60% of total billed charges for outpatient setting,386,3156.55,
PLATE VOLAR RT INTMDT 11 HOLE / 54-25684,70000462,CDM,278,RC,C1713,HCPCS,Outpatient,,,3006.24,3006.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1803.74,60,,1442.99,percent of total billed charges,60% of total Billed charges for outpatient setting,2551.7,84.88,,2041.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2254.68,75,,1803.74,percent of total billed charges,75% of total billed charges for outpatient setting,1503.12,50,,1202.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2404.99,80,,1923.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,386,12.84,,308.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3156.55,105,,2525.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.18,35,,841.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1803.74,60,,1442.99,percent of total billed charges,60% of total billed charges for outpatient setting,386,3156.55,
PLATE VOLAR SHRT NARROW / 54-25573,69162867,CDM,278,RC,C1713,HCPCS,Outpatient,,,2478,2478,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.8,60,,1189.44,percent of total billed charges,60% of total Billed charges for outpatient setting,2103.33,84.88,,1682.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1858.5,75,,1486.8,percent of total billed charges,75% of total billed charges for outpatient setting,1239,50,,991.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.18,12.84,,254.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1982.4,80,,1585.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.18,12.84,,254.54,percent of total billed charges,12.84% of total billed charges,318.18,12.84,,254.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2601.9,105,,2081.52,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.3,35,,693.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1486.8,60,,1189.44,percent of total billed charges,60% of total billed charges for outpatient setting,318.18,2601.9,
PLATE VOLAR SMARTLOCK / 54-25374,70000056,CDM,278,RC,C1713,HCPCS,Outpatient,,,2342.6,2342.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1405.56,60,,1124.45,percent of total billed charges,60% of total Billed charges for outpatient setting,1988.4,84.88,,1590.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1756.95,75,,1405.56,percent of total billed charges,75% of total billed charges for outpatient setting,1171.3,50,,937.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.79,12.84,,240.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.08,80,,1499.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.79,12.84,,240.63,percent of total billed charges,12.84% of total billed charges,300.79,12.84,,240.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2459.73,105,,1967.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.91,35,,655.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1405.56,60,,1124.45,percent of total billed charges,60% of total billed charges for outpatient setting,300.79,2459.73,
PLATE WRIST FUSION SHRT BEND / 629589,69169785,CDM,278,RC,C1713,HCPCS,Outpatient,,,2634.24,2634.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.54,60,,1264.43,percent of total billed charges,60% of total Billed charges for outpatient setting,2235.94,84.88,,1788.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1975.68,75,,1580.54,percent of total billed charges,75% of total billed charges for outpatient setting,1317.12,50,,1053.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.24,12.84,,270.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.39,80,,1685.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.24,12.84,,270.59,percent of total billed charges,12.84% of total billed charges,338.24,12.84,,270.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2765.95,105,,2212.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,921.98,35,,737.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1580.54,60,,1264.43,percent of total billed charges,60% of total billed charges for outpatient setting,338.24,2765.95,
PLATE WRIST FUSION W/STND BEND / 629579,69169589,CDM,278,RC,C1713,HCPCS,Outpatient,,,2524.48,2524.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.69,60,,1211.75,percent of total billed charges,60% of total Billed charges for outpatient setting,2142.78,84.88,,1714.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1893.36,75,,1514.69,percent of total billed charges,75% of total billed charges for outpatient setting,1262.24,50,,1009.79,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.14,12.84,,259.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.58,80,,1615.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.14,12.84,,259.31,percent of total billed charges,12.84% of total billed charges,324.14,12.84,,259.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2650.7,105,,2120.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.57,35,,706.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1514.69,60,,1211.75,percent of total billed charges,60% of total billed charges for outpatient setting,324.14,2650.7,
PLATE XTEND AC 12MM / 161.132,69162073,CDM,278,RC,,,Outpatient,,,4796,4796,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2877.6,60,,2302.08,percent of total billed charges,60% of total Billed charges for outpatient setting,4070.84,84.88,,3256.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,2398,50,,1918.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3597,75,,2877.6,percent of total billed charges,75% of total billed charges for outpatient setting,2398,50,,1918.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.81,12.84,,492.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3836.8,80,,3069.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.81,12.84,,492.65,percent of total billed charges,12.84% of total billed charges,615.81,12.84,,492.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5035.8,105,,4028.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.6,35,,1342.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2877.6,60,,2302.08,percent of total billed charges,60% of total billed charges for outpatient setting,615.81,5035.8,
PLATE XTEND AC 24MM / 161.124,69162632,CDM,278,RC,C1713,HCPCS,Outpatient,,,3690.62,3690.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2214.37,60,,1771.5,percent of total billed charges,60% of total Billed charges for outpatient setting,3132.6,84.88,,2506.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2767.97,75,,2214.38,percent of total billed charges,75% of total billed charges for outpatient setting,1845.31,50,,1476.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2952.5,80,,2362,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,473.88,12.84,,379.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3875.15,105,,3100.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.72,35,,1033.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2214.37,60,,1771.5,percent of total billed charges,60% of total billed charges for outpatient setting,473.88,3875.15,
"PLATE, DIST. RAD 8 HOLE RT / 02.110.430",69161415,CDM,278,RC,,,Outpatient,,,3859.04,3859.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.42,60,,1852.34,percent of total billed charges,60% of total Billed charges for outpatient setting,3275.55,84.88,,2620.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,1929.52,50,,1543.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2894.28,75,,2315.42,percent of total billed charges,75% of total billed charges for outpatient setting,1929.52,50,,1543.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.5,12.84,,396.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3087.23,80,,2469.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.5,12.84,,396.4,percent of total billed charges,12.84% of total billed charges,495.5,12.84,,396.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4051.99,105,,3241.59,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350.66,35,,1080.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2315.42,60,,1852.34,percent of total billed charges,60% of total billed charges for outpatient setting,495.5,4051.99,
"PLATE, DIST. RAD 9X3 HOLE RT/02.110.330",69160927,CDM,278,RC,,,Outpatient,,,3646.71,3646.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2188.03,60,,1750.42,percent of total billed charges,60% of total Billed charges for outpatient setting,3095.33,84.88,,2476.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1823.36,50,,1458.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2735.03,75,,2188.02,percent of total billed charges,75% of total billed charges for outpatient setting,1823.36,50,,1458.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.24,12.84,,374.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2917.37,80,,2333.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.24,12.84,,374.59,percent of total billed charges,12.84% of total billed charges,468.24,12.84,,374.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3829.05,105,,3063.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1276.35,35,,1021.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2188.03,60,,1750.42,percent of total billed charges,60% of total billed charges for outpatient setting,468.24,3829.05,
"PLATE, DIST. RAD 9X5 HOLE RT/02.110.350",69160712,CDM,278,RC,,,Outpatient,,,3646.71,3646.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2188.03,60,,1750.42,percent of total billed charges,60% of total Billed charges for outpatient setting,3095.33,84.88,,2476.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1823.36,50,,1458.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2735.03,75,,2188.02,percent of total billed charges,75% of total billed charges for outpatient setting,1823.36,50,,1458.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.24,12.84,,374.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2917.37,80,,2333.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.24,12.84,,374.59,percent of total billed charges,12.84% of total billed charges,468.24,12.84,,374.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3829.05,105,,3063.24,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1276.35,35,,1021.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2188.03,60,,1750.42,percent of total billed charges,60% of total billed charges for outpatient setting,468.24,3829.05,
"PLATE, DISTAL CLAVICLE5 5 HLE  628205",69161691,CDM,278,RC,,,Outpatient,,,2544,2544,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1526.4,60,,1221.12,percent of total billed charges,60% of total Billed charges for outpatient setting,2159.35,84.88,,1727.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,1272,50,,1017.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1908,75,,1526.4,percent of total billed charges,75% of total billed charges for outpatient setting,1272,50,,1017.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.65,12.84,,261.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2035.2,80,,1628.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.65,12.84,,261.32,percent of total billed charges,12.84% of total billed charges,326.65,12.84,,261.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2671.2,105,,2136.96,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.4,35,,712.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1526.4,60,,1221.12,percent of total billed charges,60% of total billed charges for outpatient setting,326.65,2671.2,
"PLATE, LEFT LAT/ANTERIOR LOCKING",69161650,CDM,278,RC,,,Outpatient,,,3856,3856,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2313.6,60,,1850.88,percent of total billed charges,60% of total Billed charges for outpatient setting,3272.97,84.88,,2618.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1928,50,,1542.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2892,75,,2313.6,percent of total billed charges,75% of total billed charges for outpatient setting,1928,50,,1542.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.11,12.84,,396.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3084.8,80,,2467.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.11,12.84,,396.09,percent of total billed charges,12.84% of total billed charges,495.11,12.84,,396.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4048.8,105,,3239.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,35,,1079.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2313.6,60,,1850.88,percent of total billed charges,60% of total billed charges for outpatient setting,495.11,4048.8,
"PLATE, SUPERIOR CLAVICLE Stryker  628148",69161551,CDM,278,RC,,,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
"PLATE, UNI 32mm  1897-22-032",69161770,CDM,278,RC,,,Outpatient,,,3400,3400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,60,,1632,percent of total billed charges,60% of total Billed charges for outpatient setting,2885.92,84.88,,2308.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1700,50,,1360,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2550,75,,2040,percent of total billed charges,75% of total billed charges for outpatient setting,1700,50,,1360,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2720,80,,2176,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3570,105,,2856,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190,35,,952,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2040,60,,1632,percent of total billed charges,60% of total billed charges for outpatient setting,436.56,3570,
PLATELET,200585,CDM,300,RC,85032,HCPCS,Outpatient,,,19.4,17.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,16.47,84.88,,13.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.55,75,,11.64,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.52,80,,12.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,100,,,Fee Schedule,100% of Custom Fee Schedule,17.46,90,,13.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,17.46,
PLATELET,201225,CDM,300,RC,85032,HCPCS,Outpatient,,,19.4,17.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,16.47,84.88,,13.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.55,75,,11.64,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.52,80,,12.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,100,,,Fee Schedule,100% of Custom Fee Schedule,17.46,90,,13.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,17.46,
PLATELET,201335,CDM,300,RC,85032,HCPCS,Outpatient,,,19.4,17.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,16.47,84.88,,13.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.55,75,,11.64,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,70,,10.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.52,80,,12.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,100,,,Fee Schedule,100% of Custom Fee Schedule,17.46,90,,13.97,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,17.46,
PLATELET ANTIBODIES,202123,CDM,302,RC,86022,HCPCS,Outpatient,,,82.67,74.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.87,70,,46.3,percent of total billed charges,70% of total billed charges for outpatient setting,70.17,84.88,,56.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.54,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62,75,,49.6,percent of total billed charges,75% of total billed charges for outpatient setting,57.87,70,,46.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.14,80,,52.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.82,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,100% of Custom Fee Schedule,74.4,90,,59.52,percent of total billed charges,90% of total billed charges for outpatient setting,18.37,74.4,
"PLATELET COUNT, AUTOMATED",201312,CDM,300,RC,85049,HCPCS,Outpatient,,,20.16,18.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,70,,11.29,percent of total billed charges,70% of total billed charges for outpatient setting,17.11,84.88,,13.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.12,75,,12.1,percent of total billed charges,75% of total billed charges for outpatient setting,14.11,70,,11.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.13,80,,12.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,100,,,Fee Schedule,100% of Custom Fee Schedule,18.14,90,,14.51,percent of total billed charges,90% of total billed charges for outpatient setting,4.48,18.14,
PLATELET FUNCTION TEST,220776,CDM,302,RC,85576,HCPCS,Outpatient,,,112.1,100.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.47,70,,62.78,percent of total billed charges,70% of total billed charges for outpatient setting,95.15,84.88,,76.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,84.08,75,,67.26,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,70,,62.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.68,80,,71.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.74,100,,,Fee Schedule,100% of Custom Fee Schedule,100.89,90,,80.71,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100.89,
PLATFORM SZ 6 ATTUNE TIB / 1506-80-006,71000933,CDM,278,RC,C1776,HCPCS,Outpatient,,,2114.1,2114.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.46,60,,1014.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.45,84.88,,1435.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.58,75,,1268.46,percent of total billed charges,75% of total billed charges for outpatient setting,1057.05,50,,845.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.28,80,,1353.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.81,105,,1775.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.94,35,,591.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.46,60,,1014.77,percent of total billed charges,60% of total billed charges for outpatient setting,271.45,2219.81,
PLATFORM SZ 7 ATTUNE TIB / 1506-80-007,71000936,CDM,278,RC,C1776,HCPCS,Outpatient,,,2114.1,2114.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.46,60,,1014.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.45,84.88,,1435.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.58,75,,1268.46,percent of total billed charges,75% of total billed charges for outpatient setting,1057.05,50,,845.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.28,80,,1353.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.81,105,,1775.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.94,35,,591.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.46,60,,1014.77,percent of total billed charges,60% of total billed charges for outpatient setting,271.45,2219.81,
PLATFORM SZ 8 ATTUNE TIB / 1506-80-008,71000856,CDM,278,RC,C1776,HCPCS,Outpatient,,,2114.1,2114.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.46,60,,1014.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.45,84.88,,1435.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.58,75,,1268.46,percent of total billed charges,75% of total billed charges for outpatient setting,1057.05,50,,845.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.28,80,,1353.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,271.45,12.84,,217.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2219.81,105,,1775.85,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.94,35,,591.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.46,60,,1014.77,percent of total billed charges,60% of total billed charges for outpatient setting,271.45,2219.81,
PLATTE SZ 8L PERSONA TI / 42-5726-064-01,71000091,CDM,278,RC,C1776,HCPCS,Outpatient,,,7400,7400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4440,60,,3552,percent of total billed charges,60% of total Billed charges for outpatient setting,6281.12,84.88,,5024.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5550,75,,4440,percent of total billed charges,75% of total billed charges for outpatient setting,3700,50,,2960,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.16,12.84,,760.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5920,80,,4736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.16,12.84,,760.13,percent of total billed charges,12.84% of total billed charges,950.16,12.84,,760.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7770,105,,6216,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2590,35,,2072,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4440,60,,3552,percent of total billed charges,60% of total billed charges for outpatient setting,950.16,7770,
PLEUR-EVAC CHEST DRAINAGE / A-8000-08L,5150201,CDM,272,RC,,,Outpatient,,,572,572,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.4,70,,320.32,percent of total billed charges,70% of total billed charges for outpatient setting,485.51,84.88,,388.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,286,50,,228.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429,75,,343.2,percent of total billed charges,75% of total billed charges for outpatient setting,400.4,70,,320.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.44,12.84,,58.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.6,80,,366.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.44,12.84,,58.75,percent of total billed charges,12.84% of total billed charges,73.44,12.84,,58.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,371.8,65,,297.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.2,35,,160.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,514.8,90,,411.84,percent of total billed charges,90% of total billed charges for outpatient setting,73.44,514.8,
PLEURX PLEURAL CATH KIT / 50-7000,69160574,CDM,272,RC,C1729,HCPCS,Outpatient,,,2049.75,2049.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.83,70,,1147.86,percent of total billed charges,70% of total billed charges for outpatient setting,1739.83,84.88,,1391.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1537.31,75,,1229.85,percent of total billed charges,75% of total billed charges for outpatient setting,1434.83,70,,1147.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.19,12.84,,210.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.8,80,,1311.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.19,12.84,,210.55,percent of total billed charges,12.84% of total billed charges,263.19,12.84,,210.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1332.34,65,,1065.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.41,35,,573.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1844.78,90,,1475.82,percent of total billed charges,90% of total billed charges for outpatient setting,263.19,1844.78,
PLT 2.5 TRILK SHORT BEND WRIST/A-4760.06,69169669,CDM,278,RC,C1713,HCPCS,Outpatient,,,6320.8,6320.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3792.48,60,,3033.98,percent of total billed charges,60% of total Billed charges for outpatient setting,5365.1,84.88,,4292.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4740.6,75,,3792.48,percent of total billed charges,75% of total billed charges for outpatient setting,3160.4,50,,2528.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.59,12.84,,649.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5056.64,80,,4045.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.59,12.84,,649.27,percent of total billed charges,12.84% of total billed charges,811.59,12.84,,649.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6636.84,105,,5309.47,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2212.28,35,,1769.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3792.48,60,,3033.98,percent of total billed charges,60% of total billed charges for outpatient setting,811.59,6636.84,
PLT 2.5 TRILOCK ULNA /A-4750.95,69169708,CDM,278,RC,C1713,HCPCS,Outpatient,,,4547.8,4547.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728.68,60,,2182.94,percent of total billed charges,60% of total Billed charges for outpatient setting,3860.17,84.88,,3088.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3410.85,75,,2728.68,percent of total billed charges,75% of total billed charges for outpatient setting,2273.9,50,,1819.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583.94,12.84,,467.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3638.24,80,,2910.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583.94,12.84,,467.15,percent of total billed charges,12.84% of total billed charges,583.94,12.84,,467.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4775.19,105,,3820.15,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.73,35,,1273.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2728.68,60,,2182.94,percent of total billed charges,60% of total billed charges for outpatient setting,583.94,4775.19,
PLT 3x2 HOLE TRAPEZOID /A-4650.56,69169699,CDM,278,RC,C1713,HCPCS,Outpatient,,,3365.2,3365.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.12,60,,1615.3,percent of total billed charges,60% of total Billed charges for outpatient setting,2856.38,84.88,,2285.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2523.9,75,,2019.12,percent of total billed charges,75% of total billed charges for outpatient setting,1682.6,50,,1346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.09,12.84,,345.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2692.16,80,,2153.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.09,12.84,,345.67,percent of total billed charges,12.84% of total billed charges,432.09,12.84,,345.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3533.46,105,,2826.77,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1177.82,35,,942.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2019.12,60,,1615.3,percent of total billed charges,60% of total billed charges for outpatient setting,432.09,3533.46,
PLT 4 HOLE STRAIGHT /A-4645.01,69169737,CDM,278,RC,C1713,HCPCS,Outpatient,,,2068.29,2068.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1240.97,60,,992.78,percent of total billed charges,60% of total Billed charges for outpatient setting,1755.56,84.88,,1404.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1551.22,75,,1240.98,percent of total billed charges,75% of total billed charges for outpatient setting,1034.15,50,,827.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.57,12.84,,212.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1654.63,80,,1323.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.57,12.84,,212.46,percent of total billed charges,12.84% of total billed charges,265.57,12.84,,212.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2068.29,65,,1654.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.9,35,,579.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1240.97,60,,992.78,percent of total billed charges,60% of total billed charges for outpatient setting,265.57,2068.29,
PLT VARIAX OLECRANON 3 HOLE RT / 629363,69169299,CDM,278,RC,C1713,HCPCS,Outpatient,,,2865.4,2865.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.24,60,,1375.39,percent of total billed charges,60% of total Billed charges for outpatient setting,2432.15,84.88,,1945.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2149.05,75,,1719.24,percent of total billed charges,75% of total billed charges for outpatient setting,1432.7,50,,1146.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.92,12.84,,294.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.32,80,,1833.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.92,12.84,,294.34,percent of total billed charges,12.84% of total billed charges,367.92,12.84,,294.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3008.67,105,,2406.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.89,35,,802.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1719.24,60,,1375.39,percent of total billed charges,60% of total billed charges for outpatient setting,367.92,3008.67,
PLT VARIAX OLECRANON 4 HOLE RT / 629364,69161955,CDM,278,RC,,,Outpatient,,,3139.92,3139.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1883.95,60,,1507.16,percent of total billed charges,60% of total Billed charges for outpatient setting,2665.16,84.88,,2132.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,1569.96,50,,1255.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2354.94,75,,1883.95,percent of total billed charges,75% of total billed charges for outpatient setting,1569.96,50,,1255.97,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.17,12.84,,322.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.94,80,,2009.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.17,12.84,,322.54,percent of total billed charges,12.84% of total billed charges,403.17,12.84,,322.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3296.92,105,,2637.54,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.97,35,,879.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1883.95,60,,1507.16,percent of total billed charges,60% of total billed charges for outpatient setting,403.17,3296.92,
PLTE LAT DST FIB LT 6H/112MM/ 02.112.143,69169695,CDM,278,RC,C1713,HCPCS,Outpatient,,,2696.94,2696.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.16,60,,1294.53,percent of total billed charges,60% of total Billed charges for outpatient setting,2289.16,84.88,,1831.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2022.71,75,,1618.17,percent of total billed charges,75% of total billed charges for outpatient setting,1348.47,50,,1078.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.29,12.84,,277.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.55,80,,1726.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.29,12.84,,277.03,percent of total billed charges,12.84% of total billed charges,346.29,12.84,,277.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2831.79,105,,2265.43,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.93,35,,755.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.16,60,,1294.53,percent of total billed charges,60% of total billed charges for outpatient setting,346.29,2831.79,
PNEUMOCOCCAL AB 23 SEROTYPES A,220155,CDM,302,RC,86317,HCPCS,Outpatient,,,67.46,60.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.26,84.88,,45.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,100,,,Fee Schedule,100% of Custom Fee Schedule,60.71,90,,48.57,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,60.71,
PNEUMOCOCCAL AB CHARGE.NOT A TEST ORDER,200276,CDM,302,RC,86317,HCPCS,Outpatient,,,67.46,60.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.26,84.88,,45.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,100,,,Fee Schedule,100% of Custom Fee Schedule,60.71,90,,48.57,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,60.71,
PNEUMOCOCCAL V (PNU-IMUNE 23) 0.5ML,3301824,CDM,636,RC,90732,HCPCS,Outpatient,,,361.74,361.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.22,70,,202.58,percent of total billed charges,70% of total billed charges for outpatient setting,307.04,84.88,,245.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,271.31,75,,217.05,percent of total billed charges,75% of total billed charges for outpatient setting,253.22,70,,202.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.45,12.84,,37.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.39,80,,231.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.45,12.84,,37.16,percent of total billed charges,12.84% of total billed charges,46.45,12.84,,37.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,235.13,65,,188.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.44,100,,,Fee Schedule,100% of Custom Fee Schedule,325.57,90,,260.46,percent of total billed charges,90% of total billed charges for outpatient setting,46.45,325.57,
POLAR CARE CUBE COLD / 10701,6152154,CDM,270,RC,,,Outpatient,,,232.56,232.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.79,70,,130.23,percent of total billed charges,70% of total billed charges for outpatient setting,197.4,84.88,,157.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.28,50,,93.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,75,,139.54,percent of total billed charges,75% of total billed charges for outpatient setting,162.79,70,,130.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.86,12.84,,23.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.05,80,,148.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.86,12.84,,23.89,percent of total billed charges,12.84% of total billed charges,29.86,12.84,,23.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.16,65,,120.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.4,35,,65.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,209.3,90,,167.44,percent of total billed charges,90% of total billed charges for outpatient setting,29.86,209.3,
POLIOVIRUS AB IMMUNE STATUS,220883,CDM,302,RC,86658,HCPCS,Outpatient,,,58.64,52.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,49.77,84.88,,39.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.98,75,,35.18,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,70,,32.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.91,80,,37.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,100,,,Fee Schedule,100% of Custom Fee Schedule,52.78,90,,42.22,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,52.78,
POLY AHG,201349,CDM,300,RC,86880,HCPCS,Outpatient,,,221.87,199.68,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.31,70,,124.25,percent of total billed charges,70% of total billed charges for outpatient setting,188.32,84.88,,150.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,166.4,75,,133.12,percent of total billed charges,75% of total billed charges for outpatient setting,155.31,70,,124.25,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,177.5,80,,142,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,7.84,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.42,100,,,Fee Schedule,100% of Custom Fee Schedule,199.68,90,,159.74,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,199.68,
POLYETHYLENE (GOLYTELY) 4000 ML SOL :,3301826,CDM,259,RC,,,Outpatient,,,47.03,47.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.92,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,39.92,84.88,,31.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.52,50,,18.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.27,75,,28.22,percent of total billed charges,75% of total billed charges for outpatient setting,32.92,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.62,80,,30.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.57,65,,24.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,35,,13.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.33,90,,33.86,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,42.33,
POLYETHYLENE (NULYTELY) 4000 ML SOL :,3301827,CDM,259,RC,,,Outpatient,,,60.49,60.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.34,70,,33.87,percent of total billed charges,70% of total billed charges for outpatient setting,51.34,84.88,,41.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.25,50,,24.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.37,75,,36.3,percent of total billed charges,75% of total billed charges for outpatient setting,42.34,70,,33.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,12.84,,6.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.39,80,,38.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,7.77,12.84,,6.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.32,65,,31.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,35,,16.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.44,90,,43.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.77,54.44,
POLYETHYLENE genCOLYTE 4000 ML PWD PEG,3301825,CDM,259,RC,,,Outpatient,,,66.66,66.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.66,70,,37.33,percent of total billed charges,70% of total billed charges for outpatient setting,56.58,84.88,,45.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.33,50,,26.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,75,,40,percent of total billed charges,75% of total billed charges for outpatient setting,46.66,70,,37.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,12.84,,6.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.33,80,,42.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.33,65,,34.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,35,,18.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.99,90,,47.99,percent of total billed charges,90% of total billed charges for outpatient setting,8.56,59.99,
POLYGAM IGIV: 10GMS,3302970,CDM,250,RC,,,Outpatient,,,4918.46,4918.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3442.92,70,,2754.34,percent of total billed charges,70% of total billed charges for outpatient setting,4174.79,84.88,,3339.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,2459.23,50,,1967.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3688.85,75,,2951.08,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.53,12.84,,505.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3934.77,80,,3147.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.53,12.84,,505.22,percent of total billed charges,12.84% of total billed charges,631.53,12.84,,505.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3197,65,,2557.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1721.46,35,,1377.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4426.61,90,,3541.29,percent of total billed charges,90% of total billed charges for outpatient setting,631.53,4426.61,
"POLYMYXIN B  500,000 UNITS/VIAL",3301828,CDM,250,RC,,,Outpatient,,,32.88,32.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.02,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,27.91,84.88,,22.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.44,50,,13.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.66,75,,19.73,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,70,,18.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,12.84,,3.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,80,,21.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,4.22,12.84,,3.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.37,65,,17.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.51,35,,9.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.59,90,,23.67,percent of total billed charges,90% of total billed charges for outpatient setting,4.22,29.59,
POLYMYXIN B (POLYTRIM) 10 ML DROP :,3301829,CDM,259,RC,,,Outpatient,,,46.98,46.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.89,70,,26.31,percent of total billed charges,70% of total billed charges for outpatient setting,39.88,84.88,,31.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.49,50,,18.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.24,75,,28.19,percent of total billed charges,75% of total billed charges for outpatient setting,32.89,70,,26.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,12.84,,4.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,80,,30.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,6.03,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,65,,24.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,35,,13.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.28,90,,33.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,42.28,
POLYMYXIN B (POLYTRIM) 10 ML DROP :,3301830,CDM,259,RC,,,Outpatient,,,52.71,52.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,70,,29.52,percent of total billed charges,70% of total billed charges for outpatient setting,44.74,84.88,,35.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.36,50,,21.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.53,75,,31.62,percent of total billed charges,75% of total billed charges for outpatient setting,36.9,70,,29.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,12.84,,5.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.17,80,,33.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,12.84,,5.42,percent of total billed charges,12.84% of total billed charges,6.77,12.84,,5.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.26,65,,27.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,35,,14.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.44,90,,37.95,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,47.44,
POLYSKIN 2 x 2.75   6640,69161861,CDM,272,RC,,,Outpatient,,,31.64,31.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.15,70,,17.72,percent of total billed charges,70% of total billed charges for outpatient setting,26.86,84.88,,21.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.82,50,,12.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.73,75,,18.98,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,70,,17.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.06,12.84,,3.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,80,,20.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.06,12.84,,3.25,percent of total billed charges,12.84% of total billed charges,4.06,12.84,,3.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.57,65,,16.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.07,35,,8.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.48,90,,22.78,percent of total billed charges,90% of total billed charges for outpatient setting,4.06,28.48,
POLYSKIN II 8X10 // 6648,69161308,CDM,272,RC,,,Outpatient,,,33.48,33.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.44,70,,18.75,percent of total billed charges,70% of total billed charges for outpatient setting,28.42,84.88,,22.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.74,50,,13.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.11,75,,20.09,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,70,,18.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.78,80,,21.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.76,65,,17.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.72,35,,9.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.13,90,,24.1,percent of total billed charges,90% of total billed charges for outpatient setting,4.3,30.13,
POLY-TUSSIN ELIXIR: 1OZ,3302945,CDM,259,RC,,,Outpatient,,,12.37,12.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,70,,6.93,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,84.88,,8.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.19,50,,4.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.28,75,,7.42,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,70,,6.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,80,,7.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,1.59,12.84,,1.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.04,65,,6.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,35,,3.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.13,90,,8.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,11.13,
POPE OTO-WICK/14-25008,6152053,CDM,270,RC,,,Outpatient,,,25.26,25.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,70,,14.14,percent of total billed charges,70% of total billed charges for outpatient setting,21.44,84.88,,17.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.63,50,,10.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.95,75,,15.16,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,70,,14.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.21,80,,16.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,3.24,12.84,,2.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.42,65,,13.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,35,,7.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.73,90,,18.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.24,22.73,
"PORPHYRINS, FRACT & QUANT, URINE",201059,CDM,300,RC,84120,HCPCS,Outpatient,,,66.2,59.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,70,,37.07,percent of total billed charges,70% of total billed charges for outpatient setting,56.19,84.88,,44.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.65,75,,39.72,percent of total billed charges,75% of total billed charges for outpatient setting,46.34,70,,37.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.96,80,,42.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,100,,,Fee Schedule,100% of Custom Fee Schedule,59.58,90,,47.66,percent of total billed charges,90% of total billed charges for outpatient setting,14.71,59.58,
PORT 120MM MARS / 632.032,69162162,CDM,272,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2384.71,70,,1907.77,percent of total billed charges,70% of total billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2214.37,65,,1771.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3066.06,90,,2452.85,percent of total billed charges,90% of total billed charges for outpatient setting,437.42,3066.06,
PORT MRI POWERPORT / 1808001,69160203,CDM,278,RC,C1788,HCPCS,Outpatient,,,976,976,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.6,60,,468.48,percent of total billed charges,60% of total Billed charges for outpatient setting,828.43,84.88,,662.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732,75,,585.6,percent of total billed charges,75% of total billed charges for outpatient setting,488,50,,390.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.32,12.84,,100.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.8,80,,624.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.32,12.84,,100.26,percent of total billed charges,12.84% of total billed charges,125.32,12.84,,100.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,976,65,,780.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.6,35,,273.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,585.6,60,,468.48,percent of total billed charges,60% of total billed charges for outpatient setting,125.32,976,
PORT MRI POWERPORT DUAL 10.0FR / 0605930,69162605,CDM,278,RC,C1788,HCPCS,Outpatient,,,584.01,584.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.41,60,,280.33,percent of total billed charges,60% of total Billed charges for outpatient setting,495.71,84.88,,396.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.01,75,,350.41,percent of total billed charges,75% of total billed charges for outpatient setting,292.01,50,,233.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.99,12.84,,59.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.21,80,,373.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.99,12.84,,59.99,percent of total billed charges,12.84% of total billed charges,74.99,12.84,,59.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,584.01,65,,467.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.4,35,,163.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.41,60,,280.33,percent of total billed charges,60% of total billed charges for outpatient setting,74.99,584.01,
POSEIDON NEPTUNE 2 MANIFOLD / PN2-4,70000034,CDM,270,RC,,,Outpatient,,,75.33,75.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.73,70,,42.18,percent of total billed charges,70% of total billed charges for outpatient setting,63.94,84.88,,51.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.67,50,,30.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.5,75,,45.2,percent of total billed charges,75% of total billed charges for outpatient setting,52.73,70,,42.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,12.84,,7.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.26,80,,48.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,12.84,,7.74,percent of total billed charges,12.84% of total billed charges,9.67,12.84,,7.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.96,65,,39.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,35,,21.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.8,90,,54.24,percent of total billed charges,90% of total billed charges for outpatient setting,9.67,67.8,
POST-VOIDING BLADDER ULTRASOUND,5100119,CDM,402,RC,51798,HCPCS,Outpatient,,,667.8,667.8,,79.81,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,566.83,84.88,,453.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,500.85,75,,400.68,percent of total billed charges,75% of total billed charges for outpatient setting,467.46,70,,373.97,percent of total billed charges,70% of total billed charges for outpatient setting,84.79,170,,,Fee Schedule,170% of Medicare OPPS rate,107.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,87.29,175,,,Fee Schedule,175% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,534.24,80,,427.39,percent of total billed charges,80% of total billed charges for outpatient setting,69.83,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,62.35,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,85.75,12.84,,68.6,percent of total billed charges,12.84% of total billed charges,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,49.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,63.57,100,,,Fee Schedule,100% of Custom Fee Schedule,601.02,90,,480.82,percent of total billed charges,90% of total billed charges for outpatient setting,49.88,601.02,
POTASSIUM,5100501,CDM,300,RC,84132,HCPCS,Outpatient,,,45.87,41.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,70,,25.69,percent of total billed charges,70% of total billed charges for outpatient setting,38.93,84.88,,31.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,34.4,75,,27.52,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,70,,25.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.7,80,,29.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,41.28,90,,33.02,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,41.28,
POTASSIUM,5100047,CDM,300,RC,84132,HCPCS,Outpatient,,,83.71,75.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,71.05,84.88,,56.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.78,75,,50.22,percent of total billed charges,75% of total billed charges for outpatient setting,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.97,80,,53.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,75.34,90,,60.27,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,75.34,
POTASSIUM - BLOOD,200515,CDM,300,RC,84132,HCPCS,Outpatient,,,21.42,19.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,18.18,84.88,,14.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,19.28,90,,15.42,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,19.28,
POTASSIUM - URINE,200516,CDM,300,RC,84133,HCPCS,Outpatient,,,21.29,19.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.9,70,,11.92,percent of total billed charges,70% of total billed charges for outpatient setting,18.07,84.88,,14.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.97,75,,12.78,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,70,,11.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.03,80,,13.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,100,,,Fee Schedule,100% of Custom Fee Schedule,19.16,90,,15.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,19.16,
POTASSIUM ACET 2 MEQ/ML INJ  20 ML,3301832,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM BLD,201235,CDM,300,RC,84132,HCPCS,Outpatient,,,21.42,19.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,18.18,84.88,,14.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.07,75,,12.86,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,70,,11.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.14,80,,13.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,100,,,Fee Schedule,100% of Custom Fee Schedule,19.28,90,,15.42,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,19.28,
POTASSIUM CIT (UROCIT-K) 10 MEQ,3304211,CDM,259,RC,,,Outpatient,,,3.76,3.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,70,,2.1,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,84.88,,2.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.88,50,,1.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.82,75,,2.26,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,70,,2.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,80,,2.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.44,65,,1.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,35,,1.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.38,90,,2.7,percent of total billed charges,90% of total billed charges for outpatient setting,0.48,3.38,
POTASSIUM CL (K-DUR SR) 20MEQ TAB : U/D,3301840,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
POTASSIUM CL (KLOR-CON) 10MEQ TAB: U/D,3301835,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
POTASSIUM CL 10 MEQ  CAP,3301838,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM CL 10MEQ 50 ML IV :,3301841,CDM,250,RC,,,Outpatient,,,9.75,9.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.83,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,8.28,84.88,,6.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.88,50,,3.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.31,75,,5.85,percent of total billed charges,75% of total billed charges for outpatient setting,6.83,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,80,,6.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.34,65,,5.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,35,,2.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.78,90,,7.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.25,8.78,
POTASSIUM CL 10MEQ TAB U/D,3301837,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
POTASSIUM CL 10MEQ VIAL : 100 ML,3301842,CDM,250,RC,,,Outpatient,,,9.75,9.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.83,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,8.28,84.88,,6.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.88,50,,3.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.31,75,,5.85,percent of total billed charges,75% of total billed charges for outpatient setting,6.83,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,80,,6.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.34,65,,5.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,35,,2.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.78,90,,7.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.25,8.78,
POTASSIUM CL 20 MEQ/100 ML HIGHLY CONC,3302940,CDM,250,RC,J3480,HCPCS,Outpatient,,,34.18,34.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.93,70,,19.14,percent of total billed charges,70% of total billed charges for outpatient setting,29.01,84.88,,23.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,25.64,75,,20.51,percent of total billed charges,75% of total billed charges for outpatient setting,23.93,70,,19.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,12.84,,3.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,80,,21.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,12.84,,3.51,percent of total billed charges,12.84% of total billed charges,4.39,12.84,,3.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.22,65,,17.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,30.76,90,,24.61,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,30.76,
POTASSIUM CL 20MEQ 10ML vial,3301843,CDM,636,RC,J3480,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,2.92,
POTASSIUM CL 20MEQ TAB,3301834,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM CL 40 MEQ 20 ML IV :,3301833,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
POTASSIUM CL 40MEQ 100ML IV :,3301844,CDM,250,RC,,,Outpatient,,,227.81,227.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.47,70,,127.58,percent of total billed charges,70% of total billed charges for outpatient setting,193.37,84.88,,154.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.91,50,,91.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.86,75,,136.69,percent of total billed charges,75% of total billed charges for outpatient setting,159.47,70,,127.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,12.84,,23.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.25,80,,145.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,12.84,,23.4,percent of total billed charges,12.84% of total billed charges,29.25,12.84,,23.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.08,65,,118.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,35,,63.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,205.03,90,,164.02,percent of total billed charges,90% of total billed charges for outpatient setting,29.25,205.03,
POTASSIUM CL 40MEQ 20 ML IV,3301839,CDM,250,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM CL 8 MEQ  TAB : U/D,3303090,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
POTASSIUM CL FOR ORAL SOLN 20MEQ PKT,3314040,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM CL ORAL SOLN 40MEQ/15 ML,3302766,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
POTASSIUM EFFERVESCENT 25MEQ TAB,3302799,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POTASSIUM IOD (SSKI) SOL 1GM/ML:30ML,3301845,CDM,259,RC,,,Outpatient,,,36.6,36.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,70,,20.5,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,84.88,,24.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.3,50,,14.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,75,,21.96,percent of total billed charges,75% of total billed charges for outpatient setting,25.62,70,,20.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,80,,23.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.79,65,,19.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.81,35,,10.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.94,90,,26.35,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,32.94,
POTASSIUM PHOS 3MMOL/ML  15 ML INJ,3301848,CDM,250,RC,,,Outpatient,,,102.12,102.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.48,70,,57.18,percent of total billed charges,70% of total billed charges for outpatient setting,86.68,84.88,,69.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.06,50,,40.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.59,75,,61.27,percent of total billed charges,75% of total billed charges for outpatient setting,71.48,70,,57.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,12.84,,10.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,80,,65.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,12.84,,10.49,percent of total billed charges,12.84% of total billed charges,13.11,12.84,,10.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.38,65,,53.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.74,35,,28.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.91,90,,73.53,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,91.91,
POTASSIUM PHOS M 3MMOL/ML 15 ML INJ :,3301847,CDM,250,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
POTASSIUM PHOS M 3MMOL/ML 5ML INJ :,3301846,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
POUCH 5MM ENDO / CD003,69161221,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448,70,,358.4,percent of total billed charges,70% of total billed charges for outpatient setting,543.23,84.88,,434.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,320,50,,256,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,480,75,,384,percent of total billed charges,75% of total billed charges for outpatient setting,448,70,,358.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.18,12.84,,65.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512,80,,409.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.18,12.84,,65.74,percent of total billed charges,12.84% of total billed charges,82.18,12.84,,65.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416,65,,332.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,35,,179.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,576,90,,460.8,percent of total billed charges,90% of total billed charges for outpatient setting,82.18,576,
POUCH CLAMP / 8770,6152632,CDM,272,RC,A4421,HCPCS,Outpatient,,,6.91,6.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,70,,3.87,percent of total billed charges,70% of total billed charges for outpatient setting,5.87,84.88,,4.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,75,,4.14,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,70,,3.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,12.84,,0.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.53,80,,4.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,12.84,,0.71,percent of total billed charges,12.84% of total billed charges,0.89,12.84,,0.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.49,65,,3.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.42,35,,1.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.22,90,,4.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.89,6.22,
POUCH OSTOMY 2.25IN / 18103,6152630,CDM,272,RC,A5063,HCPCS,Outpatient,,,9.35,9.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.55,70,,5.24,percent of total billed charges,70% of total billed charges for outpatient setting,7.94,84.88,,6.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,75,,5.61,percent of total billed charges,75% of total billed charges for outpatient setting,6.55,70,,5.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,80,,5.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.08,65,,4.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,90,,6.74,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,8.42,
POUCH TELEMETRY MULTI LYR / 905,5150045,CDM,270,RC,,,Outpatient,,,12.26,12.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.41,84.88,,8.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.13,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.2,75,,7.36,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,80,,7.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,65,,6.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,35,,3.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.03,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.03,
POVIDINE (BETADINE) OINT 30 GM,3301849,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
POVIDONE-IODINE 10% SOLN 237 ML,3302731,CDM,259,RC,,,Outpatient,,,24.06,24.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.84,70,,13.47,percent of total billed charges,70% of total billed charges for outpatient setting,20.42,84.88,,16.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.03,50,,9.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.05,75,,14.44,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,70,,13.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.25,80,,15.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.64,65,,12.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,35,,6.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.65,90,,17.32,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,21.65,
POVIDONE-IODINE10% OINT:0.89 G,3302791,CDM,259,RC,,,Outpatient,,,4.12,4.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,70,,2.3,percent of total billed charges,70% of total billed charges for outpatient setting,3.5,84.88,,2.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.06,50,,1.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.09,75,,2.47,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,70,,2.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.3,80,,2.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.68,65,,2.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,35,,1.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.71,90,,2.97,percent of total billed charges,90% of total billed charges for outpatient setting,0.53,3.71,
PPD SKIN TEST,5150300,CDM,302,RC,86580,HCPCS,Outpatient,,,38.17,34.35,,35.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,26.72,70,,21.38,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,84.88,,25.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.63,75,,22.9,percent of total billed charges,75% of total billed charges for outpatient setting,26.72,70,,21.38,percent of total billed charges,70% of total billed charges for outpatient setting,37.63,170,,,Fee Schedule,170% of Medicare OPPS rate,47.59,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.74,175,,,Fee Schedule,175% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.54,80,,24.43,percent of total billed charges,80% of total billed charges for outpatient setting,30.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,27.67,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14.87,100,,,Fee Schedule,100% of Custom Fee Schedule,34.35,90,,27.48,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,47.59,
PRAM HC (ANUSOL) 1% OINT : 1 OZ,3301850,CDM,259,RC,,,Outpatient,,,12.02,12.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,70,,6.73,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,84.88,,8.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.01,50,,4.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.02,75,,7.22,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,70,,6.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.62,80,,7.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,1.54,12.84,,1.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.81,65,,6.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,35,,3.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.82,90,,8.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.54,10.82,
PRAMIPEXOLE (MIRAPEX) 0.25 MG TAB :,3301851,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PRAMIPEXOLE (MIRAPEX) 0.5 MG TAB :,3301852,CDM,259,RC,,,Outpatient,,,5.8,5.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.06,70,,3.25,percent of total billed charges,70% of total billed charges for outpatient setting,4.92,84.88,,3.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.9,50,,2.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.35,75,,3.48,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,70,,3.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,80,,3.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.77,65,,3.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,35,,1.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.22,90,,4.18,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.22,
PRAMIPEXOLE (MIRAPEX) 1 MG TAB :,3301853,CDM,259,RC,,,Outpatient,,,5.47,5.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.64,84.88,,3.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.74,50,,2.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.38,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.56,65,,2.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.92,90,,3.94,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.92,
PRAMIPEXOLE (MIRAPEX) 1 MG TAB:UD,3301854,CDM,259,RC,,,Outpatient,,,6.07,6.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,70,,3.4,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,84.88,,4.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.04,50,,2.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.55,75,,3.64,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,70,,3.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,80,,3.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.95,65,,3.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,35,,1.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.46,90,,4.37,percent of total billed charges,90% of total billed charges for outpatient setting,0.78,5.46,
PRAMIPEXOLE dihcl(genMIRAPEX) 0.25MG TAB,3314015,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
PRAMOSONE LOTION 2.5%: 2OZ,3303115,CDM,259,RC,,,Outpatient,,,168.5,168.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.95,70,,94.36,percent of total billed charges,70% of total billed charges for outpatient setting,143.02,84.88,,114.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.25,50,,67.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.38,75,,101.1,percent of total billed charges,75% of total billed charges for outpatient setting,117.95,70,,94.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,12.84,,17.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.8,80,,107.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,12.84,,17.31,percent of total billed charges,12.84% of total billed charges,21.64,12.84,,17.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.53,65,,87.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.98,35,,47.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.65,90,,121.32,percent of total billed charges,90% of total billed charges for outpatient setting,21.64,151.65,
PRANDIN (REPAGLINIDE) 0.5 MG: TAB,3303111,CDM,259,RC,,,Outpatient,,,15.19,15.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,12.89,84.88,,10.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.6,50,,6.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.39,75,,9.11,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,80,,9.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.87,65,,7.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.32,35,,4.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.67,90,,10.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.95,13.67,
PRASUGREL GEN (EFFIENT) 10MG TAB,3314230,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PRAVACHOL 40MG TAB,3303018,CDM,259,RC,,,Outpatient,,,15.72,15.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11,70,,8.8,percent of total billed charges,70% of total billed charges for outpatient setting,13.34,84.88,,10.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.86,50,,6.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.79,75,,9.43,percent of total billed charges,75% of total billed charges for outpatient setting,11,70,,8.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,80,,10.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.22,65,,8.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,35,,4.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.15,90,,11.32,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.15,
PRAVASTATIN(PRAVACHOL)10MG TAB,3305103,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PRAZOSIN (MINIPRESS) 1 MG CAP :,3301855,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PRAZOSIN (MINIPRESS) 5 MG CAP :,3301856,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PREALBUMIN,220157,CDM,301,RC,84134,HCPCS,Outpatient,,,65.66,59.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.96,70,,36.77,percent of total billed charges,70% of total billed charges for outpatient setting,55.73,84.88,,44.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.05,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.25,75,,39.4,percent of total billed charges,75% of total billed charges for outpatient setting,45.96,70,,36.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.53,80,,42.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,100,,,Fee Schedule,100% of Custom Fee Schedule,59.09,90,,47.27,percent of total billed charges,90% of total billed charges for outpatient setting,6.81,59.09,
PRECEDEX (DEXMEDETOMIDINE)200microgm/2ml,3314325,CDM,250,RC,,,Outpatient,,,26.19,26.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,22.23,84.88,,17.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.1,50,,10.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.64,75,,15.71,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,70,,14.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.95,80,,16.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.02,65,,13.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,35,,7.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.57,90,,18.86,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,23.57,
PRECISE EZ VIEW  SINUS/T&A / EICA8875-01,69169388,CDM,272,RC,,,Outpatient,,,831.6,831.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.12,70,,465.7,percent of total billed charges,70% of total billed charges for outpatient setting,705.86,84.88,,564.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,415.8,50,,332.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,623.7,75,,498.96,percent of total billed charges,75% of total billed charges for outpatient setting,582.12,70,,465.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.78,12.84,,85.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.28,80,,532.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.78,12.84,,85.42,percent of total billed charges,12.84% of total billed charges,106.78,12.84,,85.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,540.54,65,,432.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.06,35,,232.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,748.44,90,,598.75,percent of total billed charges,90% of total billed charges for outpatient setting,106.78,748.44,
PRED-G OPTH SOL 0.3-1% : 2ML,3301157,CDM,259,RC,,,Outpatient,,,26.29,26.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,70,,14.72,percent of total billed charges,70% of total billed charges for outpatient setting,22.31,84.88,,17.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.15,50,,10.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.72,75,,15.78,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,70,,14.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,12.84,,2.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.03,80,,16.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,3.38,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.09,65,,13.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,35,,7.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.66,90,,18.93,percent of total billed charges,90% of total billed charges for outpatient setting,3.38,23.66,
PREDNISOLONE (ECONOPRED) 0.125% OPH DR:5,3301859,CDM,259,RC,,,Outpatient,,,77.73,77.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.41,70,,43.53,percent of total billed charges,70% of total billed charges for outpatient setting,65.98,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.87,50,,31.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.3,75,,46.64,percent of total billed charges,75% of total billed charges for outpatient setting,54.41,70,,43.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,12.84,,7.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.98,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.52,65,,40.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.21,35,,21.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.96,90,,55.97,percent of total billed charges,90% of total billed charges for outpatient setting,9.98,69.96,
PREDNISOLONE (MILD) 0.12% DRP:5ML,3301860,CDM,259,RC,,,Outpatient,,,71.38,71.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.97,70,,39.98,percent of total billed charges,70% of total billed charges for outpatient setting,60.59,84.88,,48.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.69,50,,28.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.54,75,,42.83,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,70,,39.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,12.84,,7.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.1,80,,45.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,12.84,,7.34,percent of total billed charges,12.84% of total billed charges,9.17,12.84,,7.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.4,65,,37.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,35,,19.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.24,90,,51.39,percent of total billed charges,90% of total billed charges for outpatient setting,9.17,64.24,
PREDNISOLONE 15/5ML SYRUP : 8 OZ,3301861,CDM,259,RC,,,Outpatient,,,225.34,225.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.74,70,,126.19,percent of total billed charges,70% of total billed charges for outpatient setting,191.27,84.88,,153.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.67,50,,90.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.01,75,,135.21,percent of total billed charges,75% of total billed charges for outpatient setting,157.74,70,,126.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,12.84,,23.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.27,80,,144.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,12.84,,23.14,percent of total billed charges,12.84% of total billed charges,28.93,12.84,,23.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,146.47,65,,117.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.87,35,,63.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,202.81,90,,162.25,percent of total billed charges,90% of total billed charges for outpatient setting,28.93,202.81,
PREDNISOLONE 15MG/5ML SYRUP :240ML,3301857,CDM,259,RC,,,Outpatient,,,203.87,203.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.71,70,,114.17,percent of total billed charges,70% of total billed charges for outpatient setting,173.04,84.88,,138.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.94,50,,81.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.9,75,,122.32,percent of total billed charges,75% of total billed charges for outpatient setting,142.71,70,,114.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.18,12.84,,20.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.1,80,,130.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.18,12.84,,20.94,percent of total billed charges,12.84% of total billed charges,26.18,12.84,,20.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.52,65,,106.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.35,35,,57.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,183.48,90,,146.78,percent of total billed charges,90% of total billed charges for outpatient setting,26.18,183.48,
PREDNISOLONE ACET 1% OPHTH SUSP 5 ML,3301858,CDM,259,RC,,,Outpatient,,,190.47,190.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.33,70,,106.66,percent of total billed charges,70% of total billed charges for outpatient setting,161.67,84.88,,129.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,95.24,50,,76.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.85,75,,114.28,percent of total billed charges,75% of total billed charges for outpatient setting,133.33,70,,106.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.46,12.84,,19.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.38,80,,121.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.46,12.84,,19.57,percent of total billed charges,12.84% of total billed charges,24.46,12.84,,19.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.81,65,,99.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.66,35,,53.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171.42,90,,137.14,percent of total billed charges,90% of total billed charges for outpatient setting,24.46,171.42,
PREDNISONE (DELTASONE) 1 MG TAB :,3301867,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PREDNISONE (DELTASONE) 20 MG TAB : U/D,3301865,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PREDNISONE (DELTASONE) 5 MG TAB :UD,3301862,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PREDNISONE (DELTASONE) 50 MG TAB : U/D,3301868,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PREDNISONE (DELTASONE) TAB : 20 MG,3301864,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PREDNISONE (DELTASONE) TAB:20MG UD,3301866,CDM,259,RC,,,Outpatient,,,13.5,13.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,70,,7.56,percent of total billed charges,70% of total billed charges for outpatient setting,11.46,84.88,,9.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,50,,5.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.13,75,,8.1,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,70,,7.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,80,,8.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.78,65,,7.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,35,,3.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.15,90,,9.72,percent of total billed charges,90% of total billed charges for outpatient setting,1.73,12.15,
PREDNISONE (genericDELTASONE)10MG TAB,3301863,CDM,259,RC,J7512,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,2.92,
PREDNISONE 5MG/5ML ORAL SOLN:120ML,3303210,CDM,259,RC,,,Outpatient,,,80.36,80.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,70,,45,percent of total billed charges,70% of total billed charges for outpatient setting,68.21,84.88,,54.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.18,50,,32.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.27,75,,48.22,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,70,,45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.29,80,,51.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,10.32,12.84,,8.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.23,65,,41.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,35,,22.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.32,90,,57.86,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,72.32,
PREG URINE QUAL,201240,CDM,300,RC,81025,HCPCS,Outpatient,,,38.75,34.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,32.89,84.88,,26.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.06,75,,23.25,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,70,,21.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,80,,24.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,100,,,Fee Schedule,100% of Custom Fee Schedule,34.88,90,,27.9,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,34.88,
PREGABALIN (genericLYRICA) 50 MG CAP,3303142,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PREGABALIN (LYRICA) 100 CAP,3306828,CDM,259,RC,,,Outpatient,,,15.19,15.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,12.89,84.88,,10.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.6,50,,6.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.39,75,,9.11,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,70,,8.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,80,,9.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,1.95,12.84,,1.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.87,65,,7.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.32,35,,4.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.67,90,,10.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.95,13.67,
PREGABALIN (LYRICA) 25MG CAP,3303110,CDM,259,RC,,,Outpatient,,,55.93,55.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,70,,31.32,percent of total billed charges,70% of total billed charges for outpatient setting,47.47,84.88,,37.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.97,50,,22.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.95,75,,33.56,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,70,,31.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,12.84,,5.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.74,80,,35.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,7.18,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.35,65,,29.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.58,35,,15.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.34,90,,40.27,percent of total billed charges,90% of total billed charges for outpatient setting,7.18,50.34,
"PREGNENOLONE, SERUM",202375,CDM,301,RC,84140,HCPCS,Outpatient,,,93.02,83.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.11,70,,52.09,percent of total billed charges,70% of total billed charges for outpatient setting,78.96,84.88,,63.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.49,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,69.77,75,,55.82,percent of total billed charges,75% of total billed charges for outpatient setting,65.11,70,,52.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.42,80,,59.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.19,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of Custom Fee Schedule,83.72,90,,66.98,percent of total billed charges,90% of total billed charges for outpatient setting,20.67,83.72,
PREMARIN VAGINAL CRM: 42.5GMS,3302797,CDM,259,RC,,,Outpatient,,,134.79,134.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.35,70,,75.48,percent of total billed charges,70% of total billed charges for outpatient setting,114.41,84.88,,91.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.4,50,,53.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.09,75,,80.87,percent of total billed charges,75% of total billed charges for outpatient setting,94.35,70,,75.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,12.84,,13.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.83,80,,86.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,12.84,,13.85,percent of total billed charges,12.84% of total billed charges,17.31,12.84,,13.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.61,65,,70.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,35,,37.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.31,90,,97.05,percent of total billed charges,90% of total billed charges for outpatient setting,17.31,121.31,
PRENATAL VIT (PRENATAL MTR) 27-1MG TAB:,3301869,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PREPARATION H SUPPOSITORIES,3313709,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PREVACID GRANULES: 30 MG,3303162,CDM,259,RC,,,Outpatient,,,22.96,22.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,19.49,84.88,,15.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.48,50,,9.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.22,75,,13.78,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,70,,12.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.37,80,,14.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,2.95,12.84,,2.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.92,65,,11.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.04,35,,6.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.66,90,,16.53,percent of total billed charges,90% of total billed charges for outpatient setting,2.95,20.66,
PREVPAC: ONE DAY THERAPY CARD,3303004,CDM,259,RC,,,Outpatient,,,88.82,88.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.17,70,,49.74,percent of total billed charges,70% of total billed charges for outpatient setting,75.39,84.88,,60.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.41,50,,35.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.62,75,,53.3,percent of total billed charges,75% of total billed charges for outpatient setting,62.17,70,,49.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,12.84,,9.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.06,80,,56.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,12.84,,9.12,percent of total billed charges,12.84% of total billed charges,11.4,12.84,,9.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.73,65,,46.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.09,35,,24.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.94,90,,63.95,percent of total billed charges,90% of total billed charges for outpatient setting,11.4,79.94,
PRIMIDONE,201489,CDM,300,RC,80188,HCPCS,Outpatient,,,74.66,67.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.26,70,,41.81,percent of total billed charges,70% of total billed charges for outpatient setting,63.37,84.88,,50.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56,75,,44.8,percent of total billed charges,75% of total billed charges for outpatient setting,52.26,70,,41.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.73,80,,47.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.47,100,,,Fee Schedule,100% of Custom Fee Schedule,67.19,90,,53.75,percent of total billed charges,90% of total billed charges for outpatient setting,16.59,67.19,
PRIMIDONE (MYSOLINE) 250 MG TAB :,3301871,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PRIMIDONE (MYSOLINE) 50 MG TAB :,3301870,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PRINEO SKIN CLOSE SYS DERMBND / CLR222US,69162193,CDM,272,RC,,,Outpatient,,,341.97,341.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.38,70,,191.5,percent of total billed charges,70% of total billed charges for outpatient setting,290.26,84.88,,232.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,170.99,50,,136.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.48,75,,205.18,percent of total billed charges,75% of total billed charges for outpatient setting,239.38,70,,191.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.91,12.84,,35.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.58,80,,218.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.91,12.84,,35.13,percent of total billed charges,12.84% of total billed charges,43.91,12.84,,35.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,222.28,65,,177.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.69,35,,95.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,307.77,90,,246.22,percent of total billed charges,90% of total billed charges for outpatient setting,43.91,307.77,
PRISTIQ ER TAB : 50MG,3303307,CDM,259,RC,,,Outpatient,,,15.23,15.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,70,,8.53,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,84.88,,10.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.62,50,,6.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.42,75,,9.14,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,70,,8.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.84,,1.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.18,80,,9.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.84,,1.57,percent of total billed charges,12.84% of total billed charges,1.96,12.84,,1.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.9,65,,7.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.33,35,,4.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.71,90,,10.97,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,13.71,
PROBE 2.3MM APC / 20132-214,71000103,CDM,272,RC,,,Outpatient,,,875.8,875.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.06,70,,490.45,percent of total billed charges,70% of total billed charges for outpatient setting,743.38,84.88,,594.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,437.9,50,,350.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,656.85,75,,525.48,percent of total billed charges,75% of total billed charges for outpatient setting,613.06,70,,490.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.45,12.84,,89.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.64,80,,560.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.45,12.84,,89.96,percent of total billed charges,12.84% of total billed charges,112.45,12.84,,89.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.27,65,,455.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.53,35,,245.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,788.22,90,,630.58,percent of total billed charges,90% of total billed charges for outpatient setting,112.45,788.22,
PROBE 2.3MM CIRC FIAPC / 20132-218,71000141,CDM,272,RC,,,Outpatient,,,971.2,971.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,679.84,70,,543.87,percent of total billed charges,70% of total billed charges for outpatient setting,824.35,84.88,,659.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,485.6,50,,388.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,728.4,75,,582.72,percent of total billed charges,75% of total billed charges for outpatient setting,679.84,70,,543.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.7,12.84,,99.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,776.96,80,,621.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.7,12.84,,99.76,percent of total billed charges,12.84% of total billed charges,124.7,12.84,,99.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.28,65,,505.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.92,35,,271.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,874.08,90,,699.26,percent of total billed charges,90% of total billed charges for outpatient setting,124.7,874.08,
PROBE 7FR GOLD / M00560071,495251,CDM,272,RC,,,Outpatient,,,683.4,683.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.38,70,,382.7,percent of total billed charges,70% of total billed charges for outpatient setting,580.07,84.88,,464.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,341.7,50,,273.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,512.55,75,,410.04,percent of total billed charges,75% of total billed charges for outpatient setting,478.38,70,,382.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,12.84,,70.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.72,80,,437.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,12.84,,70.2,percent of total billed charges,12.84% of total billed charges,87.75,12.84,,70.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,444.21,65,,355.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.19,35,,191.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,615.06,90,,492.05,percent of total billed charges,90% of total billed charges for outpatient setting,87.75,615.06,
PROBE 8IN INSULATED / 675.706S,296854,CDM,272,RC,,,Outpatient,,,1592,1592,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.4,70,,891.52,percent of total billed charges,70% of total billed charges for outpatient setting,1351.29,84.88,,1081.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,796,50,,636.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1194,75,,955.2,percent of total billed charges,75% of total billed charges for outpatient setting,1114.4,70,,891.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.6,80,,1018.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,204.41,12.84,,163.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1034.8,65,,827.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.2,35,,445.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1432.8,90,,1146.24,percent of total billed charges,90% of total billed charges for outpatient setting,204.41,1432.8,
PROBE 90 DEG APOLLO RF / AR-9811,69162608,CDM,272,RC,,,Outpatient,,,798,798,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.6,70,,446.88,percent of total billed charges,70% of total billed charges for outpatient setting,677.34,84.88,,541.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,399,50,,319.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,598.5,75,,478.8,percent of total billed charges,75% of total billed charges for outpatient setting,558.6,70,,446.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.46,12.84,,81.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638.4,80,,510.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.46,12.84,,81.97,percent of total billed charges,12.84% of total billed charges,102.46,12.84,,81.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,518.7,65,,414.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.3,35,,223.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,718.2,90,,574.56,percent of total billed charges,90% of total billed charges for outpatient setting,102.46,718.2,
PROBE ALOKA  ALPHA 6 ROBOTIC,69169797,CDM,272,RC,,,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1820,65,,1456,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2520,90,,2016,percent of total billed charges,90% of total billed charges for outpatient setting,359.52,2520,
PROBE BK ROBOTIC / 671,71000101,CDM,272,RC,,,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1820,65,,1456,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2520,90,,2016,percent of total billed charges,90% of total billed charges for outpatient setting,359.52,2520,
PROBE BK5000 ROBOTIC / 742,71000081,CDM,272,RC,,,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1960,70,,1568,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1820,65,,1456,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2520,90,,2016,percent of total billed charges,90% of total billed charges for outpatient setting,359.52,2520,
PROBE COVER  5 x 72  DISCONTINUED,6152905,CDM,272,RC,,,Outpatient,,,51.47,51.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.03,70,,28.82,percent of total billed charges,70% of total billed charges for outpatient setting,43.69,84.88,,34.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.74,50,,20.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.6,75,,30.88,percent of total billed charges,75% of total billed charges for outpatient setting,36.03,70,,28.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,12.84,,5.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,80,,32.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,12.84,,5.29,percent of total billed charges,12.84% of total billed charges,6.61,12.84,,5.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.46,65,,26.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.01,35,,14.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.32,90,,37.06,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,46.32,
PROBE INCREMENTING W/STND PRASS TI NIMS,69161671,CDM,272,RC,,,Outpatient,,,758.52,758.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.96,70,,424.77,percent of total billed charges,70% of total billed charges for outpatient setting,643.83,84.88,,515.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,379.26,50,,303.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.89,75,,455.11,percent of total billed charges,75% of total billed charges for outpatient setting,530.96,70,,424.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.39,12.84,,77.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.82,80,,485.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.39,12.84,,77.91,percent of total billed charges,12.84% of total billed charges,97.39,12.84,,77.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,493.04,65,,394.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.48,35,,212.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,682.67,90,,546.14,percent of total billed charges,90% of total billed charges for outpatient setting,97.39,682.67,
PROBE NANOSCOPE / AR-10100N,69169542,CDM,272,RC,,,Outpatient,,,651,651,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.7,70,,364.56,percent of total billed charges,70% of total billed charges for outpatient setting,552.57,84.88,,442.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,325.5,50,,260.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,488.25,75,,390.6,percent of total billed charges,75% of total billed charges for outpatient setting,455.7,70,,364.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.59,12.84,,66.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.8,80,,416.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.59,12.84,,66.87,percent of total billed charges,12.84% of total billed charges,83.59,12.84,,66.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,423.15,65,,338.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.85,35,,182.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,585.9,90,,468.72,percent of total billed charges,90% of total billed charges for outpatient setting,83.59,585.9,
PROBE PEDIGUARD 3.2MM / P1-AU412,69162335,CDM,272,RC,,,Outpatient,,,2760,2760,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1932,70,,1545.6,percent of total billed charges,70% of total billed charges for outpatient setting,2342.69,84.88,,1874.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,1380,50,,1104,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2070,75,,1656,percent of total billed charges,75% of total billed charges for outpatient setting,1932,70,,1545.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.38,12.84,,283.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2208,80,,1766.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.38,12.84,,283.5,percent of total billed charges,12.84% of total billed charges,354.38,12.84,,283.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1794,65,,1435.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966,35,,772.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2484,90,,1987.2,percent of total billed charges,90% of total billed charges for outpatient setting,354.38,2484,
PROBE PEDIGUARD CURV XS / P1-AU451,69162413,CDM,272,RC,,,Outpatient,,,2760,2760,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1932,70,,1545.6,percent of total billed charges,70% of total billed charges for outpatient setting,2342.69,84.88,,1874.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,1380,50,,1104,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2070,75,,1656,percent of total billed charges,75% of total billed charges for outpatient setting,1932,70,,1545.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.38,12.84,,283.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2208,80,,1766.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.38,12.84,,283.5,percent of total billed charges,12.84% of total billed charges,354.38,12.84,,283.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1794,65,,1435.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966,35,,772.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2484,90,,1987.2,percent of total billed charges,90% of total billed charges for outpatient setting,354.38,2484,
PROBE PULSE OX ADULT/0600-00-0043-01,6151032,CDM,272,RC,,,Outpatient,,,100.74,100.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,70,,56.42,percent of total billed charges,70% of total billed charges for outpatient setting,85.51,84.88,,68.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.37,50,,40.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.56,75,,60.45,percent of total billed charges,75% of total billed charges for outpatient setting,70.52,70,,56.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,12.84,,10.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,80,,64.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,12.84,,10.35,percent of total billed charges,12.84% of total billed charges,12.94,12.84,,10.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.48,65,,52.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,35,,28.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.67,90,,72.54,percent of total billed charges,90% of total billed charges for outpatient setting,12.94,90.67,
PROBE PULSE OX PEDI/0600-00-0044-01,6151031,CDM,272,RC,,,Outpatient,,,135.42,135.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.79,70,,75.83,percent of total billed charges,70% of total billed charges for outpatient setting,114.94,84.88,,91.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.71,50,,54.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.57,75,,81.26,percent of total billed charges,75% of total billed charges for outpatient setting,94.79,70,,75.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,12.84,,13.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.34,80,,86.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,12.84,,13.91,percent of total billed charges,12.84% of total billed charges,17.39,12.84,,13.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.02,65,,70.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.4,35,,37.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.88,90,,97.5,percent of total billed charges,90% of total billed charges for outpatient setting,17.39,121.88,
PROBENECID (BENEMID) 500 MG TAB :,3301872,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROBLOC NDL INSUL STM 19G / PL19100GC,69162016,CDM,272,RC,,,Outpatient,,,170.34,170.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.24,70,,95.39,percent of total billed charges,70% of total billed charges for outpatient setting,144.58,84.88,,115.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.17,50,,68.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.76,75,,102.21,percent of total billed charges,75% of total billed charges for outpatient setting,119.24,70,,95.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.87,12.84,,17.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,80,,109.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.87,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,21.87,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.72,65,,88.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.62,35,,47.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.31,90,,122.65,percent of total billed charges,90% of total billed charges for outpatient setting,21.87,153.31,
PROBLOC NEEDLE 22Gx50MM / PB22050GC,69162600,CDM,272,RC,,,Outpatient,,,143.3,143.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.31,70,,80.25,percent of total billed charges,70% of total billed charges for outpatient setting,121.63,84.88,,97.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.65,50,,57.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.48,75,,85.98,percent of total billed charges,75% of total billed charges for outpatient setting,100.31,70,,80.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.64,80,,91.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.15,65,,74.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,35,,40.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.97,90,,103.18,percent of total billed charges,90% of total billed charges for outpatient setting,18.4,128.97,
PROBLOC NEEDLE INSUL 20GX150MM,69162154,CDM,272,RC,,,Outpatient,,,83.28,83.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.3,70,,46.64,percent of total billed charges,70% of total billed charges for outpatient setting,70.69,84.88,,56.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.64,50,,33.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.46,75,,49.97,percent of total billed charges,75% of total billed charges for outpatient setting,58.3,70,,46.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,12.84,,8.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.62,80,,53.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,12.84,,8.55,percent of total billed charges,12.84% of total billed charges,10.69,12.84,,8.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.13,65,,43.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,35,,23.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,74.95,90,,59.96,percent of total billed charges,90% of total billed charges for outpatient setting,10.69,74.95,
PROBLOC NEEDLE INSUL STIM 19G,69161538,CDM,272,RC,,,Outpatient,,,143.3,143.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.31,70,,80.25,percent of total billed charges,70% of total billed charges for outpatient setting,121.63,84.88,,97.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.65,50,,57.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.48,75,,85.98,percent of total billed charges,75% of total billed charges for outpatient setting,100.31,70,,80.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.64,80,,91.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,18.4,12.84,,14.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.15,65,,74.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,35,,40.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,128.97,90,,103.18,percent of total billed charges,90% of total billed charges for outpatient setting,18.4,128.97,
PROC CATEGORY I,5100115,CDM,360,RC,,,Outpatient,,,318.19,318.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.73,70,,178.18,percent of total billed charges,70% of total billed charges for outpatient setting,270.08,84.88,,216.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.1,50,,127.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.64,75,,190.91,percent of total billed charges,75% of total billed charges for outpatient setting,222.73,70,,178.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.86,12.84,,32.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.55,80,,203.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.86,12.84,,32.69,percent of total billed charges,12.84% of total billed charges,40.86,12.84,,32.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.37,35,,89.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.37,90,,229.1,percent of total billed charges,90% of total billed charges for outpatient setting,40.86,286.37,
PROC CATEGORY II,5100120,CDM,360,RC,,,Outpatient,,,636.37,636.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,540.15,84.88,,432.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.19,50,,254.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.28,75,,381.82,percent of total billed charges,75% of total billed charges for outpatient setting,445.46,70,,356.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.1,80,,407.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,81.71,12.84,,65.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.73,35,,178.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.73,90,,458.18,percent of total billed charges,90% of total billed charges for outpatient setting,81.71,572.73,
PROC CATEGORY III,5100125,CDM,750,RC,,,Outpatient,,,954.54,954.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.18,70,,534.54,percent of total billed charges,70% of total billed charges for outpatient setting,810.21,84.88,,648.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,477.27,50,,381.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.91,75,,572.73,percent of total billed charges,75% of total billed charges for outpatient setting,668.18,70,,534.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.56,12.84,,98.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.63,80,,610.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.56,12.84,,98.05,percent of total billed charges,12.84% of total billed charges,122.56,12.84,,98.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.09,35,,267.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,859.09,90,,687.27,percent of total billed charges,90% of total billed charges for outpatient setting,122.56,859.09,
PROCAIN WITH NAPA,200070,CDM,300,RC,80192,HCPCS,Outpatient,,,75.38,67.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.77,70,,42.22,percent of total billed charges,70% of total billed charges for outpatient setting,63.98,84.88,,51.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.54,75,,45.23,percent of total billed charges,75% of total billed charges for outpatient setting,52.77,70,,42.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.3,80,,48.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.76,100,,,Fee Schedule,100% of Custom Fee Schedule,67.84,90,,54.27,percent of total billed charges,90% of total billed charges for outpatient setting,16.75,67.84,
PROCAIN WITH NAPA,220036,CDM,300,RC,80192,HCPCS,Outpatient,,,75.38,67.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.77,70,,42.22,percent of total billed charges,70% of total billed charges for outpatient setting,63.98,84.88,,51.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.54,75,,45.23,percent of total billed charges,75% of total billed charges for outpatient setting,52.77,70,,42.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.3,80,,48.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.76,100,,,Fee Schedule,100% of Custom Fee Schedule,67.84,90,,54.27,percent of total billed charges,90% of total billed charges for outpatient setting,16.75,67.84,
PROCAINAMIDE (PRONESTYL) 250 MG CAP :,3301876,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROCAINAMIDE (PRONESTYL) 500 MG  CAP :,3301878,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PROCAINAMIDE (PRONESTYL) 500 MG INJ:,3301874,CDM,250,RC,,,Outpatient,,,5.04,5.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,84.88,,3.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.52,50,,2.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.78,75,,3.02,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,70,,2.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,80,,3.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.28,65,,2.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,35,,1.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.54,90,,3.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.65,4.54,
PROCAINAMIDE 100MG/ML 10ML VIAL,3302668,CDM,636,RC,J2690,HCPCS,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.12,100,,,Fee Schedule,100% of Custom Fee Schedule,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,118.65,
PROCAINAMIDE ER (PROCANBID) 500 MG TAB:,3301877,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PROCAINAMIDE SA (PROCANBID) 500 MG TAB :,3301873,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PROCAINAMIDE SR (PROCAINAMD) 750 MG TAB:,3301875,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PROCALAMINE 3% SOLN: 1000CC,3302814,CDM,250,RC,,,Outpatient,,,173.24,173.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.27,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,147.05,84.88,,117.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.62,50,,69.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.93,75,,103.94,percent of total billed charges,75% of total billed charges for outpatient setting,121.27,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.24,12.84,,17.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.59,80,,110.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.24,12.84,,17.79,percent of total billed charges,12.84% of total billed charges,22.24,12.84,,17.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.61,65,,90.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.63,35,,48.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.92,90,,124.74,percent of total billed charges,90% of total billed charges for outpatient setting,22.24,155.92,
PROCALCITONIN,220444,CDM,301,RC,84145,HCPCS,Outpatient,,,122.49,110.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.74,70,,68.59,percent of total billed charges,70% of total billed charges for outpatient setting,103.97,84.88,,83.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,91.87,75,,73.5,percent of total billed charges,75% of total billed charges for outpatient setting,85.74,70,,68.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.99,80,,78.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,27.76,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.79,100,,,Fee Schedule,100% of Custom Fee Schedule,110.24,90,,88.19,percent of total billed charges,90% of total billed charges for outpatient setting,25.57,110.24,
PROCANBID: 500 MG TAB,3302893,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
PROCEDURE CANCELLED,5000160,CDM,360,RC,,,Outpatient,,,335.72,335.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,284.96,84.88,,227.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.86,50,,134.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.79,75,,201.43,percent of total billed charges,75% of total billed charges for outpatient setting,235,70,,188,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.58,80,,214.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,43.11,12.84,,34.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.5,35,,94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.15,90,,241.72,percent of total billed charges,90% of total billed charges for outpatient setting,43.11,302.15,
PROCEDURE PERFORMED IN ASU,5050500,CDM,360,RC,,,Outpatient,,,1409.14,1409.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,986.4,70,,789.12,percent of total billed charges,70% of total billed charges for outpatient setting,1196.08,84.88,,956.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,704.57,50,,563.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1056.86,75,,845.49,percent of total billed charges,75% of total billed charges for outpatient setting,986.4,70,,789.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.93,12.84,,144.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.31,80,,901.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.93,12.84,,144.74,percent of total billed charges,12.84% of total billed charges,180.93,12.84,,144.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.2,35,,394.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.23,90,,1014.58,percent of total billed charges,90% of total billed charges for outpatient setting,180.93,1268.23,
PROCHLORP (COMPAZINE) 10 MG TAB :,3301882,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROCHLORP (COMPAZINE) 25 MG SUPP :,3301884,CDM,259,RC,,,Outpatient,,,8.86,8.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,70,,4.96,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,84.88,,6.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.43,50,,3.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.65,75,,5.32,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,70,,4.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,80,,5.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.76,65,,4.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.1,35,,2.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.97,90,,6.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,7.97,
PROCHLORP (COMPAZINE) 5 MG SUPP :,3301885,CDM,259,RC,,,Outpatient,,,8.17,8.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,70,,4.58,percent of total billed charges,70% of total billed charges for outpatient setting,6.93,84.88,,5.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.09,50,,3.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.13,75,,4.9,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,70,,4.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,80,,5.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,1.05,12.84,,0.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.31,65,,4.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.86,35,,2.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.35,90,,5.88,percent of total billed charges,90% of total billed charges for outpatient setting,1.05,7.35,
PROCHLORP (COMPAZINE) 5 MG TAB :,3301883,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PROCHLORP (COMPAZINE) 5 MG TAB : U/D,3301886,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROCHLORP (COMPAZINE) 5 MG/ML INJ : 2 ML,3301880,CDM,250,RC,,,Outpatient,,,9.83,9.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,8.34,84.88,,6.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.92,50,,3.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.37,75,,5.9,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,70,,5.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,80,,6.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.39,65,,5.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,35,,2.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.85,90,,7.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.26,8.85,
PROCHLORP (COMPAZINE) 5MG/ML INJ  2 ML,3301881,CDM,636,RC,J0780,HCPCS,Outpatient,,,47.7,47.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,70,,26.71,percent of total billed charges,70% of total billed charges for outpatient setting,40.49,84.88,,32.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,35.78,75,,28.62,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,70,,26.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,12.84,,4.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.16,80,,30.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,6.12,12.84,,4.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.01,65,,24.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,100,,,Fee Schedule,100% of Custom Fee Schedule,42.93,90,,34.34,percent of total billed charges,90% of total billed charges for outpatient setting,4.13,42.93,
PROCHLORP (COMPAZINE) 5MG/ML INJ : 10 ML,3301879,CDM,250,RC,,,Outpatient,,,110.53,110.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.37,70,,61.9,percent of total billed charges,70% of total billed charges for outpatient setting,93.82,84.88,,75.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.27,50,,44.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.9,75,,66.32,percent of total billed charges,75% of total billed charges for outpatient setting,77.37,70,,61.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.19,12.84,,11.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.42,80,,70.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.19,12.84,,11.35,percent of total billed charges,12.84% of total billed charges,14.19,12.84,,11.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.84,65,,57.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.69,35,,30.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.48,90,,79.58,percent of total billed charges,90% of total billed charges for outpatient setting,14.19,99.48,
PROGESTERONE,220251,CDM,301,RC,84144,HCPCS,Outpatient,,,93.87,84.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.71,70,,52.57,percent of total billed charges,70% of total billed charges for outpatient setting,79.68,84.88,,63.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,70.4,75,,56.32,percent of total billed charges,75% of total billed charges for outpatient setting,65.71,70,,52.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.1,80,,60.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,30.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.56,100,,,Fee Schedule,100% of Custom Fee Schedule,84.48,90,,67.58,percent of total billed charges,90% of total billed charges for outpatient setting,20.86,84.48,
PROINSULIN,220078,CDM,301,RC,84206,HCPCS,Outpatient,,,120.11,108.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.08,70,,67.26,percent of total billed charges,70% of total billed charges for outpatient setting,101.95,84.88,,81.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,90.08,75,,72.06,percent of total billed charges,75% of total billed charges for outpatient setting,84.08,70,,67.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.09,80,,76.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.78,100,,,Fee Schedule,100% of Custom Fee Schedule,108.1,90,,86.48,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,108.1,
PROLACTIN,220447,CDM,301,RC,84146,HCPCS,Outpatient,,,87.21,78.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,70,,48.84,percent of total billed charges,70% of total billed charges for outpatient setting,74.02,84.88,,59.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.27,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.41,75,,52.33,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,70,,48.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.77,80,,55.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,100,,,Fee Schedule,100% of Custom Fee Schedule,78.49,90,,62.79,percent of total billed charges,90% of total billed charges for outpatient setting,19.38,78.49,
PROLENE 0 CT-1 / 8424H,69162275,CDM,272,RC,,,Outpatient,,,17.55,17.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,84.88,,11.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.78,50,,7.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.16,75,,10.53,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,80,,11.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.41,65,,9.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,35,,4.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.8,90,,12.64,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,15.8,
PROLEX-D GENERIC,3303074,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
PROMETHAZINE (genPHENERGAN) 25MG INJ 1ML,3301890,CDM,250,RC,J2550,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PROMETHAZINE (genPHENERGAN) TAB 25MG,3302798,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PROMETHAZINE (PHENERGAN) 25 MG TAB :,3301887,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
PROMETHAZINE (PHENERGAN) 50 MG INJ :,3301889,CDM,250,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
PROMETHAZINE (PHENERGAN) 50MG/ML INJ:1ML,3301888,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PROMETHAZINE 6.25 MG/5ML:120 ML,3302955,CDM,259,RC,,,Outpatient,,,16.64,16.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.65,70,,9.32,percent of total billed charges,70% of total billed charges for outpatient setting,14.12,84.88,,11.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.32,50,,6.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.48,75,,9.98,percent of total billed charges,75% of total billed charges for outpatient setting,11.65,70,,9.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.31,80,,10.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,2.14,12.84,,1.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.82,65,,8.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,35,,4.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.98,90,,11.98,percent of total billed charges,90% of total billed charges for outpatient setting,2.14,14.98,
PROMETHAZINE GEL 25mg/ml,3302919,CDM,259,RC,Q0169,HCPCS,Outpatient,,,66.15,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,56.15,84.88,,44.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.61,75,,39.69,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,70,,37.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,80,,42.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,8.49,12.84,,6.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43,65,,34.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.54,90,,47.63,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,59.54,
PROMETHAZINE(PHENERGAN) 12.5 MG SUPP:,3302653,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROMETHAZINE(PHENERGAN)25MG SUPP,3302651,CDM,259,RC,,,Outpatient,,,35.11,35.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,70,,19.66,percent of total billed charges,70% of total billed charges for outpatient setting,29.8,84.88,,23.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.56,50,,14.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,75,,21.06,percent of total billed charges,75% of total billed charges for outpatient setting,24.58,70,,19.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,12.84,,3.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.09,80,,22.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.51,12.84,,3.61,percent of total billed charges,12.84% of total billed charges,4.51,12.84,,3.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.82,65,,18.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,35,,9.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.6,90,,25.28,percent of total billed charges,90% of total billed charges for outpatient setting,4.51,31.6,
PROMETHAZINE(PHENERGAN)50 MG SUPP:,3302652,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PRONE KIT-PKIT SST LPV PILLOW/ARM PAD,69162266,CDM,271,RC,,,Outpatient,,,230.79,230.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.55,70,,129.24,percent of total billed charges,70% of total billed charges for outpatient setting,195.89,84.88,,156.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.4,50,,92.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.09,75,,138.47,percent of total billed charges,75% of total billed charges for outpatient setting,161.55,70,,129.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,12.84,,23.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.63,80,,147.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,12.84,,23.7,percent of total billed charges,12.84% of total billed charges,29.63,12.84,,23.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.01,65,,120.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.78,35,,64.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.71,90,,166.17,percent of total billed charges,90% of total billed charges for outpatient setting,29.63,207.71,
PROPAFENONE(RYTHMOL SR) : 225MG,3303291,CDM,259,RC,,,Outpatient,,,16.96,16.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,70,,9.5,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,84.88,,11.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.48,50,,6.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.72,75,,10.18,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,70,,9.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,80,,10.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.02,65,,8.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.94,35,,4.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.26,90,,12.21,percent of total billed charges,90% of total billed charges for outpatient setting,2.18,15.26,
PROPAFENONE(RYTHMOL) : 150 MG,3302909,CDM,259,RC,,,Outpatient,,,8.76,8.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.13,70,,4.9,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,84.88,,5.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.38,50,,3.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.57,75,,5.26,percent of total billed charges,75% of total billed charges for outpatient setting,6.13,70,,4.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,80,,5.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.12,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.69,65,,4.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,35,,2.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.88,90,,6.3,percent of total billed charges,90% of total billed charges for outpatient setting,1.12,7.88,
PROPANTHELINE (PRO-BANTHINE) 15 MG TAB:,3301891,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PROPANTHELINE (PRO-BANTHINE) TAB 15MG:UD,3301892,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
PROPARACAINE (ALCAINE) 0.5% 15ML DROP:,3301893,CDM,259,RC,,,Outpatient,,,23.39,23.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.37,70,,13.1,percent of total billed charges,70% of total billed charges for outpatient setting,19.85,84.88,,15.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.7,50,,9.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.54,75,,14.03,percent of total billed charges,75% of total billed charges for outpatient setting,16.37,70,,13.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.71,80,,14.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,3,12.84,,2.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.2,65,,12.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,35,,6.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.05,90,,16.84,percent of total billed charges,90% of total billed charges for outpatient setting,3,21.05,
PROPARACAINE (genALCAINE) 0.5% DROP 15ML,3301894,CDM,259,RC,,,Outpatient,,,144.8,144.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.36,70,,81.09,percent of total billed charges,70% of total billed charges for outpatient setting,122.91,84.88,,98.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.4,50,,57.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.6,75,,86.88,percent of total billed charges,75% of total billed charges for outpatient setting,101.36,70,,81.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.59,12.84,,14.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.84,80,,92.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.59,12.84,,14.87,percent of total billed charges,12.84% of total billed charges,18.59,12.84,,14.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.12,65,,75.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.68,35,,40.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.32,90,,104.26,percent of total billed charges,90% of total billed charges for outpatient setting,18.59,130.32,
PROPEL 23MM / 70011,69162262,CDM,278,RC,C2625,HCPCS,Outpatient,,,3122.84,3122.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1873.7,60,,1498.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2650.67,84.88,,2120.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2342.13,75,,1873.7,percent of total billed charges,75% of total billed charges for outpatient setting,1561.42,50,,1249.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.97,12.84,,320.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2498.27,80,,1998.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.97,12.84,,320.78,percent of total billed charges,12.84% of total billed charges,400.97,12.84,,320.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3278.98,105,,2623.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.99,35,,874.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1873.7,60,,1498.96,percent of total billed charges,60% of total billed charges for outpatient setting,400.97,3278.98,
PROPOFOL  10MG/ML INJ 50ML,3301896,CDM,250,RC,,,Outpatient,,,278.16,278.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.71,70,,155.77,percent of total billed charges,70% of total billed charges for outpatient setting,236.1,84.88,,188.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,139.08,50,,111.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.62,75,,166.9,percent of total billed charges,75% of total billed charges for outpatient setting,194.71,70,,155.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.72,12.84,,28.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.53,80,,178.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.72,12.84,,28.58,percent of total billed charges,12.84% of total billed charges,35.72,12.84,,28.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.8,65,,144.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.36,35,,77.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,250.34,90,,200.27,percent of total billed charges,90% of total billed charges for outpatient setting,35.72,250.34,
PROPOFOL 10MG/ML INJ 20 ML,3301895,CDM,636,RC,J2704,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.11,2.78,
PROPOFOL 10MG/ML INJ 50ML,3305570,CDM,636,RC,J2704,HCPCS,Outpatient,,,41.22,41.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.85,70,,23.08,percent of total billed charges,70% of total billed charges for outpatient setting,34.99,84.88,,27.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.92,75,,24.74,percent of total billed charges,75% of total billed charges for outpatient setting,28.85,70,,23.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.98,80,,26.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.79,65,,21.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,100,,,Fee Schedule,100% of Custom Fee Schedule,37.1,90,,29.68,percent of total billed charges,90% of total billed charges for outpatient setting,0.11,37.1,
PROPOFOL 10MG/ML INJ: 100ML,3309431,CDM,636,RC,J2704,HCPCS,Outpatient,,,38.77,38.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,32.91,84.88,,26.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.08,75,,23.26,percent of total billed charges,75% of total billed charges for outpatient setting,27.14,70,,21.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,80,,24.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,4.98,12.84,,3.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.2,65,,20.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,100,,,Fee Schedule,100% of Custom Fee Schedule,34.89,90,,27.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.11,34.89,
PROPOXYPHENE (DARVOCET-N) 100MG TAB: U/D,3301897,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PROPOXYPHENE (DARVON) :65 MG,3302792,CDM,259,RC,,,Outpatient,,,17.19,17.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,14.59,84.88,,11.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.6,50,,6.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.89,75,,10.31,percent of total billed charges,75% of total billed charges for outpatient setting,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,80,,11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.17,65,,8.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,35,,4.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.47,90,,12.38,percent of total billed charges,90% of total billed charges for outpatient setting,2.21,15.47,
PROPRANOLOL (INDERAL SA) 80MG CAP:,3301901,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROPRANOLOL (INDERAL) 1 MG AMP,3301902,CDM,636,RC,J1800,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.12,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,9.12,
PROPRANOLOL (INDERAL) 10 MG TAB :,3301899,CDM,259,RC,,,Outpatient,,,12.26,12.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.41,84.88,,8.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.13,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.2,75,,7.36,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,80,,7.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,65,,6.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,35,,3.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.03,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.03,
PROPRANOLOL (INDERAL) 40MG TAB,3301900,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PRO-PREDICT HACA,200049,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
PROPYLTHIOURACIL TAB: 50 MG,3301903,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PROSTATIC ACID PHOSPHATASE PAP,220202,CDM,301,RC,84066,HCPCS,Outpatient,,,43.47,39.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,36.9,84.88,,29.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.6,75,,26.08,percent of total billed charges,75% of total billed charges for outpatient setting,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.78,80,,27.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.32,100,,,Fee Schedule,100% of Custom Fee Schedule,39.12,90,,31.3,percent of total billed charges,90% of total billed charges for outpatient setting,9.66,39.12,
PROSTHESIS 22CM SCROTAL / ES2922,1438622,CDM,278,RC,C1813,HCPCS,Outpatient,,,27457.5,27457.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16474.5,60,,13179.6,percent of total billed charges,60% of total Billed charges for outpatient setting,23305.93,84.88,,18644.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20593.13,75,,16474.5,percent of total billed charges,75% of total billed charges for outpatient setting,13728.75,50,,10983,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3525.54,12.84,,2820.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21966,80,,17572.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3525.54,12.84,,2820.43,percent of total billed charges,12.84% of total billed charges,3525.54,12.84,,2820.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28830.38,105,,23064.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9610.13,35,,7688.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16474.5,60,,13179.6,percent of total billed charges,60% of total billed charges for outpatient setting,3525.54,28830.38,
PROTAMINE SULF 10MG/ML  INJ 25ML,3301904,CDM,636,RC,J2720,HCPCS,Outpatient,,,157.19,157.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,70,,88.02,percent of total billed charges,70% of total billed charges for outpatient setting,133.42,84.88,,106.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,117.89,75,,94.31,percent of total billed charges,75% of total billed charges for outpatient setting,110.03,70,,88.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.18,12.84,,16.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,80,,100.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.18,12.84,,16.14,percent of total billed charges,12.84% of total billed charges,20.18,12.84,,16.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.17,65,,81.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,100,,,Fee Schedule,100% of Custom Fee Schedule,141.47,90,,113.18,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,141.47,
PROTECTOR EXTREMITY XODUS / 40433,1741488,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,101.86,84.88,,81.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,60,50,,48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,75,,72,percent of total billed charges,75% of total billed charges for outpatient setting,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,80,,76.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78,65,,62.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,35,,33.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108,90,,86.4,percent of total billed charges,90% of total billed charges for outpatient setting,15.41,108,
PROTEIN C ACTIVITY LEVEL,220003,CDM,301,RC,85303,HCPCS,Outpatient,,,62.28,56.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.6,70,,34.88,percent of total billed charges,70% of total billed charges for outpatient setting,52.86,84.88,,42.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.71,75,,37.37,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,70,,34.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.82,80,,39.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.19,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.2,100,,,Fee Schedule,100% of Custom Fee Schedule,56.05,90,,44.84,percent of total billed charges,90% of total billed charges for outpatient setting,13.84,56.05,
PROTEIN C ANTIGEN,220816,CDM,300,RC,85302,HCPCS,Outpatient,,,54.05,48.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.84,70,,30.27,percent of total billed charges,70% of total billed charges for outpatient setting,45.88,84.88,,36.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.54,75,,32.43,percent of total billed charges,75% of total billed charges for outpatient setting,37.84,70,,30.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.24,80,,34.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.8,100,,,Fee Schedule,100% of Custom Fee Schedule,48.65,90,,38.92,percent of total billed charges,90% of total billed charges for outpatient setting,12.01,48.65,
PROTEIN C FUNCTIONAL,220017,CDM,301,RC,85303,HCPCS,Outpatient,,,62.28,56.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.6,70,,34.88,percent of total billed charges,70% of total billed charges for outpatient setting,52.86,84.88,,42.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.71,75,,37.37,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,70,,34.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.82,80,,39.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.19,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.2,100,,,Fee Schedule,100% of Custom Fee Schedule,56.05,90,,44.84,percent of total billed charges,90% of total billed charges for outpatient setting,13.84,56.05,
PROTEIN C RESISTANCE FACTOR LEVEL,200002,CDM,301,RC,85307,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
PROTEIN C RESISTANCE FACTOR LEVEL,220004,CDM,301,RC,85307,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
PROTEIN ELECTRO SERUM,220821,CDM,301,RC,84165,HCPCS,Outpatient,,,48.33,43.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,41.02,84.88,,32.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.25,75,,29,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,80,,30.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,100,,,Fee Schedule,100% of Custom Fee Schedule,43.5,90,,34.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,43.5,
"PROTEIN ELECTROPHOR FRACT & QUANT, CSF",200767,CDM,300,RC,84166,HCPCS,Outpatient,,,80.24,72.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.17,70,,44.94,percent of total billed charges,70% of total billed charges for outpatient setting,68.11,84.88,,54.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.18,75,,48.14,percent of total billed charges,75% of total billed charges for outpatient setting,56.17,70,,44.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.19,80,,51.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.82,100,,,Fee Schedule,100% of Custom Fee Schedule,72.22,90,,57.78,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,72.22,
PROTEIN ELECTROPHOR FRACT QUANT URINE,220302,CDM,300,RC,84166,HCPCS,Outpatient,,,80.24,72.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.17,70,,44.94,percent of total billed charges,70% of total billed charges for outpatient setting,68.11,84.88,,54.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.18,75,,48.14,percent of total billed charges,75% of total billed charges for outpatient setting,56.17,70,,44.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.19,80,,51.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.82,100,,,Fee Schedule,100% of Custom Fee Schedule,72.22,90,,57.78,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,72.22,
PROTEIN RANDOM URINE,220790,CDM,301,RC,84156,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
PROTEIN S ACTIVITY LEVEL,220005,CDM,301,RC,85306,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
"PROTEIN S, FREE ANTIGEN",220818,CDM,300,RC,85306,HCPCS,Outpatient,,,68.94,62.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,58.52,84.88,,46.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51.71,75,,41.37,percent of total billed charges,75% of total billed charges for outpatient setting,48.26,70,,38.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.15,80,,44.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.06,100,,,Fee Schedule,100% of Custom Fee Schedule,62.05,90,,49.64,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,62.05,
"PROTEIN S, TOTAL",220817,CDM,300,RC,85305,HCPCS,Outpatient,,,52.25,47.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.58,70,,29.26,percent of total billed charges,70% of total billed charges for outpatient setting,44.35,84.88,,35.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.19,75,,31.35,percent of total billed charges,75% of total billed charges for outpatient setting,36.58,70,,29.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.8,80,,33.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,100,,,Fee Schedule,100% of Custom Fee Schedule,47.03,90,,37.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,47.03,
PROTEINEX LIQUID 15gm/30ml,3314042,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
PROTEINEX LIQUID: 240 ML,3302905,CDM,259,RC,,,Outpatient,,,47.28,47.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,70,,26.48,percent of total billed charges,70% of total billed charges for outpatient setting,40.13,84.88,,32.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.64,50,,18.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.46,75,,28.37,percent of total billed charges,75% of total billed charges for outpatient setting,33.1,70,,26.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,12.84,,4.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.82,80,,30.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,6.07,12.84,,4.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.73,65,,24.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.55,35,,13.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.55,90,,34.04,percent of total billed charges,90% of total billed charges for outpatient setting,6.07,42.55,
PROTIME PT WITH INR,200285,CDM,305,RC,85610,HCPCS,Outpatient,,,19.31,17.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.52,70,,10.82,percent of total billed charges,70% of total billed charges for outpatient setting,16.39,84.88,,13.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.75,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.48,75,,11.58,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,70,,10.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,80,,12.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,100,,,Fee Schedule,100% of Custom Fee Schedule,17.38,90,,13.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.29,17.38,
PROX TENODESIS IMPL SYS / AR-2290,69162434,CDM,278,RC,C1776,HCPCS,Outpatient,,,2480.62,2480.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488.37,60,,1190.7,percent of total billed charges,60% of total Billed charges for outpatient setting,2105.55,84.88,,1684.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1860.47,75,,1488.38,percent of total billed charges,75% of total billed charges for outpatient setting,1240.31,50,,992.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.51,12.84,,254.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,80,,1587.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.51,12.84,,254.81,percent of total billed charges,12.84% of total billed charges,318.51,12.84,,254.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2604.65,105,,2083.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.22,35,,694.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1488.37,60,,1190.7,percent of total billed charges,60% of total billed charges for outpatient setting,318.51,2604.65,
PSA DIAGNOSTIC,200205,CDM,300,RC,84153,HCPCS,Outpatient,,,82.76,74.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,70.25,84.88,,56.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.07,75,,49.66,percent of total billed charges,75% of total billed charges for outpatient setting,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,80,,52.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,74.48,90,,59.58,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,74.48,
PSA SCREENING,200204,CDM,300,RC,G0103,HCPCS,Outpatient,,,86.9,78.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,73.76,84.88,,59.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.18,75,,52.14,percent of total billed charges,75% of total billed charges for outpatient setting,60.83,70,,48.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.52,80,,55.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,11.16,12.84,,8.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,78.21,90,,62.57,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,78.21,
PSA ULTRASENSITIVE,200919,CDM,300,RC,84153,HCPCS,Outpatient,,,82.76,74.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,70.25,84.88,,56.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.07,75,,49.66,percent of total billed charges,75% of total billed charges for outpatient setting,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,80,,52.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,74.48,90,,59.58,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,74.48,
"PSA, FREE PERCENTAGE FREE, TOTAL PSA",220377,CDM,300,RC,84153,HCPCS,Outpatient,,,82.76,74.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,70.25,84.88,,56.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.07,75,,49.66,percent of total billed charges,75% of total billed charges for outpatient setting,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,80,,52.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,74.48,90,,59.58,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,74.48,
"PSA, TOTAL",200520,CDM,300,RC,84153,HCPCS,Outpatient,,,82.76,74.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,70.25,84.88,,56.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.07,75,,49.66,percent of total billed charges,75% of total billed charges for outpatient setting,57.93,70,,46.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,80,,52.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,100,,,Fee Schedule,100% of Custom Fee Schedule,74.48,90,,59.58,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,74.48,
"PSEUDOCHOLINESTERASE,PLASMA",220105,CDM,301,RC,82480,HCPCS,Outpatient,,,35.42,31.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.79,70,,19.83,percent of total billed charges,70% of total billed charges for outpatient setting,30.06,84.88,,24.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.57,75,,21.26,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,70,,19.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,80,,22.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,11.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.94,100,,,Fee Schedule,100% of Custom Fee Schedule,31.88,90,,25.5,percent of total billed charges,90% of total billed charges for outpatient setting,7.87,31.88,
PSEUDOEPHED (TRIPROLID) 2.5 MG TAB :,3301906,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PSEUDOEPHEDRIN (PSEUDOEPHED) 30MG TAB:UD,3301908,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PSEUDOEPHEDRINE (PSEUDOEPHED) TAB : 30MG,3301907,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
PSEUDOEPHEDRINE 15 MG/5 ML:SOLN 120 ML,3302867,CDM,259,RC,,,Outpatient,,,30.95,30.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,70,,17.34,percent of total billed charges,70% of total billed charges for outpatient setting,26.27,84.88,,21.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.48,50,,12.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.21,75,,18.57,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,70,,17.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,80,,19.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.12,65,,16.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.83,35,,8.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.86,90,,22.29,percent of total billed charges,90% of total billed charges for outpatient setting,3.97,27.86,
PSEUDOEPHEDRINE 30 MG/5 ML:SOLN 120 ML,3302869,CDM,259,RC,,,Outpatient,,,30.95,30.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,70,,17.34,percent of total billed charges,70% of total billed charges for outpatient setting,26.27,84.88,,21.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.48,50,,12.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.21,75,,18.57,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,70,,17.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,80,,19.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,3.97,12.84,,3.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.12,65,,16.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.83,35,,8.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.86,90,,22.29,percent of total billed charges,90% of total billed charges for outpatient setting,3.97,27.86,
PSI-TEC TUBING (Lipo)  PT-5558,69161474,CDM,272,RC,,,Outpatient,,,98.42,98.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,83.54,84.88,,66.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.21,50,,39.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,75,,59.06,percent of total billed charges,75% of total billed charges for outpatient setting,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,80,,62.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.97,65,,51.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,35,,27.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.58,90,,70.86,percent of total billed charges,90% of total billed charges for outpatient setting,12.64,88.58,
PSYLLIUM (METAMUCIL) ORNG PK 5.8GMS,3301910,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
PT EVAL HIGH COMPLEXITY 45 MIN,5100274,CDM,420,RC,97163,HCPCS,Outpatient,,,373.03,373.03,,153.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,316.63,84.88,,253.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,279.77,75,,223.82,percent of total billed charges,75% of total billed charges for outpatient setting,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,328.22,170,,,Fee Schedule,170% of Medicare OPPS rate,206.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,167.79,175,,,Fee Schedule,175% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.42,80,,238.74,percent of total billed charges,80% of total billed charges for outpatient setting,134.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,119.85,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.51,100,,,Fee Schedule,100% of Custom Fee Schedule,335.73,90,,268.58,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,335.73,
PT EVAL LOW COMPLEXITY 20 MIN,5100272,CDM,420,RC,97161,HCPCS,Outpatient,,,373.03,373.03,,153.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,316.63,84.88,,253.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,279.77,75,,223.82,percent of total billed charges,75% of total billed charges for outpatient setting,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,328.22,170,,,Fee Schedule,170% of Medicare OPPS rate,206.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,167.79,175,,,Fee Schedule,175% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,298.42,80,,238.74,percent of total billed charges,80% of total billed charges for outpatient setting,134.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,119.85,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.51,100,,,Fee Schedule,100% of Custom Fee Schedule,335.73,90,,268.58,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,335.73,
PT EVAL MOD COMPLEXITY 30 MIN,5100273,CDM,420,RC,97162,HCPCS,Outpatient,,,432.6,432.6,,153.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,328.22,170,,,Fee Schedule,170% of Medicare OPPS rate,206.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,167.79,175,,,Fee Schedule,175% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,134.23,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,119.85,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,95.88,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,82.51,100,,,Fee Schedule,100% of Custom Fee Schedule,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,389.34,
PT EVALUATION,5100176,CDM,420,RC,97001,HCPCS,Outpatient,,,373.03,373.03,GP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,316.63,84.88,,253.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.52,50,,149.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.77,75,,223.82,percent of total billed charges,75% of total billed charges for outpatient setting,261.12,70,,208.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.9,12.84,,38.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.42,80,,238.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.9,12.84,,38.32,percent of total billed charges,12.84% of total billed charges,47.9,12.84,,38.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,35,,104.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,335.73,90,,268.58,percent of total billed charges,90% of total billed charges for outpatient setting,47.9,335.73,
PT GAIT TRAINING,5100174,CDM,420,RC,97116,HCPCS,Outpatient,,,157.03,157.03,,44.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,109.92,70,,87.94,percent of total billed charges,70% of total billed charges for outpatient setting,133.29,84.88,,106.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.67,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,117.77,75,,94.22,percent of total billed charges,75% of total billed charges for outpatient setting,109.92,70,,87.94,percent of total billed charges,70% of total billed charges for outpatient setting,96.29,170,,,Fee Schedule,170% of Medicare OPPS rate,60.42,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,49.18,175,,,Fee Schedule,175% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.62,80,,100.5,percent of total billed charges,80% of total billed charges for outpatient setting,39.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,35.13,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.56,100,,,Fee Schedule,100% of Custom Fee Schedule,141.33,90,,113.06,percent of total billed charges,90% of total billed charges for outpatient setting,20.16,156,
PT MECHANICAL TRACTION,5100178,CDM,420,RC,97012,HCPCS,Outpatient,,,93.95,93.95,,22.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,65.77,70,,52.62,percent of total billed charges,70% of total billed charges for outpatient setting,79.74,84.88,,63.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,70.46,75,,56.37,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,70,,52.62,percent of total billed charges,70% of total billed charges for outpatient setting,47.31,170,,,Fee Schedule,170% of Medicare OPPS rate,29.89,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.06,12.84,,9.648,percent of total billed charges,12.84% of total billed charges,24.33,175,,,Fee Schedule,175% of Medicare OPPS rate,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,75.16,80,,60.13,percent of total billed charges,80% of total billed charges for outpatient setting,19.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,17.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.06,12.84,,9.65,percent of total billed charges,12.84% of total billed charges,12.06,12.84,,9.65,percent of total billed charges,12.84% of total billed charges,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.9,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,16.56,100,,,Fee Schedule,100% of Custom Fee Schedule,84.56,90,,67.65,percent of total billed charges,90% of total billed charges for outpatient setting,12.06,156,
PT MODALITY  HOT OR COLD PACKS,5100177,CDM,420,RC,97010,HCPCS,Outpatient,,,51.65,51.65,,9.57,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,36.16,70,,28.93,percent of total billed charges,70% of total billed charges for outpatient setting,43.84,84.88,,35.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.74,75,,30.99,percent of total billed charges,75% of total billed charges for outpatient setting,36.16,70,,28.93,percent of total billed charges,70% of total billed charges for outpatient setting,20.09,170,,,Fee Schedule,170% of Medicare OPPS rate,12.86,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,6.63,12.84,,5.304,percent of total billed charges,12.84% of total billed charges,10.47,175,,,Fee Schedule,175% of Medicare OPPS rate,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,41.32,80,,33.06,percent of total billed charges,80% of total billed charges for outpatient setting,8.37,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,7.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,6.63,12.84,,5.3,percent of total billed charges,12.84% of total billed charges,6.63,12.84,,5.3,percent of total billed charges,12.84% of total billed charges,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,8.26,100,,,Fee Schedule,100% of Custom Fee Schedule,46.49,90,,37.19,percent of total billed charges,90% of total billed charges for outpatient setting,5.98,156,
PT NEUROMUSC REEDUCATION,5100173,CDM,420,RC,97112,HCPCS,Outpatient,,,182.25,182.25,,51.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,127.58,70,,102.06,percent of total billed charges,70% of total billed charges for outpatient setting,154.69,84.88,,123.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,136.69,75,,109.35,percent of total billed charges,75% of total billed charges for outpatient setting,127.58,70,,102.06,percent of total billed charges,70% of total billed charges for outpatient setting,110.77,170,,,Fee Schedule,170% of Medicare OPPS rate,69.17,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,56.3,175,,,Fee Schedule,175% of Medicare OPPS rate,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,145.8,80,,116.64,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,40.21,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,23.4,12.84,,18.72,percent of total billed charges,12.84% of total billed charges,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.17,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,164.03,90,,131.22,percent of total billed charges,90% of total billed charges for outpatient setting,23.4,164.03,
PT PROCEDURE EA 15 MINUTES,5100179,CDM,420,RC,97110,HCPCS,Outpatient,,,178.46,178.46,,44.96,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,151.48,84.88,,121.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.85,75,,107.08,percent of total billed charges,75% of total billed charges for outpatient setting,124.92,70,,99.94,percent of total billed charges,70% of total billed charges for outpatient setting,96.29,170,,,Fee Schedule,170% of Medicare OPPS rate,60.42,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.18,175,,,Fee Schedule,175% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,142.77,80,,114.22,percent of total billed charges,80% of total billed charges for outpatient setting,39.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,35.13,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,28.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,32.91,100,,,Fee Schedule,100% of Custom Fee Schedule,160.61,90,,128.49,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,160.61,
PT REEVAL 20 MIN,5100275,CDM,420,RC,97164,HCPCS,Outpatient,,,297.41,297.41,,105.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,208.19,70,,166.55,percent of total billed charges,70% of total billed charges for outpatient setting,252.44,84.88,,201.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,223.06,75,,178.45,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,70,,166.55,percent of total billed charges,70% of total billed charges for outpatient setting,225.34,170,,,Fee Schedule,170% of Medicare OPPS rate,142.2,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.75,175,,,Fee Schedule,175% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.93,80,,190.34,percent of total billed charges,80% of total billed charges for outpatient setting,92.6,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,82.68,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.83,100,,,Fee Schedule,100% of Custom Fee Schedule,267.67,90,,214.14,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,267.67,
PT REEVALUATION,5100181,CDM,420,RC,97164,HCPCS,Outpatient,,,249.29,249.29,,105.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,174.5,70,,139.6,percent of total billed charges,70% of total billed charges for outpatient setting,211.6,84.88,,169.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,79.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.97,75,,149.58,percent of total billed charges,75% of total billed charges for outpatient setting,174.5,70,,139.6,percent of total billed charges,70% of total billed charges for outpatient setting,225.34,170,,,Fee Schedule,170% of Medicare OPPS rate,142.2,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.75,175,,,Fee Schedule,175% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,199.43,80,,159.54,percent of total billed charges,80% of total billed charges for outpatient setting,92.6,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,82.68,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,66.14,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.83,100,,,Fee Schedule,100% of Custom Fee Schedule,224.36,90,,179.49,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,225.34,
PT/OT FUNCTIONAL THERAPEUTIC ACTIVITIES,5100191,CDM,430,RC,97530,HCPCS,Outpatient,,,97.22,97.22,,55.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.05,70,,54.44,percent of total billed charges,70% of total billed charges for outpatient setting,82.52,84.88,,66.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.92,75,,58.34,percent of total billed charges,75% of total billed charges for outpatient setting,68.05,70,,54.44,percent of total billed charges,70% of total billed charges for outpatient setting,119.56,170,,,Fee Schedule,170% of Medicare OPPS rate,75.01,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.06,175,,,Fee Schedule,175% of Medicare OPPS rate,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,77.78,80,,62.22,percent of total billed charges,80% of total billed charges for outpatient setting,48.85,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,43.61,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,156,100,,,Case rate,pays based on fixed rate ,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,34.89,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,35.08,100,,,Fee Schedule,100% of Custom Fee Schedule,87.5,90,,70,percent of total billed charges,90% of total billed charges for outpatient setting,8.76,156,
PTH INTACT,220301,CDM,300,RC,83970,HCPCS,Outpatient,,,185.76,167.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.03,70,,104.02,percent of total billed charges,70% of total billed charges for outpatient setting,157.67,84.88,,126.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,139.32,75,,111.46,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,70,,104.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.61,80,,118.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,60.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.27,100,,,Fee Schedule,100% of Custom Fee Schedule,167.18,90,,133.74,percent of total billed charges,90% of total billed charges for outpatient setting,41.28,167.18,
PTH-RP,220896,CDM,300,RC,82397,HCPCS,Outpatient,,,63.54,57.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,53.93,84.88,,43.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.66,75,,38.13,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,70,,35.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,80,,40.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,100% of Custom Fee Schedule,57.19,90,,45.75,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,57.19,
PTT,200300,CDM,305,RC,85730,HCPCS,Outpatient,,,27.05,24.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,70,,15.15,percent of total billed charges,70% of total billed charges for outpatient setting,22.96,84.88,,18.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.29,75,,16.23,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,70,,15.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,80,,17.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.76,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,100,,,Fee Schedule,100% of Custom Fee Schedule,24.35,90,,19.48,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,24.35,
PUDDING VARIBAR ESOPHAG / 900006,70000428,CDM,270,RC,,,Outpatient,,,203.28,203.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.3,70,,113.84,percent of total billed charges,70% of total billed charges for outpatient setting,172.54,84.88,,138.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.64,50,,81.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.46,75,,121.97,percent of total billed charges,75% of total billed charges for outpatient setting,142.3,70,,113.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.62,80,,130.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,26.1,12.84,,20.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,132.13,65,,105.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.15,35,,56.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.95,90,,146.36,percent of total billed charges,90% of total billed charges for outpatient setting,26.1,182.95,
PULL G TUBE 20FR / 6820,6050116,CDM,272,RC,,,Outpatient,,,292.01,292.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.41,70,,163.53,percent of total billed charges,70% of total billed charges for outpatient setting,247.86,84.88,,198.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.01,50,,116.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.01,75,,175.21,percent of total billed charges,75% of total billed charges for outpatient setting,204.41,70,,163.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,12.84,,29.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.61,80,,186.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,12.84,,29.99,percent of total billed charges,12.84% of total billed charges,37.49,12.84,,29.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.81,65,,151.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.2,35,,81.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,262.81,90,,210.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,262.81,
PULSE GENERATOR / MODEL 102,70000023,CDM,272,RC,,,Outpatient,,,15690,15690,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10983,70,,8786.4,percent of total billed charges,70% of total billed charges for outpatient setting,13317.67,84.88,,10654.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,7845,50,,6276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11767.5,75,,9414,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2014.6,12.84,,1611.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12552,80,,10041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2014.6,12.84,,1611.68,percent of total billed charges,12.84% of total billed charges,2014.6,12.84,,1611.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10198.5,65,,8158.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5491.5,35,,4393.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14121,90,,11296.8,percent of total billed charges,90% of total billed charges for outpatient setting,2000,14121,
PULSE OX ADULT MASIMO / 1859,755265,CDM,271,RC,,,Outpatient,,,57.12,57.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,70,,31.98,percent of total billed charges,70% of total billed charges for outpatient setting,48.48,84.88,,38.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.56,50,,22.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.84,75,,34.27,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,70,,31.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.7,80,,36.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.13,65,,29.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,35,,15.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.41,90,,41.13,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,51.41,
PULSE OX SENSOR ADUL DISP / MAXA,69160692,CDM,271,RC,E0445,HCPCS,Outpatient,,,47.11,47.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.98,70,,26.38,percent of total billed charges,70% of total billed charges for outpatient setting,39.99,84.88,,31.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.33,75,,28.26,percent of total billed charges,75% of total billed charges for outpatient setting,32.98,70,,26.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.05,12.84,,4.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,80,,30.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.05,12.84,,4.84,percent of total billed charges,12.84% of total billed charges,6.05,12.84,,4.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.62,65,,24.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,35,,13.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.4,90,,33.92,percent of total billed charges,90% of total billed charges for outpatient setting,6.05,42.4,
PULSE OX SENSOR PEDI DISP / MAXP,69160425,CDM,271,RC,,,Outpatient,,,53.69,53.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,70,,30.06,percent of total billed charges,70% of total billed charges for outpatient setting,45.57,84.88,,36.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.85,50,,21.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.27,75,,32.22,percent of total billed charges,75% of total billed charges for outpatient setting,37.58,70,,30.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,12.84,,5.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.95,80,,34.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,12.84,,5.51,percent of total billed charges,12.84% of total billed charges,6.89,12.84,,5.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.9,65,,27.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,35,,15.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.32,90,,38.66,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,48.32,
PULSEVAC PLUS FAN KIT / 210-118,6152103,CDM,270,RC,,,Outpatient,,,134.9,134.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.43,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.5,84.88,,91.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.45,50,,53.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.18,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.43,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,12.84,,13.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.92,80,,86.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,17.32,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.69,65,,70.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,35,,37.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.41,90,,97.13,percent of total billed charges,90% of total billed charges for outpatient setting,17.32,121.41,
PUMPING SYSTEM URTEROSCOPY / M0067201011,6152339,CDM,272,RC,,,Outpatient,,,260.88,260.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.62,70,,146.1,percent of total billed charges,70% of total billed charges for outpatient setting,221.43,84.88,,177.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.44,50,,104.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.66,75,,156.53,percent of total billed charges,75% of total billed charges for outpatient setting,182.62,70,,146.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.5,12.84,,26.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.7,80,,166.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.5,12.84,,26.8,percent of total billed charges,12.84% of total billed charges,33.5,12.84,,26.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,169.57,65,,135.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.31,35,,73.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,234.79,90,,187.83,percent of total billed charges,90% of total billed charges for outpatient setting,33.5,234.79,
PUNCH BIOPSY STRL 3MM / 96-1105,70000355,CDM,270,RC,,,Outpatient,,,24.92,24.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,70,,13.95,percent of total billed charges,70% of total billed charges for outpatient setting,21.15,84.88,,16.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.46,50,,9.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.69,75,,14.95,percent of total billed charges,75% of total billed charges for outpatient setting,17.44,70,,13.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,80,,15.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,3.2,12.84,,2.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.2,65,,12.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.72,35,,6.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.43,90,,17.94,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,22.43,
"PUNCH, DISPOSABLE AR-1927PBS",69161459,CDM,272,RC,,,Outpatient,,,334.18,334.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,283.65,84.88,,226.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.09,50,,133.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.64,75,,200.51,percent of total billed charges,75% of total billed charges for outpatient setting,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.34,80,,213.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.22,65,,173.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.96,35,,93.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.76,90,,240.61,percent of total billed charges,90% of total billed charges for outpatient setting,42.91,300.76,
PURKINJE CELL SCREEN,200471,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
PURKINJE TITER,200472,CDM,301,RC,86256,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.85,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
PUTTY 5CC DBM INFLUX / IFLX-PT-05,7374948,CDM,278,RC,C9359,HCPCS,Outpatient,,,2362,2362,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.2,60,,1133.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2004.87,84.88,,1603.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1771.5,75,,1417.2,percent of total billed charges,75% of total billed charges for outpatient setting,1181,50,,944.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.28,12.84,,242.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1889.6,80,,1511.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.28,12.84,,242.62,percent of total billed charges,12.84% of total billed charges,303.28,12.84,,242.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2480.1,105,,1984.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826.7,35,,661.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1417.2,60,,1133.76,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2480.1,
PV LASER OTHER,6151502,CDM,360,RC,,,Outpatient,,,1136.23,1136.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.36,70,,636.29,percent of total billed charges,70% of total billed charges for outpatient setting,964.43,84.88,,771.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,568.12,50,,454.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.17,75,,681.74,percent of total billed charges,75% of total billed charges for outpatient setting,795.36,70,,636.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.89,12.84,,116.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.98,80,,727.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.89,12.84,,116.71,percent of total billed charges,12.84% of total billed charges,145.89,12.84,,116.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.68,35,,318.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1022.61,90,,818.09,percent of total billed charges,90% of total billed charges for outpatient setting,145.89,1022.61,
PVP 4OZ (BETADINE) SCRUB SOLN / 29904-00,69161276,CDM,272,RC,,,Outpatient,,,6.88,6.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,5.84,84.88,,4.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.44,50,,2.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.16,75,,4.13,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,80,,4.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.47,65,,3.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,35,,1.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.19,90,,4.95,percent of total billed charges,90% of total billed charges for outpatient setting,0.88,6.19,
PVP 4OZ BETADINE TOP SOLN / 29906-004,69161277,CDM,272,RC,,,Outpatient,,,9.27,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,84.88,,6.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.64,50,,3.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.95,75,,5.56,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,70,,5.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,80,,5.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,1.19,12.84,,0.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.03,65,,4.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,35,,2.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.34,90,,6.67,percent of total billed charges,90% of total billed charges for outpatient setting,1.19,8.34,
PYLORIK / 0514OK,6051155,CDM,272,RC,,,Outpatient,,,772.63,772.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.84,70,,432.67,percent of total billed charges,70% of total billed charges for outpatient setting,655.81,84.88,,524.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,386.32,50,,309.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,579.47,75,,463.58,percent of total billed charges,75% of total billed charges for outpatient setting,540.84,70,,432.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.21,12.84,,79.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.1,80,,494.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.21,12.84,,79.37,percent of total billed charges,12.84% of total billed charges,99.21,12.84,,79.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,502.21,65,,401.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.42,35,,216.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,695.37,90,,556.3,percent of total billed charges,90% of total billed charges for outpatient setting,99.21,695.37,
PYRIDOSTIGMINE (MESTINON) 60MG TAB :,3301911,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PYRIDOSTIGMINE(REGONOL)5 MG/ML:5 ML,3302780,CDM,250,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
PYRIDOXINE (MESTINON) 50 MG TAB :,3301912,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
PYRIMETHAMINE (DARAPRIM) 25 MG TAB :,3301913,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
QUADCUT BLADE 3MM X13CM 1883080EM,69162153,CDM,272,RC,,,Outpatient,,,1405.95,1405.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,984.17,70,,787.34,percent of total billed charges,70% of total billed charges for outpatient setting,1193.37,84.88,,954.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,702.98,50,,562.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1054.46,75,,843.57,percent of total billed charges,75% of total billed charges for outpatient setting,984.17,70,,787.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.52,12.84,,144.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.76,80,,899.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.52,12.84,,144.42,percent of total billed charges,12.84% of total billed charges,180.52,12.84,,144.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,913.87,65,,731.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.08,35,,393.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1265.36,90,,1012.29,percent of total billed charges,90% of total billed charges for outpatient setting,180.52,1265.36,
QUANTIFERON-TB GOLD PLUS,222016,CDM,302,RC,86480,HCPCS,Outpatient,,,278.91,251.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.24,70,,156.19,percent of total billed charges,70% of total billed charges for outpatient setting,236.74,84.88,,189.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,106.42,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,209.18,75,,167.34,percent of total billed charges,75% of total billed charges for outpatient setting,195.24,70,,156.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.13,80,,178.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,90.49,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.54,100,,,Fee Schedule,100% of Custom Fee Schedule,251.02,90,,200.82,percent of total billed charges,90% of total billed charges for outpatient setting,61.98,251.02,
QUANTIFICATION,201514,CDM,306,RC,87522,HCPCS,Outpatient,,,192.78,173.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,163.63,84.88,,130.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,144.59,75,,115.67,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,70,,107.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.22,80,,123.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,100,,,Fee Schedule,100% of Custom Fee Schedule,173.5,90,,138.8,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,173.5,
QUETIAPINE  GENERIC (SEROQUEL) 25MG,3301915,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
QUETIAPINE (genSEROQUEL) 50MG XL TAB,3313897,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
QUETIAPINE (genSEROQUEL)100MG TAB,3301916,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
QUETIAPINE FUMARATE (SEROQUEL) 200MG TAB,3303060,CDM,259,RC,,,Outpatient,,,3.07,3.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,75,,1.84,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.76,90,,2.21,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.76,
QUICK CLIP / HX201UR135B,6051162,CDM,272,RC,,,Outpatient,,,337.43,337.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,70,,188.96,percent of total billed charges,70% of total billed charges for outpatient setting,286.41,84.88,,229.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,168.72,50,,134.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.07,75,,202.46,percent of total billed charges,75% of total billed charges for outpatient setting,236.2,70,,188.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.94,80,,215.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,43.33,12.84,,34.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.33,65,,175.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.1,35,,94.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.69,90,,242.95,percent of total billed charges,90% of total billed charges for outpatient setting,43.33,303.69,
QUICKTRACH 2.0MM  / 120900020,69160432,CDM,272,RC,,,Outpatient,,,938.62,938.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.03,70,,525.62,percent of total billed charges,70% of total billed charges for outpatient setting,796.7,84.88,,637.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,469.31,50,,375.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,703.97,75,,563.18,percent of total billed charges,75% of total billed charges for outpatient setting,657.03,70,,525.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.52,12.84,,96.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.9,80,,600.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.52,12.84,,96.42,percent of total billed charges,12.84% of total billed charges,120.52,12.84,,96.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,610.1,65,,488.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.52,35,,262.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,844.76,90,,675.81,percent of total billed charges,90% of total billed charges for outpatient setting,120.52,844.76,
QUICKTRACH 4.0MM  / 120900040,69160433,CDM,272,RC,,,Outpatient,,,938.62,938.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.03,70,,525.62,percent of total billed charges,70% of total billed charges for outpatient setting,796.7,84.88,,637.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,469.31,50,,375.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,703.97,75,,563.18,percent of total billed charges,75% of total billed charges for outpatient setting,657.03,70,,525.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.52,12.84,,96.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.9,80,,600.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.52,12.84,,96.42,percent of total billed charges,12.84% of total billed charges,120.52,12.84,,96.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,610.1,65,,488.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.52,35,,262.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,844.76,90,,675.81,percent of total billed charges,90% of total billed charges for outpatient setting,120.52,844.76,
QUINAPRIL 20 MG TAB (ACCUPRIL),3303128,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
QUINAPRIL 20MG TAB (ACCUPRIL),3301917,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
QUINIDINE,200056,CDM,301,RC,80194,HCPCS,Outpatient,,,65.7,59.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,55.77,84.88,,44.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.28,75,,39.42,percent of total billed charges,75% of total billed charges for outpatient setting,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.56,80,,42.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.31,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.69,100,,,Fee Schedule,100% of Custom Fee Schedule,59.13,90,,47.3,percent of total billed charges,90% of total billed charges for outpatient setting,14.6,59.13,
QUINIDINE,220032,CDM,301,RC,80194,HCPCS,Outpatient,,,65.7,59.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,55.77,84.88,,44.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.28,75,,39.42,percent of total billed charges,75% of total billed charges for outpatient setting,45.99,70,,36.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.56,80,,42.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.31,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.69,100,,,Fee Schedule,100% of Custom Fee Schedule,59.13,90,,47.3,percent of total billed charges,90% of total billed charges for outpatient setting,14.6,59.13,
QUINIDINE (QUINAGLUTE) 324 MG TAB:,3301918,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
QUINIDINE (QUINAGLUTE) TAB:324MG UD,3301919,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
QUINIDINE (QUINIDINE SULF) 200 MG TAB:,3301920,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
QUINIDINE SULFATE TAB:200MG UD,3301921,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
QUININE 325 MG: CAP,3303141,CDM,259,RC,,,Outpatient,,,13.29,13.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,84.88,,9.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.65,50,,5.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,75,,7.98,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,70,,7.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,80,,8.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.64,65,,6.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,35,,3.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.96,90,,9.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,11.96,
QUININE SULFATE :260MG,3301922,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
RA LATEX,220456,CDM,300,RC,86431,HCPCS,Outpatient,,,25.52,22.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,70,,14.29,percent of total billed charges,70% of total billed charges for outpatient setting,21.66,84.88,,17.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.14,75,,15.31,percent of total billed charges,75% of total billed charges for outpatient setting,17.86,70,,14.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.42,80,,16.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,100,,,Fee Schedule,100% of Custom Fee Schedule,22.97,90,,18.38,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,22.97,
RABIES (BAYRAB) 150 U/ML INJ : 10 ML,3301925,CDM,250,RC,,,Outpatient,,,471.77,471.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.24,70,,264.19,percent of total billed charges,70% of total billed charges for outpatient setting,400.44,84.88,,320.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,235.89,50,,188.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.83,75,,283.06,percent of total billed charges,75% of total billed charges for outpatient setting,330.24,70,,264.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.58,12.84,,48.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.42,80,,301.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.58,12.84,,48.46,percent of total billed charges,12.84% of total billed charges,60.58,12.84,,48.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,306.65,65,,245.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.12,35,,132.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,424.59,90,,339.67,percent of total billed charges,90% of total billed charges for outpatient setting,60.58,424.59,
RABIES (BAYRAB) 150U/ML INJ:10ML,3301926,CDM,250,RC,,,Outpatient,,,2368.56,2368.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1657.99,70,,1326.39,percent of total billed charges,70% of total billed charges for outpatient setting,2010.43,84.88,,1608.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,1184.28,50,,947.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1776.42,75,,1421.14,percent of total billed charges,75% of total billed charges for outpatient setting,1657.99,70,,1326.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.12,12.84,,243.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.85,80,,1515.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.12,12.84,,243.3,percent of total billed charges,12.84% of total billed charges,304.12,12.84,,243.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1539.56,65,,1231.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,829,35,,663.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2131.7,90,,1705.36,percent of total billed charges,90% of total billed charges for outpatient setting,304.12,2131.7,
RABIES (IMOGAM RABIES-HT) 150UML INJ:,3301924,CDM,250,RC,,,Outpatient,,,2007.25,2007.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1405.08,70,,1124.06,percent of total billed charges,70% of total billed charges for outpatient setting,1703.75,84.88,,1363,percent of total billed charges,84.88% of total billed charges for outpatient setting,1003.63,50,,802.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1505.44,75,,1204.35,percent of total billed charges,75% of total billed charges for outpatient setting,1405.08,70,,1124.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.73,12.84,,206.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1605.8,80,,1284.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.73,12.84,,206.18,percent of total billed charges,12.84% of total billed charges,257.73,12.84,,206.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1304.71,65,,1043.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.54,35,,562.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1806.53,90,,1445.22,percent of total billed charges,90% of total billed charges for outpatient setting,257.73,1806.53,
RABIES (IMOGAM RABIES-HT) 150UML INJ:2ML,3301923,CDM,250,RC,,,Outpatient,,,460.34,460.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.24,70,,257.79,percent of total billed charges,70% of total billed charges for outpatient setting,390.74,84.88,,312.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,230.17,50,,184.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.26,75,,276.21,percent of total billed charges,75% of total billed charges for outpatient setting,322.24,70,,257.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.11,12.84,,47.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.27,80,,294.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.11,12.84,,47.29,percent of total billed charges,12.84% of total billed charges,59.11,12.84,,47.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,299.22,65,,239.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.12,35,,128.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,414.31,90,,331.45,percent of total billed charges,90% of total billed charges for outpatient setting,59.11,414.31,
RABIES (IMOVAX RABIES VAC) 2.5 U INJ:,3301927,CDM,250,RC,,,Outpatient,,,432.71,432.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.9,70,,242.32,percent of total billed charges,70% of total billed charges for outpatient setting,367.28,84.88,,293.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.36,50,,173.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.53,75,,259.62,percent of total billed charges,75% of total billed charges for outpatient setting,302.9,70,,242.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.56,12.84,,44.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.17,80,,276.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.56,12.84,,44.45,percent of total billed charges,12.84% of total billed charges,55.56,12.84,,44.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.26,65,,225.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.45,35,,121.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.44,90,,311.55,percent of total billed charges,90% of total billed charges for outpatient setting,55.56,389.44,
RABIES (RABAVERT CHICK-EMB) 2.5 U INJ:,3301928,CDM,250,RC,,,Outpatient,,,404.62,404.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.23,70,,226.58,percent of total billed charges,70% of total billed charges for outpatient setting,343.44,84.88,,274.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.31,50,,161.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.47,75,,242.78,percent of total billed charges,75% of total billed charges for outpatient setting,283.23,70,,226.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.95,12.84,,41.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.7,80,,258.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.95,12.84,,41.56,percent of total billed charges,12.84% of total billed charges,51.95,12.84,,41.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263,65,,210.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.62,35,,113.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,364.16,90,,291.33,percent of total billed charges,90% of total billed charges for outpatient setting,51.95,364.16,
RACEPINEPHRINE 2.25% 0.5ML INH SOLN,3301018,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
RAD EXAM CHEST **W FLUOROSCO,2410950,CDM,324,RC,71034,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.37,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,186.37,
RAD EXM CHEST C**OMPLETE,2410945,CDM,324,RC,71030,HCPCS,Outpatient,,,196.88,147.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.82,70,,110.26,percent of total billed charges,70% of total billed charges for outpatient setting,167.11,84.88,,133.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.44,50,,78.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.66,75,,118.13,percent of total billed charges,75% of total billed charges for outpatient setting,137.82,70,,110.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.28,12.84,,20.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,80,,126,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.28,12.84,,20.22,percent of total billed charges,12.84% of total billed charges,25.28,12.84,,20.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,177.19,90,,141.75,percent of total billed charges,90% of total billed charges for outpatient setting,25.28,177.19,
RADENOID BLADE 4mm  Pedi / 1884008,69160398,CDM,272,RC,,,Outpatient,,,754.9,754.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.43,70,,422.74,percent of total billed charges,70% of total billed charges for outpatient setting,640.76,84.88,,512.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,377.45,50,,301.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,566.18,75,,452.94,percent of total billed charges,75% of total billed charges for outpatient setting,528.43,70,,422.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.93,12.84,,77.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.92,80,,483.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.93,12.84,,77.54,percent of total billed charges,12.84% of total billed charges,96.93,12.84,,77.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,490.69,65,,392.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.22,35,,211.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,679.41,90,,543.53,percent of total billed charges,90% of total billed charges for outpatient setting,96.93,679.41,
RADIAL ARTERY CATHETER SET / RA-04020,69159933,CDM,272,RC,,,Outpatient,,,66.64,66.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.65,70,,37.32,percent of total billed charges,70% of total billed charges for outpatient setting,56.56,84.88,,45.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.32,50,,26.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.98,75,,39.98,percent of total billed charges,75% of total billed charges for outpatient setting,46.65,70,,37.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,12.84,,6.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.31,80,,42.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,8.56,12.84,,6.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.32,65,,34.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.32,35,,18.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.98,90,,47.98,percent of total billed charges,90% of total billed charges for outpatient setting,8.56,59.98,
RADIAL HEAD 22L WW MODULAR  / MRH35022L,69169480,CDM,278,RC,C1776,HCPCS,Outpatient,,,5627.5,5627.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.5,60,,2701.2,percent of total billed charges,60% of total Billed charges for outpatient setting,4776.62,84.88,,3821.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.63,75,,3376.5,percent of total billed charges,75% of total billed charges for outpatient setting,2813.75,50,,2251,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.57,12.84,,578.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4502,80,,3601.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.57,12.84,,578.06,percent of total billed charges,12.84% of total billed charges,722.57,12.84,,578.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5908.88,105,,4727.1,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1969.63,35,,1575.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3376.5,60,,2701.2,percent of total billed charges,60% of total billed charges for outpatient setting,722.57,5908.88,
RADIAL HEAD 26mm x17.5  09.402.426S,69161789,CDM,278,RC,C1776,HCPCS,Outpatient,,,4816,4816,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2889.6,60,,2311.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4087.82,84.88,,3270.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3612,75,,2889.6,percent of total billed charges,75% of total billed charges for outpatient setting,2408,50,,1926.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.37,12.84,,494.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3852.8,80,,3082.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.37,12.84,,494.7,percent of total billed charges,12.84% of total billed charges,618.37,12.84,,494.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5056.8,105,,4045.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.6,35,,1348.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2889.6,60,,2311.68,percent of total billed charges,60% of total billed charges for outpatient setting,618.37,5056.8,
RADIAL HEAD STEM 02 WW / MRH35002,69169481,CDM,278,RC,C1776,HCPCS,Outpatient,,,5627.5,5627.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.5,60,,2701.2,percent of total billed charges,60% of total Billed charges for outpatient setting,4776.62,84.88,,3821.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.63,75,,3376.5,percent of total billed charges,75% of total billed charges for outpatient setting,2813.75,50,,2251,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.57,12.84,,578.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4502,80,,3601.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.57,12.84,,578.06,percent of total billed charges,12.84% of total billed charges,722.57,12.84,,578.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5908.88,105,,4727.1,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1969.63,35,,1575.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3376.5,60,,2701.2,percent of total billed charges,60% of total billed charges for outpatient setting,722.57,5908.88,
RADIAL STEM 8mm x28 04.402.008S,69161790,CDM,278,RC,C1776,HCPCS,Outpatient,,,4816,4816,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2889.6,60,,2311.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4087.82,84.88,,3270.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3612,75,,2889.6,percent of total billed charges,75% of total billed charges for outpatient setting,2408,50,,1926.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.37,12.84,,494.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3852.8,80,,3082.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.37,12.84,,494.7,percent of total billed charges,12.84% of total billed charges,618.37,12.84,,494.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5056.8,105,,4045.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.6,35,,1348.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2889.6,60,,2311.68,percent of total billed charges,60% of total billed charges for outpatient setting,618.37,5056.8,
RADIOLOGIC EXAMINATION CHEST COMPLETE,2400945,CDM,324,RC,71030,HCPCS,Outpatient,,,196.88,147.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.82,70,,110.26,percent of total billed charges,70% of total billed charges for outpatient setting,167.11,84.88,,133.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.44,50,,78.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.66,75,,118.13,percent of total billed charges,75% of total billed charges for outpatient setting,137.82,70,,110.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.28,12.84,,20.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,80,,126,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.28,12.84,,20.22,percent of total billed charges,12.84% of total billed charges,25.28,12.84,,20.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,177.19,90,,141.75,percent of total billed charges,90% of total billed charges for outpatient setting,25.28,177.19,
RADIOLOGY CUSTOM PACK / 41-6625A,69160855,CDM,272,RC,,,Outpatient,,,59.43,59.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.6,70,,33.28,percent of total billed charges,70% of total billed charges for outpatient setting,50.44,84.88,,40.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.72,50,,23.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.57,75,,35.66,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,70,,33.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,12.84,,6.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.54,80,,38.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,12.84,,6.1,percent of total billed charges,12.84% of total billed charges,7.63,12.84,,6.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.63,65,,30.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,35,,16.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.49,90,,42.79,percent of total billed charges,90% of total billed charges for outpatient setting,7.63,53.49,
RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING A,3000625,CDM,250,RC,,,Outpatient,,,499.88,499.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.92,70,,279.94,percent of total billed charges,70% of total billed charges for outpatient setting,424.3,84.88,,339.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.94,50,,199.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.91,75,,299.93,percent of total billed charges,75% of total billed charges for outpatient setting,349.92,70,,279.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.18,12.84,,51.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.9,80,,319.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.18,12.84,,51.34,percent of total billed charges,12.84% of total billed charges,64.18,12.84,,51.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,324.92,65,,259.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.96,35,,139.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.89,90,,359.91,percent of total billed charges,90% of total billed charges for outpatient setting,64.18,449.89,
RADIOPHARMACEUTICAL DIAGNOSTIC INDIUM IN,3000550,CDM,250,RC,,,Outpatient,,,518.27,518.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.79,70,,290.23,percent of total billed charges,70% of total billed charges for outpatient setting,439.91,84.88,,351.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,259.14,50,,207.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,388.7,75,,310.96,percent of total billed charges,75% of total billed charges for outpatient setting,362.79,70,,290.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,12.84,,53.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.62,80,,331.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,12.84,,53.24,percent of total billed charges,12.84% of total billed charges,66.55,12.84,,53.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,336.88,65,,269.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.39,35,,145.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,466.44,90,,373.15,percent of total billed charges,90% of total billed charges for outpatient setting,66.55,466.44,
RADIOPHARMACEUTICAL DIAGNOSTIC SODIUM IO,3000530,CDM,250,RC,,,Outpatient,,,85.22,85.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,72.33,84.88,,57.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.61,50,,34.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.92,75,,51.14,percent of total billed charges,75% of total billed charges for outpatient setting,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.18,80,,54.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.39,65,,44.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,35,,23.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.7,90,,61.36,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,76.7,
RADIOPHARMACEUTICAL DIAGNOSTIC TECHNETIU,3000520,CDM,250,RC,,,Outpatient,,,85.22,85.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,72.33,84.88,,57.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.61,50,,34.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.92,75,,51.14,percent of total billed charges,75% of total billed charges for outpatient setting,59.65,70,,47.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.18,80,,54.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,10.94,12.84,,8.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.39,65,,44.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.83,35,,23.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.7,90,,61.36,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,76.7,
RADIOPHARMACEUTICAL DIAGNOSTIC TECHNETIU,3000730,CDM,636,RC,A9561,HCPCS,Outpatient,,,125.33,125.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.73,70,,70.18,percent of total billed charges,70% of total billed charges for outpatient setting,106.38,84.88,,85.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.52,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,94,75,,75.2,percent of total billed charges,75% of total billed charges for outpatient setting,87.73,70,,70.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.09,12.84,,12.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.26,80,,80.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.09,12.84,,12.87,percent of total billed charges,12.84% of total billed charges,16.09,12.84,,12.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.46,65,,65.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.8,90,,90.24,percent of total billed charges,90% of total billed charges for outpatient setting,16.09,112.8,
RADIOPHARMACEUTICAL DIAGNOSTIC TECHNETIU,3000570,CDM,250,RC,,,Outpatient,,,2591.6,2591.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.12,70,,1451.3,percent of total billed charges,70% of total billed charges for outpatient setting,2199.75,84.88,,1759.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,1295.8,50,,1036.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1943.7,75,,1554.96,percent of total billed charges,75% of total billed charges for outpatient setting,1814.12,70,,1451.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.76,12.84,,266.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2073.28,80,,1658.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.76,12.84,,266.21,percent of total billed charges,12.84% of total billed charges,332.76,12.84,,266.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1684.54,65,,1347.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.06,35,,725.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2332.44,90,,1865.95,percent of total billed charges,90% of total billed charges for outpatient setting,332.76,2332.44,
RADIOPHARMACEUTICAL TIMOR LIMITED,3000120,CDM,341,RC,78800,HCPCS,Outpatient,,,1120.35,840.26,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,950.95,84.88,,760.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,840.26,75,,672.21,percent of total billed charges,75% of total billed charges for outpatient setting,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,896.28,80,,717.02,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1008.32,90,,806.66,percent of total billed charges,90% of total billed charges for outpatient setting,143.85,1008.32,
RADIOPHARMACEUTICAL TIMOR LIMITED MULTIP,3000125,CDM,341,RC,78801,HCPCS,Outpatient,,,1120.35,840.26,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,950.95,84.88,,760.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,840.26,75,,672.21,percent of total billed charges,75% of total billed charges for outpatient setting,784.25,70,,627.4,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,896.28,80,,717.02,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,143.85,12.84,,115.08,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,455.34,100,,,Fee Schedule,100% of Custom Fee Schedule,1008.32,90,,806.66,percent of total billed charges,90% of total billed charges for outpatient setting,143.85,1008.32,
RALOXIFENE (EVISTA) TAB: 60 MG,3301929,CDM,259,RC,,,Outpatient,,,7.04,7.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.93,70,,3.94,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,84.88,,4.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.52,50,,2.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.28,75,,4.22,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,70,,3.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,80,,4.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,0.9,12.84,,0.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.58,65,,3.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,35,,1.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.34,90,,5.07,percent of total billed charges,90% of total billed charges for outpatient setting,0.9,6.34,
RAMIPRIL (ALTACE) 2.5 MG: CAP,3302827,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
RAMIPRIL (ALTACE) CAP: 5 MG,3301930,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RAMIPRIL (genericALTACE) 10 MG CAP,3302828,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
RANITIDINE (ZANTAC) TAB 150MG,3302628,CDM,636,RC,J2780,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,6.8,
RANOLAZINE ER (GENERIC RANEXA) 1000MG,3313026,CDM,259,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
RANOLAZINE ER (GENERIC RANEXA) 500MG,3303178,CDM,259,RC,,,Outpatient,,,29.46,29.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.62,70,,16.5,percent of total billed charges,70% of total billed charges for outpatient setting,25.01,84.88,,20.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.73,50,,11.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.1,75,,17.68,percent of total billed charges,75% of total billed charges for outpatient setting,20.62,70,,16.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.57,80,,18.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,3.78,12.84,,3.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.15,65,,15.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,35,,8.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.51,90,,21.21,percent of total billed charges,90% of total billed charges for outpatient setting,3.78,26.51,
RAPACURONIUM (RAPLON) INJ:100MG,3301931,CDM,250,RC,,,Outpatient,,,448.04,448.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,70,,250.9,percent of total billed charges,70% of total billed charges for outpatient setting,380.3,84.88,,304.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,224.02,50,,179.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,336.03,75,,268.82,percent of total billed charges,75% of total billed charges for outpatient setting,313.63,70,,250.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.53,12.84,,46.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.43,80,,286.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.53,12.84,,46.02,percent of total billed charges,12.84% of total billed charges,57.53,12.84,,46.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,291.23,65,,232.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.81,35,,125.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,403.24,90,,322.59,percent of total billed charges,90% of total billed charges for outpatient setting,57.53,403.24,
RASP 2.1MM HELI ELITE / 5820-080-021,37033,CDM,272,RC,,,Outpatient,,,401.28,401.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,340.61,84.88,,272.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.64,50,,160.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.96,75,,240.77,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,70,,224.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.02,80,,256.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,51.52,12.84,,41.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.83,65,,208.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.45,35,,112.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.15,90,,288.92,percent of total billed charges,90% of total billed charges for outpatient setting,51.52,361.15,
RASP CROSS CUTTING LARGE / SR-51-083,6150560,CDM,272,RC,,,Outpatient,,,562.38,562.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,477.35,84.88,,381.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.19,50,,224.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.79,75,,337.43,percent of total billed charges,75% of total billed charges for outpatient setting,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.9,80,,359.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,365.55,65,,292.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,35,,157.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,90,,404.91,percent of total billed charges,90% of total billed charges for outpatient setting,72.21,506.14,
RASP METAL CUT 3.2X18.3MM / 5130-080-030,417865,CDM,272,RC,,,Outpatient,,,434.44,434.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.11,70,,243.29,percent of total billed charges,70% of total billed charges for outpatient setting,368.75,84.88,,295,percent of total billed charges,84.88% of total billed charges for outpatient setting,217.22,50,,173.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.83,75,,260.66,percent of total billed charges,75% of total billed charges for outpatient setting,304.11,70,,243.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.78,12.84,,44.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.55,80,,278.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.78,12.84,,44.62,percent of total billed charges,12.84% of total billed charges,55.78,12.84,,44.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,282.39,65,,225.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.05,35,,121.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,391,90,,312.8,percent of total billed charges,90% of total billed charges for outpatient setting,55.78,391,
RAST AREA 7,220144,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
"RAST,SINGLE ALLERGEN,SEROLAB",200964,CDM,302,RC,86003,HCPCS,Outpatient,,,23.49,21.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Custom Fee Schedule,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,21.14,
RAZADYNE(GALANTAMINE) TABS: 4 MG,3302850,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
RAZOR DOUBLE SIDED NS / DYND70837,70000340,CDM,271,RC,,,Outpatient,,,1.18,1.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.83,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,1,84.88,,0.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.59,50,,0.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.89,75,,0.71,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,70,,0.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,80,,0.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,0.15,12.84,,0.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.77,65,,0.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.41,35,,0.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.06,90,,0.85,percent of total billed charges,90% of total billed charges for outpatient setting,0.15,1.06,
"RBC, AUTOMATED",200129,CDM,310,RC,85041,HCPCS,Outpatient,,,13.59,12.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,84.88,,9.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.19,75,,8.15,percent of total billed charges,75% of total billed charges for outpatient setting,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.87,80,,8.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,100,,,Fee Schedule,100% of Custom Fee Schedule,12.23,90,,9.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,12.23,
REAMER  METATARSAL 18MM  AR-8944MR-18,69162355,CDM,272,RC,,,Outpatient,,,1946.7,1946.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.69,70,,1090.15,percent of total billed charges,70% of total billed charges for outpatient setting,1652.36,84.88,,1321.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,973.35,50,,778.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1460.03,75,,1168.02,percent of total billed charges,75% of total billed charges for outpatient setting,1362.69,70,,1090.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.96,12.84,,199.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1557.36,80,,1245.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.96,12.84,,199.97,percent of total billed charges,12.84% of total billed charges,249.96,12.84,,199.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1265.36,65,,1012.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.35,35,,545.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.03,90,,1401.62,percent of total billed charges,90% of total billed charges for outpatient setting,249.96,1752.03,
REAMER 10MM LOW PROFILE /  AR-1410LP,71000158,CDM,272,RC,,,Outpatient,,,780,780,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,436.8,percent of total billed charges,70% of total billed charges for outpatient setting,662.06,84.88,,529.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,390,50,,312,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585,75,,468,percent of total billed charges,75% of total billed charges for outpatient setting,546,70,,436.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624,80,,499.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,100.15,12.84,,80.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,507,65,,405.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,35,,218.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,702,90,,561.6,percent of total billed charges,90% of total billed charges for outpatient setting,100.15,702,
REAMER 11MM LOW PROFILE /  AR-1411LP,69162562,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
REAMER 2MM STRYKER / XFO12002,70000677,CDM,278,RC,C1713,HCPCS,Outpatient,,,888.99,888.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,533.39,60,,426.71,percent of total billed charges,60% of total Billed charges for outpatient setting,754.57,84.88,,603.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.74,75,,533.39,percent of total billed charges,75% of total billed charges for outpatient setting,444.5,50,,355.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.15,12.84,,91.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.19,80,,568.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.15,12.84,,91.32,percent of total billed charges,12.84% of total billed charges,114.15,12.84,,91.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,888.99,65,,711.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.15,35,,248.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,533.39,60,,426.71,percent of total billed charges,60% of total billed charges for outpatient setting,114.15,888.99,
REAMER 3.5-4MM HOLLOW NS / 309.035,415383,CDM,272,RC,,,Outpatient,,,1814.5,1814.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1270.15,70,,1016.12,percent of total billed charges,70% of total billed charges for outpatient setting,1540.15,84.88,,1232.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,907.25,50,,725.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1360.88,75,,1088.7,percent of total billed charges,75% of total billed charges for outpatient setting,1270.15,70,,1016.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.98,12.84,,186.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1451.6,80,,1161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.98,12.84,,186.38,percent of total billed charges,12.84% of total billed charges,232.98,12.84,,186.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1179.43,65,,943.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.08,35,,508.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1633.05,90,,1306.44,percent of total billed charges,90% of total billed charges for outpatient setting,232.98,1633.05,
REAMER 6MM LOW PROFILE / AR-1406LP,69162055,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
REAMER 8.5MM LOW PROFILE / AR-1408LP-50,71000897,CDM,272,RC,,,Outpatient,,,819,819,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,695.17,84.88,,556.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,409.5,50,,327.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.25,75,,491.4,percent of total billed charges,75% of total billed charges for outpatient setting,573.3,70,,458.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,80,,524.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,105.16,12.84,,84.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,532.35,65,,425.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,35,,229.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,737.1,90,,589.68,percent of total billed charges,90% of total billed charges for outpatient setting,105.16,737.1,
REAMER 8MM LOW PROFILE / AR-1408LP,69169833,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
REAMER LOW PROFILE 9.5MM / AR-1409LP-50,69161806,CDM,272,RC,,,Outpatient,,,868.88,868.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.22,70,,486.58,percent of total billed charges,70% of total billed charges for outpatient setting,737.51,84.88,,590.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,434.44,50,,347.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,651.66,75,,521.33,percent of total billed charges,75% of total billed charges for outpatient setting,608.22,70,,486.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.56,12.84,,89.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.1,80,,556.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.56,12.84,,89.25,percent of total billed charges,12.84% of total billed charges,111.56,12.84,,89.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,564.77,65,,451.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.11,35,,243.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,781.99,90,,625.59,percent of total billed charges,90% of total billed charges for outpatient setting,111.56,781.99,
REAMER PHALANGEAL 14MM  AR-8944PR-14,69162354,CDM,272,RC,,,Outpatient,,,1946.7,1946.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.69,70,,1090.15,percent of total billed charges,70% of total billed charges for outpatient setting,1652.36,84.88,,1321.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,973.35,50,,778.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1460.03,75,,1168.02,percent of total billed charges,75% of total billed charges for outpatient setting,1362.69,70,,1090.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.96,12.84,,199.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1557.36,80,,1245.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.96,12.84,,199.97,percent of total billed charges,12.84% of total billed charges,249.96,12.84,,199.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1265.36,65,,1012.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.35,35,,545.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752.03,90,,1401.62,percent of total billed charges,90% of total billed charges for outpatient setting,249.96,1752.03,
RECLAST 1MG/UNIT (WASTAGE),3305390,CDM,636,RC,Q2051,HCPCS,Outpatient,,,845.15,845.15,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.61,70,,473.29,percent of total billed charges,70% of total billed charges for outpatient setting,717.36,84.88,,573.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,422.58,50,,338.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.86,75,,507.09,percent of total billed charges,75% of total billed charges for outpatient setting,591.61,70,,473.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,12.84,,86.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.12,80,,540.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,12.84,,86.82,percent of total billed charges,12.84% of total billed charges,108.52,12.84,,86.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,549.35,65,,439.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.8,35,,236.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,760.64,90,,608.51,percent of total billed charges,90% of total billed charges for outpatient setting,108.52,760.64,
RECLAST 5MG/100 ML INJ (1MG/UNIT),3302825,CDM,636,RC,J3489,HCPCS,Outpatient,,,845.15,845.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.61,70,,473.29,percent of total billed charges,70% of total billed charges for outpatient setting,717.36,84.88,,573.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,633.86,75,,507.09,percent of total billed charges,75% of total billed charges for outpatient setting,591.61,70,,473.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,12.84,,86.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.12,80,,540.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,12.84,,86.82,percent of total billed charges,12.84% of total billed charges,108.52,12.84,,86.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,549.35,65,,439.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of Custom Fee Schedule,760.64,90,,608.51,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,760.64,
RECOVERY 1ST HOUR,7601645,CDM,710,RC,,,Outpatient,,,2160.97,2160.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512.68,70,,1210.14,percent of total billed charges,70% of total billed charges for outpatient setting,1834.23,84.88,,1467.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1080.49,50,,864.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1620.73,75,,1296.58,percent of total billed charges,75% of total billed charges for outpatient setting,1512.68,70,,1210.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.47,12.84,,221.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728.78,80,,1383.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.47,12.84,,221.98,percent of total billed charges,12.84% of total billed charges,277.47,12.84,,221.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1404.63,65,,1123.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.34,35,,605.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1944.87,90,,1555.9,percent of total billed charges,90% of total billed charges for outpatient setting,277.47,1944.87,
RECOVERY 30 MINUTES OR LESS,7601644,CDM,710,RC,,,Outpatient,,,1625.68,1625.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.98,70,,910.38,percent of total billed charges,70% of total billed charges for outpatient setting,1379.88,84.88,,1103.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,812.84,50,,650.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1219.26,75,,975.41,percent of total billed charges,75% of total billed charges for outpatient setting,1137.98,70,,910.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.74,12.84,,166.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.54,80,,1040.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.74,12.84,,166.99,percent of total billed charges,12.84% of total billed charges,208.74,12.84,,166.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1056.69,65,,845.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.99,35,,455.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1463.11,90,,1170.49,percent of total billed charges,90% of total billed charges for outpatient setting,208.74,1463.11,
RECOVERY ADDL 30MIN,7601650,CDM,710,RC,,,Outpatient,,,1080.96,1080.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.67,70,,605.34,percent of total billed charges,70% of total billed charges for outpatient setting,917.52,84.88,,734.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,540.48,50,,432.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,810.72,75,,648.58,percent of total billed charges,75% of total billed charges for outpatient setting,756.67,70,,605.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.8,12.84,,111.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.77,80,,691.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.8,12.84,,111.04,percent of total billed charges,12.84% of total billed charges,138.8,12.84,,111.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,702.62,65,,562.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.34,35,,302.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,972.86,90,,778.29,percent of total billed charges,90% of total billed charges for outpatient setting,138.8,972.86,
RED BLOOD CELLS,1000040,CDM,381,RC,P9021,HCPCS,Outpatient,,,252.35,252.35,,224.84,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,176.65,70,,141.32,percent of total billed charges,70% of total billed charges for outpatient setting,214.19,84.88,,171.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,198.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,189.26,75,,151.41,percent of total billed charges,75% of total billed charges for outpatient setting,176.65,70,,141.32,percent of total billed charges,70% of total billed charges for outpatient setting,238.9,170,,,Fee Schedule,170% of Medicare OPPS rate,302.13,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,32.4,12.84,,25.92,percent of total billed charges,12.84% of total billed charges,245.92,175,,,Fee Schedule,175% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,201.88,80,,161.5,percent of total billed charges,80% of total billed charges for outpatient setting,196.74,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,175.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,32.4,12.84,,25.92,percent of total billed charges,12.84% of total billed charges,32.4,12.84,,25.92,percent of total billed charges,12.84% of total billed charges,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,164.03,65,,131.22,percent of total billed charges,65% of total billed charges for outpatient setting,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,140.53,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,180.21,100,,,Fee Schedule,100% of Custom Fee Schedule,227.12,90,,181.7,percent of total billed charges,90% of total billed charges for outpatient setting,32.4,302.13,
RED BLOOD CELLS LEUKOCYTES REDUCED,1000020,CDM,381,RC,P9016,HCPCS,Outpatient,,,359.76,359.76,,307.82,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,251.83,70,,201.46,percent of total billed charges,70% of total billed charges for outpatient setting,305.36,84.88,,244.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,255.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,269.82,75,,215.86,percent of total billed charges,75% of total billed charges for outpatient setting,251.83,70,,201.46,percent of total billed charges,70% of total billed charges for outpatient setting,327.06,170,,,Fee Schedule,170% of Medicare OPPS rate,413.63,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,46.19,12.84,,36.952,percent of total billed charges,12.84% of total billed charges,336.68,175,,,Fee Schedule,175% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,287.81,80,,230.25,percent of total billed charges,80% of total billed charges for outpatient setting,269.33,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,240.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,46.19,12.84,,36.95,percent of total billed charges,12.84% of total billed charges,46.19,12.84,,36.95,percent of total billed charges,12.84% of total billed charges,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,233.84,65,,187.07,percent of total billed charges,65% of total billed charges for outpatient setting,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,192.39,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.87,100,,,Fee Schedule,100% of Custom Fee Schedule,323.78,90,,259.02,percent of total billed charges,90% of total billed charges for outpatient setting,46.19,413.63,
RED BLOOD CELLS LEUKOCYTES REDUCED IRRAD,1000105,CDM,381,RC,P9040,HCPCS,Outpatient,,,898.15,898.15,,425.64,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,628.71,70,,502.97,percent of total billed charges,70% of total billed charges for outpatient setting,762.35,84.88,,609.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,361.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,673.61,75,,538.89,percent of total billed charges,75% of total billed charges for outpatient setting,628.71,70,,502.97,percent of total billed charges,70% of total billed charges for outpatient setting,452.25,170,,,Fee Schedule,170% of Medicare OPPS rate,571.96,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,115.32,12.84,,92.256,percent of total billed charges,12.84% of total billed charges,465.55,175,,,Fee Schedule,175% of Medicare OPPS rate,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,718.52,80,,574.82,percent of total billed charges,80% of total billed charges for outpatient setting,372.44,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,332.53,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,115.32,12.84,,92.26,percent of total billed charges,12.84% of total billed charges,115.32,12.84,,92.26,percent of total billed charges,12.84% of total billed charges,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,583.8,65,,467.04,percent of total billed charges,65% of total billed charges for outpatient setting,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,266.02,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,331.19,100,,,Fee Schedule,100% of Custom Fee Schedule,808.34,90,,646.67,percent of total billed charges,90% of total billed charges for outpatient setting,115.32,808.34,
RED BLOOD CELLS WASHED,1000045,CDM,381,RC,P9022,HCPCS,Outpatient,,,388.75,388.75,,620.54,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,272.13,70,,217.7,percent of total billed charges,70% of total billed charges for outpatient setting,329.97,84.88,,263.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,534.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,291.56,75,,233.25,percent of total billed charges,75% of total billed charges for outpatient setting,272.13,70,,217.7,percent of total billed charges,70% of total billed charges for outpatient setting,659.34,170,,,Fee Schedule,170% of Medicare OPPS rate,833.87,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,49.92,12.84,,39.936,percent of total billed charges,12.84% of total billed charges,678.73,175,,,Fee Schedule,175% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,311,80,,248.8,percent of total billed charges,80% of total billed charges for outpatient setting,542.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,484.81,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,49.92,12.84,,39.94,percent of total billed charges,12.84% of total billed charges,49.92,12.84,,39.94,percent of total billed charges,12.84% of total billed charges,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,252.69,65,,202.15,percent of total billed charges,65% of total billed charges for outpatient setting,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.85,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,136.06,35,,108.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,349.88,90,,279.9,percent of total billed charges,90% of total billed charges for outpatient setting,49.92,833.87,
RED CELL VOLUME DETERMINATION,3000180,CDM,341,RC,78120,HCPCS,Outpatient,,,811.23,608.42,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,688.57,84.88,,550.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,608.42,75,,486.74,percent of total billed charges,75% of total billed charges for outpatient setting,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,104.16,12.84,,83.328,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,648.98,80,,519.18,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,673.24,100,,,Fee Schedule,100% of Custom Fee Schedule,730.11,90,,584.09,percent of total billed charges,90% of total billed charges for outpatient setting,104.16,774,
REFLUDAN(LEPIRUDIN rDNA)50MG/ML:VIAL,3302806,CDM,250,RC,,,Outpatient,,,313.16,313.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.21,70,,175.37,percent of total billed charges,70% of total billed charges for outpatient setting,265.81,84.88,,212.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.58,50,,125.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.87,75,,187.9,percent of total billed charges,75% of total billed charges for outpatient setting,219.21,70,,175.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.21,12.84,,32.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.53,80,,200.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.21,12.84,,32.17,percent of total billed charges,12.84% of total billed charges,40.21,12.84,,32.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.55,65,,162.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.61,35,,87.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.84,90,,225.47,percent of total billed charges,90% of total billed charges for outpatient setting,40.21,281.84,
REFRESH LIQUIGEL OPTH SOLN,3303203,CDM,259,RC,,,Outpatient,,,43.7,43.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,37.09,84.88,,29.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.85,50,,17.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.78,75,,26.22,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,70,,24.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,80,,27.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,5.61,12.84,,4.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.41,65,,22.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,35,,12.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.33,90,,31.46,percent of total billed charges,90% of total billed charges for outpatient setting,5.61,39.33,
REFRESH PM OPHTH OINTMENT  3.5GM,3302969,CDM,259,RC,,,Outpatient,,,59.99,59.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.99,70,,33.59,percent of total billed charges,70% of total billed charges for outpatient setting,50.92,84.88,,40.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,30,50,,24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.99,75,,35.99,percent of total billed charges,75% of total billed charges for outpatient setting,41.99,70,,33.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,12.84,,6.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.99,80,,38.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,12.84,,6.16,percent of total billed charges,12.84% of total billed charges,7.7,12.84,,6.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.99,65,,31.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,35,,16.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.99,90,,43.19,percent of total billed charges,90% of total billed charges for outpatient setting,7.7,53.99,
REGADENOSON (LEXISCAN) 0.4MG/5ML,3303329,CDM,636,RC,J2785,HCPCS,Outpatient,,,943.96,943.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.77,70,,528.62,percent of total billed charges,70% of total billed charges for outpatient setting,801.23,84.88,,640.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,707.97,75,,566.38,percent of total billed charges,75% of total billed charges for outpatient setting,660.77,70,,528.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.2,12.84,,96.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.17,80,,604.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.2,12.84,,96.96,percent of total billed charges,12.84% of total billed charges,121.2,12.84,,96.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,613.57,65,,490.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of Custom Fee Schedule,849.56,90,,679.65,percent of total billed charges,90% of total billed charges for outpatient setting,62.24,849.56,
REGADENOSON generic LEXISCAN  0.4MG/5ML,3314196,CDM,636,RC,J2785,HCPCS,Outpatient,,,227.75,227.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.43,70,,127.54,percent of total billed charges,70% of total billed charges for outpatient setting,193.31,84.88,,154.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,170.81,75,,136.65,percent of total billed charges,75% of total billed charges for outpatient setting,159.43,70,,127.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.24,12.84,,23.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.2,80,,145.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.24,12.84,,23.39,percent of total billed charges,12.84% of total billed charges,29.24,12.84,,23.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.04,65,,118.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of Custom Fee Schedule,204.98,90,,163.98,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,204.98,
REGLAN 10MG TAB (METOCLOPRAMIDE):,3302661,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
REGLAN INJ : 5MG/ML 2ML,3302660,CDM,250,RC,,,Outpatient,,,6.05,6.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,70,,3.39,percent of total billed charges,70% of total billed charges for outpatient setting,5.14,84.88,,4.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.03,50,,2.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.54,75,,3.63,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,70,,3.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,80,,3.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.93,65,,3.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,35,,1.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.45,90,,4.36,percent of total billed charges,90% of total billed charges for outpatient setting,0.78,5.45,
REMICADE INJ :100 MG,3302715,CDM,250,RC,,,Outpatient,,,1864.4,1864.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305.08,70,,1044.06,percent of total billed charges,70% of total billed charges for outpatient setting,1582.5,84.88,,1266,percent of total billed charges,84.88% of total billed charges for outpatient setting,932.2,50,,745.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1398.3,75,,1118.64,percent of total billed charges,75% of total billed charges for outpatient setting,1305.08,70,,1044.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.39,12.84,,191.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1491.52,80,,1193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.39,12.84,,191.51,percent of total billed charges,12.84% of total billed charges,239.39,12.84,,191.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1211.86,65,,969.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.54,35,,522.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1677.96,90,,1342.37,percent of total billed charges,90% of total billed charges for outpatient setting,239.39,1677.96,
REMOTE CONTROL PATIENT - AXONICS / 2301,69169722,CDM,272,RC,,,Outpatient,,,3234,3234,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2263.8,70,,1811.04,percent of total billed charges,70% of total billed charges for outpatient setting,2745.02,84.88,,2196.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1617,50,,1293.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2425.5,75,,1940.4,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.25,12.84,,332.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2587.2,80,,2069.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.25,12.84,,332.2,percent of total billed charges,12.84% of total billed charges,415.25,12.84,,332.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2102.1,65,,1681.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1131.9,35,,905.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2910.6,90,,2328.48,percent of total billed charges,90% of total billed charges for outpatient setting,415.25,2910.6,
REMOVAL OF DEVITALIZED TISSUE,5100159,CDM,510,RC,97602,HCPCS,Outpatient,,,474.93,474.93,,257.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,332.45,70,,265.96,percent of total billed charges,70% of total billed charges for outpatient setting,403.12,84.88,,322.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,356.2,75,,284.96,percent of total billed charges,75% of total billed charges for outpatient setting,332.45,70,,265.96,percent of total billed charges,70% of total billed charges for outpatient setting,273.56,170,,,Fee Schedule,170% of Medicare OPPS rate,345.97,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,60.98,12.84,,48.784,percent of total billed charges,12.84% of total billed charges,281.6,175,,,Fee Schedule,175% of Medicare OPPS rate,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,379.94,80,,303.95,percent of total billed charges,80% of total billed charges for outpatient setting,225.28,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,201.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,60.98,12.84,,48.78,percent of total billed charges,12.84% of total billed charges,60.98,12.84,,48.78,percent of total billed charges,12.84% of total billed charges,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,308.7,65,,246.96,percent of total billed charges,65% of total billed charges for outpatient setting,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.91,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,99.6,100,,,Fee Schedule,100% of Custom Fee Schedule,427.44,90,,341.95,percent of total billed charges,90% of total billed charges for outpatient setting,60.98,427.44,
REMOVAL OF FOREIGN BODY ESOPHAGEAL WITH,2400595,CDM,320,RC,74235,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
REMOVER STAPLE SKIN PRECISE / DYNJ04058Z,6150432,CDM,272,RC,,,Outpatient,,,7.09,7.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.96,70,,3.97,percent of total billed charges,70% of total billed charges for outpatient setting,6.02,84.88,,4.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.55,50,,2.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.32,75,,4.26,percent of total billed charges,75% of total billed charges for outpatient setting,4.96,70,,3.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,80,,4.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,0.91,12.84,,0.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.61,65,,3.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,35,,1.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.38,90,,5.1,percent of total billed charges,90% of total billed charges for outpatient setting,0.91,6.38,
RENAGEL 800 MG : TAB,3302992,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
RENAL CRYOTHERAPY PROCEDURE,69160872,CDM,360,RC,,,Outpatient,,,17043.36,17043.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11930.35,70,,9544.28,percent of total billed charges,70% of total billed charges for outpatient setting,14466.4,84.88,,11573.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,8521.68,50,,6817.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12782.52,75,,10226.02,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2188.37,12.84,,1750.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13634.69,80,,10907.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2188.37,12.84,,1750.7,percent of total billed charges,12.84% of total billed charges,2188.37,12.84,,1750.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5965.18,35,,4772.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15339.02,90,,12271.22,percent of total billed charges,90% of total billed charges for outpatient setting,2000,15339.02,
RENAL CYST STUDY TRANSLUMBAR CONTRAST VI,2400780,CDM,320,RC,74470,HCPCS,Outpatient,,,1545.1,1158.83,,692.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,1311.48,84.88,,1049.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1158.83,75,,927.06,percent of total billed charges,75% of total billed charges for outpatient setting,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,736.08,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,198.39,12.84,,158.712,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1236.08,80,,988.86,percent of total billed charges,80% of total billed charges for outpatient setting,606.18,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,878.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1390.59,90,,1112.47,percent of total billed charges,90% of total billed charges for outpatient setting,128,1390.59,
RENAL FUNCTION PANEL,200025,CDM,300,RC,80069,HCPCS,Outpatient,,,39.06,35.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,70,,21.87,percent of total billed charges,70% of total billed charges for outpatient setting,33.15,84.88,,26.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.91,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,29.3,75,,23.44,percent of total billed charges,75% of total billed charges for outpatient setting,27.34,70,,21.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.25,80,,25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,12.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,100% of Custom Fee Schedule,35.15,90,,28.12,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,35.15,
RENAL/BIL/FLUSH/SEL,2200700,CDM,323,RC,,,Outpatient,,,5129.58,3847.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3590.71,70,,2872.57,percent of total billed charges,70% of total billed charges for outpatient setting,4353.99,84.88,,3483.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,2564.79,50,,2051.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3847.19,75,,3077.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.64,12.84,,526.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4103.66,80,,3282.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.64,12.84,,526.91,percent of total billed charges,12.84% of total billed charges,658.64,12.84,,526.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1795.35,35,,1436.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4616.62,90,,3693.3,percent of total billed charges,90% of total billed charges for outpatient setting,128,4616.62,
RENAL/UNI/FLUSH/SEL,2200695,CDM,323,RC,,,Outpatient,,,5129.58,3847.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3590.71,70,,2872.57,percent of total billed charges,70% of total billed charges for outpatient setting,4353.99,84.88,,3483.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,2564.79,50,,2051.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3847.19,75,,3077.75,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.64,12.84,,526.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4103.66,80,,3282.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.64,12.84,,526.91,percent of total billed charges,12.84% of total billed charges,658.64,12.84,,526.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1795.35,35,,1436.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4616.62,90,,3693.3,percent of total billed charges,90% of total billed charges for outpatient setting,128,4616.62,
"RENIN,PLASMA",220427,CDM,301,RC,84244,HCPCS,Outpatient,,,98.96,89.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.27,70,,55.42,percent of total billed charges,70% of total billed charges for outpatient setting,84,84.88,,67.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,74.22,75,,59.38,percent of total billed charges,75% of total billed charges for outpatient setting,69.27,70,,55.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.17,80,,63.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,32.12,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,100,,,Fee Schedule,100% of Custom Fee Schedule,89.06,90,,71.25,percent of total billed charges,90% of total billed charges for outpatient setting,21.99,89.06,
RENO - 30 50 ML,3302295,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENO - 60 10ML,3302260,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENO - 60 50ML,3302265,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENO -60 100ML,3302270,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENO -60 150ML,3302275,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENO DIP 300 ML,3302300,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOCAL 76 100 ML,3302310,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOCAL 76 150 ML,3302315,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOCAL 76 200 ML,3302320,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOCAL 76 50ML,3302305,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOGRAFIN 60 SOLN: 100ML,3302290,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOGRAFIN 60 SOLN: 10ML,3302280,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
RENOGRAFIN 60 SOLN: 50ML,3302285,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
REPTILASE TEST,201316,CDM,300,RC,85635,HCPCS,Outpatient,,,44.33,39.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,70,,24.82,percent of total billed charges,70% of total billed charges for outpatient setting,37.63,84.88,,30.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.91,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,33.25,75,,26.6,percent of total billed charges,75% of total billed charges for outpatient setting,31.03,70,,24.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.46,80,,28.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.38,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.67,100,,,Fee Schedule,100% of Custom Fee Schedule,39.9,90,,31.92,percent of total billed charges,90% of total billed charges for outpatient setting,9.85,39.9,
REQUIP (ROPINIROLE) 0.25 MG: TAB,3303133,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
RESERVOIR PAIN CONTROL PUMP 600ML,3309100,CDM,250,RC,,,Outpatient,,,1103.13,1103.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.19,70,,617.75,percent of total billed charges,70% of total billed charges for outpatient setting,936.34,84.88,,749.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,551.57,50,,441.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,827.35,75,,661.88,percent of total billed charges,75% of total billed charges for outpatient setting,772.19,70,,617.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.64,12.84,,113.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.5,80,,706,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.64,12.84,,113.31,percent of total billed charges,12.84% of total billed charges,141.64,12.84,,113.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,717.03,65,,573.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.1,35,,308.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,992.82,90,,794.26,percent of total billed charges,90% of total billed charges for outpatient setting,141.64,992.82,
RESEVOIR 125ML TITAN / ER8125,999588,CDM,278,RC,L8699,HCPCS,Outpatient,,,6030.5,6030.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3618.3,60,,2894.64,percent of total billed charges,60% of total Billed charges for outpatient setting,5118.69,84.88,,4094.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,3015.25,50,,2412.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4522.88,75,,3618.3,percent of total billed charges,75% of total billed charges for outpatient setting,3015.25,50,,2412.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.32,12.84,,619.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4824.4,80,,3859.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.32,12.84,,619.46,percent of total billed charges,12.84% of total billed charges,774.32,12.84,,619.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6332.03,105,,5065.62,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2110.68,35,,1688.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3618.3,60,,2894.64,percent of total billed charges,60% of total billed charges for outpatient setting,774.32,6332.03,
RESOR BALSAM (ANUSOL) SUPP :,3301933,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
RESOR BALSAM (HEMORRHOIDAL) SUPP:,3301932,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
RESUSCITATOR ADULT FILTERED / AF-5140MB,814281,CDM,272,RC,,,Outpatient,,,53.63,53.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.54,70,,30.03,percent of total billed charges,70% of total billed charges for outpatient setting,45.52,84.88,,36.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.82,50,,21.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.22,75,,32.18,percent of total billed charges,75% of total billed charges for outpatient setting,37.54,70,,30.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,12.84,,5.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.9,80,,34.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,12.84,,5.51,percent of total billed charges,12.84% of total billed charges,6.89,12.84,,5.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.86,65,,27.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.77,35,,15.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.27,90,,38.62,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,48.27,
RESUSCITATOR ADULT W/PEEP / 8501,3750010,CDM,270,RC,,,Outpatient,,,91.91,91.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.34,70,,51.47,percent of total billed charges,70% of total billed charges for outpatient setting,78.01,84.88,,62.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.96,50,,36.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.93,75,,55.14,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,70,,51.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.53,80,,58.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,11.8,12.84,,9.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.74,65,,47.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.17,35,,25.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.72,90,,66.18,percent of total billed charges,90% of total billed charges for outpatient setting,11.8,82.72,
RESUSCITATOR INFANT W/ PEEP,3750011,CDM,270,RC,,,Outpatient,,,135.45,135.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.82,70,,75.86,percent of total billed charges,70% of total billed charges for outpatient setting,114.97,84.88,,91.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.73,50,,54.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.59,75,,81.27,percent of total billed charges,75% of total billed charges for outpatient setting,94.82,70,,75.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,12.84,,13.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.36,80,,86.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,12.84,,13.91,percent of total billed charges,12.84% of total billed charges,17.39,12.84,,13.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.04,65,,70.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.41,35,,37.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.91,90,,97.53,percent of total billed charges,90% of total billed charges for outpatient setting,17.39,121.91,
RESUSCITATOR PED FILTERED / AF-2140MB,814077,CDM,272,RC,,,Outpatient,,,61.04,61.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.73,70,,34.18,percent of total billed charges,70% of total billed charges for outpatient setting,51.81,84.88,,41.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.52,50,,24.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.78,75,,36.62,percent of total billed charges,75% of total billed charges for outpatient setting,42.73,70,,34.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,12.84,,6.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.83,80,,39.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,12.84,,6.27,percent of total billed charges,12.84% of total billed charges,7.84,12.84,,6.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.68,65,,31.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.36,35,,17.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,54.94,90,,43.95,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,54.94,
RETENTION BRIDGE SUTURE / RSB5,69160822,CDM,272,RC,,,Outpatient,,,50.35,50.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.25,70,,28.2,percent of total billed charges,70% of total billed charges for outpatient setting,42.74,84.88,,34.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.18,50,,20.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.76,75,,30.21,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,70,,28.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,12.84,,5.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,80,,32.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,12.84,,5.17,percent of total billed charges,12.84% of total billed charges,6.46,12.84,,5.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.73,65,,26.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,35,,14.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.32,90,,36.26,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,45.32,
RETIC COUNT,220162,CDM,305,RC,85045,HCPCS,Outpatient,,,17.96,16.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.57,70,,10.06,percent of total billed charges,70% of total billed charges for outpatient setting,15.24,84.88,,12.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.47,75,,10.78,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,70,,10.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.37,80,,11.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.58,100,,,Fee Schedule,100% of Custom Fee Schedule,16.16,90,,12.93,percent of total billed charges,90% of total billed charges for outpatient setting,3.99,16.16,
RETICULIN ANTIBODIES,200654,CDM,302,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
RETRACTOR ALEXIS 2.5-6CM SMALL / C8301,69162095,CDM,272,RC,,,Outpatient,,,248,248,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.6,70,,138.88,percent of total billed charges,70% of total billed charges for outpatient setting,210.5,84.88,,168.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,124,50,,99.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186,75,,148.8,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,70,,138.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.4,80,,158.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.2,65,,128.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.8,35,,69.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.2,90,,178.56,percent of total billed charges,90% of total billed charges for outpatient setting,31.84,223.2,
RETRACTOR ALEXIS 5-9CM MED / C8302,69161261,CDM,272,RC,,,Outpatient,,,218.4,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,185.38,84.88,,148.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.2,50,,87.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.8,75,,131.04,percent of total billed charges,75% of total billed charges for outpatient setting,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,80,,139.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.96,65,,113.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.44,35,,61.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.56,90,,157.25,percent of total billed charges,90% of total billed charges for outpatient setting,28.04,196.56,
RETRACTOR ALEXIS 9-14CM LG / C8303,69160145,CDM,272,RC,,,Outpatient,,,281.79,281.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.25,70,,157.8,percent of total billed charges,70% of total billed charges for outpatient setting,239.18,84.88,,191.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,140.9,50,,112.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.34,75,,169.07,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,70,,157.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,12.84,,28.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.43,80,,180.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,12.84,,28.94,percent of total billed charges,12.84% of total billed charges,36.18,12.84,,28.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.16,65,,146.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.63,35,,78.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,253.61,90,,202.89,percent of total billed charges,90% of total billed charges for outpatient setting,36.18,253.61,
RETRIEVE BONE MARROW ASP KIT / 691.100S,69161943,CDM,272,RC,,,Outpatient,,,1587.64,1587.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.35,70,,889.08,percent of total billed charges,70% of total billed charges for outpatient setting,1347.59,84.88,,1078.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,793.82,50,,635.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1190.73,75,,952.58,percent of total billed charges,75% of total billed charges for outpatient setting,1111.35,70,,889.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.85,12.84,,163.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1270.11,80,,1016.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.85,12.84,,163.08,percent of total billed charges,12.84% of total billed charges,203.85,12.84,,163.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1031.97,65,,825.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.67,35,,444.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1428.88,90,,1143.1,percent of total billed charges,90% of total billed charges for outpatient setting,203.85,1428.88,
RETRIEVE TIP  691.003S,69162106,CDM,272,RC,,,Outpatient,,,1055.54,1055.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.88,70,,591.1,percent of total billed charges,70% of total billed charges for outpatient setting,895.94,84.88,,716.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,527.77,50,,422.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,791.66,75,,633.33,percent of total billed charges,75% of total billed charges for outpatient setting,738.88,70,,591.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.53,12.84,,108.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.43,80,,675.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.53,12.84,,108.42,percent of total billed charges,12.84% of total billed charges,135.53,12.84,,108.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,686.1,65,,548.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.44,35,,295.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,949.99,90,,759.99,percent of total billed charges,90% of total billed charges for outpatient setting,135.53,949.99,
RETRIEVE WIRE  691.022S,69162107,CDM,272,RC,,,Outpatient,,,661.88,661.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.32,70,,370.66,percent of total billed charges,70% of total billed charges for outpatient setting,561.8,84.88,,449.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,330.94,50,,264.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.41,75,,397.13,percent of total billed charges,75% of total billed charges for outpatient setting,463.32,70,,370.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.99,12.84,,67.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.5,80,,423.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.99,12.84,,67.99,percent of total billed charges,12.84% of total billed charges,84.99,12.84,,67.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,430.22,65,,344.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.66,35,,185.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,595.69,90,,476.55,percent of total billed charges,90% of total billed charges for outpatient setting,84.99,595.69,
RETRIEVER ROTH NET 2.5X350 / 00711152,70000119,CDM,272,RC,,,Outpatient,,,454.23,454.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.96,70,,254.37,percent of total billed charges,70% of total billed charges for outpatient setting,385.55,84.88,,308.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,227.12,50,,181.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.67,75,,272.54,percent of total billed charges,75% of total billed charges for outpatient setting,317.96,70,,254.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,80,,290.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,58.32,12.84,,46.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,295.25,65,,236.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,35,,127.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,408.81,90,,327.05,percent of total billed charges,90% of total billed charges for outpatient setting,58.32,408.81,
RETROBUTTON DRILL PIN II,69161475,CDM,272,RC,,,Outpatient,,,512.41,512.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.69,70,,286.95,percent of total billed charges,70% of total billed charges for outpatient setting,434.93,84.88,,347.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.21,50,,204.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,384.31,75,,307.45,percent of total billed charges,75% of total billed charges for outpatient setting,358.69,70,,286.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.79,12.84,,52.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.93,80,,327.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.79,12.84,,52.63,percent of total billed charges,12.84% of total billed charges,65.79,12.84,,52.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,333.07,65,,266.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.34,35,,143.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,461.17,90,,368.94,percent of total billed charges,90% of total billed charges for outpatient setting,65.79,461.17,
RETROCUTTER 8.5MM  / AR-1204R-085S,69162465,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
RETROCUTTER 9.5MM  / AR-1204R-095S,69161923,CDM,272,RC,,,Outpatient,,,843.57,843.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,716.02,84.88,,572.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,421.79,50,,337.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,632.68,75,,506.14,percent of total billed charges,75% of total billed charges for outpatient setting,590.5,70,,472.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.86,80,,539.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,108.31,12.84,,86.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,548.32,65,,438.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.25,35,,236.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,759.21,90,,607.37,percent of total billed charges,90% of total billed charges for outpatient setting,108.31,759.21,
"RETRODRILL GD ASSMBLY, CANLTED AR-1250RP",69161924,CDM,272,RC,,,Outpatient,,,627.27,627.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.09,70,,351.27,percent of total billed charges,70% of total billed charges for outpatient setting,532.43,84.88,,425.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,313.64,50,,250.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,470.45,75,,376.36,percent of total billed charges,75% of total billed charges for outpatient setting,439.09,70,,351.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.54,12.84,,64.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.82,80,,401.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.54,12.84,,64.43,percent of total billed charges,12.84% of total billed charges,80.54,12.84,,64.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,407.73,65,,326.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.54,35,,175.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,564.54,90,,451.63,percent of total billed charges,90% of total billed charges for outpatient setting,80.54,564.54,
RETRT GELPORT / C8XX2,69161848,CDM,272,RC,,,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1592.5,70,,1274,percent of total billed charges,70% of total billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1592.5,70,,1274,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1478.75,65,,1183,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2047.5,90,,1638,percent of total billed charges,90% of total billed charges for outpatient setting,292.11,2047.5,
REVEAL LINQ INSRTBL CARDIAC MNTR/LINQSYS,69162524,CDM,278,RC,C1764,HCPCS,Outpatient,,,3446,3446,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.6,60,,1654.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2924.96,84.88,,2339.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2584.5,75,,2067.6,percent of total billed charges,75% of total billed charges for outpatient setting,1723,50,,1378.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.47,12.84,,353.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2756.8,80,,2205.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.47,12.84,,353.98,percent of total billed charges,12.84% of total billed charges,442.47,12.84,,353.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3618.3,105,,2894.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.1,35,,964.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2067.6,60,,1654.08,percent of total billed charges,60% of total billed charges for outpatient setting,442.47,3618.3,
REVEAL XT 9529-CARDIAC MONITOR,69161489,CDM,278,RC,C1764,HCPCS,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,60,,3840,percent of total billed charges,60% of total Billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8400,105,,6720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4800,60,,3840,percent of total billed charges,60% of total billed charges for outpatient setting,1027.2,8400,
RHEUMATOID FACTOR,201205,CDM,300,RC,86430,HCPCS,Outpatient,,,27.63,24.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,70,,15.47,percent of total billed charges,70% of total billed charges for outpatient setting,23.45,84.88,,18.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.72,75,,16.58,percent of total billed charges,75% of total billed charges for outpatient setting,19.34,70,,15.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.1,80,,17.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,100,,,Fee Schedule,100% of Custom Fee Schedule,24.87,90,,19.9,percent of total billed charges,90% of total billed charges for outpatient setting,6.14,24.87,
RHEUMATOID FACTOR,220528,CDM,300,RC,86430,HCPCS,Outpatient,,,27.63,24.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,70,,15.47,percent of total billed charges,70% of total billed charges for outpatient setting,23.45,84.88,,18.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.72,75,,16.58,percent of total billed charges,75% of total billed charges for outpatient setting,19.34,70,,15.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.1,80,,17.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,100,,,Fee Schedule,100% of Custom Fee Schedule,24.87,90,,19.9,percent of total billed charges,90% of total billed charges for outpatient setting,6.14,24.87,
RHINO ROCKET SLIMLNE LG / 11S-SO800-08AS,69161470,CDM,272,RC,,,Outpatient,,,117,117,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.9,70,,65.52,percent of total billed charges,70% of total billed charges for outpatient setting,99.31,84.88,,79.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.5,50,,46.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,75,,70.2,percent of total billed charges,75% of total billed charges for outpatient setting,81.9,70,,65.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.02,12.84,,12.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,80,,74.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.02,12.84,,12.02,percent of total billed charges,12.84% of total billed charges,15.02,12.84,,12.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.05,65,,60.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.95,35,,32.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.3,90,,84.24,percent of total billed charges,90% of total billed charges for outpatient setting,15.02,105.3,
RHINOCORT AQ:,3300693,CDM,259,RC,,,Outpatient,,,131.06,131.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.74,70,,73.39,percent of total billed charges,70% of total billed charges for outpatient setting,111.24,84.88,,88.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.53,50,,52.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.3,75,,78.64,percent of total billed charges,75% of total billed charges for outpatient setting,91.74,70,,73.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,12.84,,13.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.85,80,,83.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,12.84,,13.46,percent of total billed charges,12.84% of total billed charges,16.83,12.84,,13.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.19,65,,68.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.87,35,,36.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,117.95,90,,94.36,percent of total billed charges,90% of total billed charges for outpatient setting,16.83,117.95,
RHO D IMMUNE GLOBULIN 300MCG SYR,3314110,CDM,636,RC,J2790,HCPCS,Outpatient,,,280.8,280.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.56,70,,157.25,percent of total billed charges,70% of total billed charges for outpatient setting,238.34,84.88,,190.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,210.6,75,,168.48,percent of total billed charges,75% of total billed charges for outpatient setting,196.56,70,,157.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.05,12.84,,28.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.64,80,,179.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.05,12.84,,28.84,percent of total billed charges,12.84% of total billed charges,36.05,12.84,,28.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,182.52,65,,146.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.38,100,,,Fee Schedule,100% of Custom Fee Schedule,252.72,90,,202.18,percent of total billed charges,90% of total billed charges for outpatient setting,36.05,252.72,
RIBS,2400185,CDM,320,RC,71111,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
RIBS BILATERAL 3 VWS,2400180,CDM,320,RC,71110,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
RIBS UNILATERAL POSTEROANTERIO LEFT,2400176,CDM,320,RC,71101,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
RIBS UNILATERAL POSTEROANTERIO RIGHT,2400175,CDM,320,RC,71101,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
RIBS UNILATERAL TWO VIEWS LEFT,2400171,CDM,320,RC,71100,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
RIBS UNILATERAL TWO VIEWS RIGHT,2400170,CDM,320,RC,71100,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
RIFAMPIN (RIFADIN) CAP 300 MG  U/D,3301936,CDM,259,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,70,,3.36,percent of total billed charges,70% of total billed charges for outpatient setting,5.09,84.88,,4.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,3,50,,2.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.5,75,,3.6,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,70,,3.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,12.84,,0.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,80,,3.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,0.77,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.9,65,,3.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,35,,1.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.4,90,,4.32,percent of total billed charges,90% of total billed charges for outpatient setting,0.77,5.4,
RIFAMPIN (RIFADIN) CAP: 300 MG,3301935,CDM,259,RC,,,Outpatient,,,6.07,6.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,70,,3.4,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,84.88,,4.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.04,50,,2.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.55,75,,3.64,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,70,,3.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,80,,3.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,0.78,12.84,,0.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.95,65,,3.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,35,,1.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.46,90,,4.37,percent of total billed charges,90% of total billed charges for outpatient setting,0.78,5.46,
RIFAMPIN 150MG CAP,3313918,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
RIFAMPIN 600MG INJ,3303267,CDM,250,RC,,,Outpatient,,,562.8,562.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.96,70,,315.17,percent of total billed charges,70% of total billed charges for outpatient setting,477.7,84.88,,382.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.4,50,,225.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422.1,75,,337.68,percent of total billed charges,75% of total billed charges for outpatient setting,393.96,70,,315.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,12.84,,57.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.24,80,,360.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,12.84,,57.81,percent of total billed charges,12.84% of total billed charges,72.26,12.84,,57.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,365.82,65,,292.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.98,35,,157.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.52,90,,405.22,percent of total billed charges,90% of total billed charges for outpatient setting,72.26,506.52,
RIFAXIMIN (XIFAXAN) 200MG:TAB,3303263,CDM,259,RC,,,Outpatient,,,36.58,36.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.61,70,,20.49,percent of total billed charges,70% of total billed charges for outpatient setting,31.05,84.88,,24.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.29,50,,14.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.44,75,,21.95,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,70,,20.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.26,80,,23.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,4.7,12.84,,3.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.78,65,,19.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.8,35,,10.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.92,90,,26.34,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,32.92,
RIFAXIMIN (XIFAXAN) 550MG: TAB,3303343,CDM,259,RC,,,Outpatient,,,90.62,90.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.43,70,,50.74,percent of total billed charges,70% of total billed charges for outpatient setting,76.92,84.88,,61.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.31,50,,36.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.97,75,,54.38,percent of total billed charges,75% of total billed charges for outpatient setting,63.43,70,,50.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,12.84,,9.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.5,80,,58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,11.64,12.84,,9.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.9,65,,47.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.72,35,,25.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.56,90,,65.25,percent of total billed charges,90% of total billed charges for outpatient setting,11.64,81.56,
RIGHT ANGLE LOOP 24FR YELLOW / MLE-24-01,6150600,CDM,270,RC,,,Outpatient,,,259.26,259.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.48,70,,145.18,percent of total billed charges,70% of total billed charges for outpatient setting,220.06,84.88,,176.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,129.63,50,,103.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.45,75,,155.56,percent of total billed charges,75% of total billed charges for outpatient setting,181.48,70,,145.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.29,12.84,,26.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.41,80,,165.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.29,12.84,,26.63,percent of total billed charges,12.84% of total billed charges,33.29,12.84,,26.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,168.52,65,,134.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.74,35,,72.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,233.33,90,,186.66,percent of total billed charges,90% of total billed charges for outpatient setting,33.29,233.33,
RIGHT ANGLE LOOP 26FR WHITE / MLE-26-012,6150601,CDM,270,RC,,,Outpatient,,,239.84,239.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.89,70,,134.31,percent of total billed charges,70% of total billed charges for outpatient setting,203.58,84.88,,162.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.92,50,,95.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.88,75,,143.9,percent of total billed charges,75% of total billed charges for outpatient setting,167.89,70,,134.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,12.84,,24.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.87,80,,153.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,12.84,,24.64,percent of total billed charges,12.84% of total billed charges,30.8,12.84,,24.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,155.9,65,,124.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.94,35,,67.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,215.86,90,,172.69,percent of total billed charges,90% of total billed charges for outpatient setting,30.8,215.86,
RING FOOT LONG 155MM / 4934-4-155,70000664,CDM,278,RC,C1713,HCPCS,Outpatient,,,4027.3,4027.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2416.38,60,,1933.1,percent of total billed charges,60% of total Billed charges for outpatient setting,3418.37,84.88,,2734.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3020.48,75,,2416.38,percent of total billed charges,75% of total billed charges for outpatient setting,2013.65,50,,1610.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.11,12.84,,413.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3221.84,80,,2577.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.11,12.84,,413.69,percent of total billed charges,12.84% of total billed charges,517.11,12.84,,413.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4228.67,105,,3382.94,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1409.56,35,,1127.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2416.38,60,,1933.1,percent of total billed charges,60% of total billed charges for outpatient setting,517.11,4228.67,
RING FULL DIA180MM / 4933-5-180,70000665,CDM,278,RC,C1713,HCPCS,Outpatient,,,3151.8,3151.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891.08,60,,1512.86,percent of total billed charges,60% of total Billed charges for outpatient setting,2675.25,84.88,,2140.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2363.85,75,,1891.08,percent of total billed charges,75% of total billed charges for outpatient setting,1575.9,50,,1260.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.69,12.84,,323.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2521.44,80,,2017.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.69,12.84,,323.75,percent of total billed charges,12.84% of total billed charges,404.69,12.84,,323.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3309.39,105,,2647.51,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.13,35,,882.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1891.08,60,,1512.86,percent of total billed charges,60% of total billed charges for outpatient setting,404.69,3309.39,
RISPERIDONE (RISPERDAL) 0.25 MG TAB:,3301937,CDM,259,RC,,,Outpatient,,,8.48,8.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.94,70,,4.75,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,84.88,,5.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.24,50,,3.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.36,75,,5.09,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,70,,4.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.78,80,,5.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,1.09,12.84,,0.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.51,65,,4.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.97,35,,2.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.63,90,,6.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.09,7.63,
RISPERIDONE (RISPERDAL) 0.5 MG TAB:,3301938,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
RISPERIDONE (RISPERDAL) 1 MG TAB:,3301939,CDM,259,RC,,,Outpatient,,,6.88,6.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,5.84,84.88,,4.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.44,50,,2.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.16,75,,4.13,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,70,,3.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,80,,4.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.88,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.47,65,,3.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,35,,1.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.19,90,,4.95,percent of total billed charges,90% of total billed charges for outpatient setting,0.88,6.19,
RISPERIDONE (RISPERDAL) 1 MG TAB:  U/D,3301940,CDM,259,RC,,,Outpatient,,,7.72,7.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,70,,4.32,percent of total billed charges,70% of total billed charges for outpatient setting,6.55,84.88,,5.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.86,50,,3.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.79,75,,4.63,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,70,,4.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.18,80,,4.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.02,65,,4.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,35,,2.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.95,90,,5.56,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.95,
RITUXIMAB (RITUXAN) 100mg/unit (WASTAGE),3305501,CDM,636,RC,J9310,HCPCS,Outpatient,,,2519.75,2519.75,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.83,70,,1411.06,percent of total billed charges,70% of total billed charges for outpatient setting,2138.76,84.88,,1711.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,1259.88,50,,1007.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1889.81,75,,1511.85,percent of total billed charges,75% of total billed charges for outpatient setting,1763.83,70,,1411.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.54,12.84,,258.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2015.8,80,,1612.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.54,12.84,,258.83,percent of total billed charges,12.84% of total billed charges,323.54,12.84,,258.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1637.84,65,,1310.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.91,35,,705.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2267.78,90,,1814.22,percent of total billed charges,90% of total billed charges for outpatient setting,323.54,2267.78,
RITUXIMAB (RITUXAN) 100mg/unit :10ML INJ,3305123,CDM,636,RC,J9310,HCPCS,Outpatient,,,2519.75,2519.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.83,70,,1411.06,percent of total billed charges,70% of total billed charges for outpatient setting,2138.76,84.88,,1711.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,1259.88,50,,1007.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1889.81,75,,1511.85,percent of total billed charges,75% of total billed charges for outpatient setting,1763.83,70,,1411.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.54,12.84,,258.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2015.8,80,,1612.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.54,12.84,,258.83,percent of total billed charges,12.84% of total billed charges,323.54,12.84,,258.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1637.84,65,,1310.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,824.81,100,,,Fee Schedule,100% of Custom Fee Schedule,2267.78,90,,1814.22,percent of total billed charges,90% of total billed charges for outpatient setting,323.54,2267.78,
RITUXIMAB (RITUXAN) 100mg/unit 50ML INJ,3305122,CDM,636,RC,J9310,HCPCS,Outpatient,,,2614.58,2614.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.21,70,,1464.17,percent of total billed charges,70% of total billed charges for outpatient setting,2219.26,84.88,,1775.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1307.29,50,,1045.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1960.94,75,,1568.75,percent of total billed charges,75% of total billed charges for outpatient setting,1830.21,70,,1464.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.71,12.84,,268.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2091.66,80,,1673.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.71,12.84,,268.57,percent of total billed charges,12.84% of total billed charges,335.71,12.84,,268.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1699.48,65,,1359.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,824.81,100,,,Fee Schedule,100% of Custom Fee Schedule,2353.12,90,,1882.5,percent of total billed charges,90% of total billed charges for outpatient setting,335.71,2353.12,
RIVAROXABAN (XARELTO) 10MG TABS,3306130,CDM,259,RC,,,Outpatient,,,93.11,93.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.18,70,,52.14,percent of total billed charges,70% of total billed charges for outpatient setting,79.03,84.88,,63.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.56,50,,37.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.83,75,,55.86,percent of total billed charges,75% of total billed charges for outpatient setting,65.18,70,,52.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,12.84,,9.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.49,80,,59.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,12.84,,9.57,percent of total billed charges,12.84% of total billed charges,11.96,12.84,,9.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.52,65,,48.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,35,,26.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.8,90,,67.04,percent of total billed charges,90% of total billed charges for outpatient setting,11.96,83.8,
RIVAROXABAN (XARELTO) 15MG TABS,3305792,CDM,259,RC,,,Outpatient,,,27.99,27.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,70,,15.67,percent of total billed charges,70% of total billed charges for outpatient setting,23.76,84.88,,19.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,14,50,,11.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.99,75,,16.79,percent of total billed charges,75% of total billed charges for outpatient setting,19.59,70,,15.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,12.84,,2.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.39,80,,17.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,12.84,,2.87,percent of total billed charges,12.84% of total billed charges,3.59,12.84,,2.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.19,65,,14.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.8,35,,7.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.19,90,,20.15,percent of total billed charges,90% of total billed charges for outpatient setting,3.59,25.19,
RIVAROXABAN (XARELTO) 20MG TABS,3314052,CDM,259,RC,,,Outpatient,,,85.33,85.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.73,70,,47.78,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,84.88,,57.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.67,50,,34.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64,75,,51.2,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,70,,47.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.26,80,,54.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.46,65,,44.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.87,35,,23.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.8,90,,61.44,percent of total billed charges,90% of total billed charges for outpatient setting,10.96,76.8,
RIVASTIGMINE (EXELON) 4.5MG:CAP,3305736,CDM,259,RC,,,Outpatient,,,18.57,18.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13,70,,10.4,percent of total billed charges,70% of total billed charges for outpatient setting,15.76,84.88,,12.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.29,50,,7.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.93,75,,11.14,percent of total billed charges,75% of total billed charges for outpatient setting,13,70,,10.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.86,80,,11.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.07,65,,9.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,35,,5.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.71,90,,13.37,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.71,
RIVASTIGMINE (EXELON) 4.6MG/24HR:PATCH,3303773,CDM,259,RC,,,Outpatient,,,40.62,40.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,70,,22.74,percent of total billed charges,70% of total billed charges for outpatient setting,34.48,84.88,,27.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.31,50,,16.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.47,75,,24.38,percent of total billed charges,75% of total billed charges for outpatient setting,28.43,70,,22.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,12.84,,4.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.5,80,,26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,12.84,,4.18,percent of total billed charges,12.84% of total billed charges,5.22,12.84,,4.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.4,65,,21.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,35,,11.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.56,90,,29.25,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,36.56,
RIZATRIPTAN (MAXALT) TAB: 10 MG,3301941,CDM,259,RC,,,Outpatient,,,46.98,46.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.89,70,,26.31,percent of total billed charges,70% of total billed charges for outpatient setting,39.88,84.88,,31.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.49,50,,18.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.24,75,,28.19,percent of total billed charges,75% of total billed charges for outpatient setting,32.89,70,,26.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,12.84,,4.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,80,,30.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,6.03,12.84,,4.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,65,,24.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,35,,13.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.28,90,,33.82,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,42.28,
RIZATRIPTAN 10MG TABS,3303359,CDM,250,RC,,,Outpatient,,,79.34,79.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,67.34,84.88,,53.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.67,50,,31.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.51,75,,47.61,percent of total billed charges,75% of total billed charges for outpatient setting,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.47,80,,50.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.57,65,,41.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,35,,22.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.41,90,,57.13,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,71.41,
ROBOT ASSISTANCE,69161307,CDM,360,RC,S2900,HCPCS,Outpatient,,,1704.34,1704.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.04,70,,954.43,percent of total billed charges,70% of total billed charges for outpatient setting,1446.64,84.88,,1157.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,852.17,50,,681.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1278.26,75,,1022.61,percent of total billed charges,75% of total billed charges for outpatient setting,1193.04,70,,954.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.84,12.84,,175.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.47,80,,1090.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.84,12.84,,175.07,percent of total billed charges,12.84% of total billed charges,218.84,12.84,,175.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.52,35,,477.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1533.91,90,,1227.13,percent of total billed charges,90% of total billed charges for outpatient setting,218.84,1533.91,
ROBOT ASSISTANCE - ORTHO,71000460,CDM,360,RC,S2900,HCPCS,Outpatient,,,1704.34,1704.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.04,70,,954.43,percent of total billed charges,70% of total billed charges for outpatient setting,1446.64,84.88,,1157.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,852.17,50,,681.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1278.26,75,,1022.61,percent of total billed charges,75% of total billed charges for outpatient setting,1193.04,70,,954.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.84,12.84,,175.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.47,80,,1090.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.84,12.84,,175.07,percent of total billed charges,12.84% of total billed charges,218.84,12.84,,175.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.52,35,,477.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1533.91,90,,1227.13,percent of total billed charges,90% of total billed charges for outpatient setting,218.84,1533.91,
"ROCKY MOUNTAIN SPOTTED FEVER,IGG",220640,CDM,310,RC,86757,HCPCS,Outpatient,,,87.08,78.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,73.91,84.88,,59.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.31,75,,52.25,percent of total billed charges,75% of total billed charges for outpatient setting,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.66,80,,55.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.7,100,,,Fee Schedule,100% of Custom Fee Schedule,78.37,90,,62.7,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,78.37,
"ROCKY MOUNTAIN SPOTTED FEVER,IGM",220639,CDM,310,RC,86757,HCPCS,Outpatient,,,87.08,78.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,73.91,84.88,,59.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,65.31,75,,52.25,percent of total billed charges,75% of total billed charges for outpatient setting,60.96,70,,48.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.66,80,,55.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.26,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.7,100,,,Fee Schedule,100% of Custom Fee Schedule,78.37,90,,62.7,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,78.37,
ROCURONIUM (ZEMERON) 10MG/ML 5ML,3301942,CDM,250,RC,J3490,HCPCS,Outpatient,,,28.73,28.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.11,70,,16.09,percent of total billed charges,70% of total billed charges for outpatient setting,24.39,84.88,,19.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.55,75,,17.24,percent of total billed charges,75% of total billed charges for outpatient setting,20.11,70,,16.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.69,12.84,,2.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.98,80,,18.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.69,12.84,,2.95,percent of total billed charges,12.84% of total billed charges,3.69,12.84,,2.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.67,65,,14.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.06,35,,8.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.86,90,,20.69,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,25.86,
ROD 150MM THREADED / 4933-1-150,70000770,CDM,278,RC,C1713,HCPCS,Outpatient,,,278.8,278.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,60,,133.82,percent of total billed charges,60% of total Billed charges for outpatient setting,236.65,84.88,,189.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.1,75,,167.28,percent of total billed charges,75% of total billed charges for outpatient setting,139.4,50,,111.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.8,12.84,,28.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.04,80,,178.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.8,12.84,,28.64,percent of total billed charges,12.84% of total billed charges,35.8,12.84,,28.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,278.8,65,,223.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.58,35,,78.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.28,60,,133.82,percent of total billed charges,60% of total billed charges for outpatient setting,35.8,278.8,
ROD 2.5X950MM REAMING W/BALL / 351.706S,69162056,CDM,272,RC,,,Outpatient,,,631.48,631.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.04,70,,353.63,percent of total billed charges,70% of total billed charges for outpatient setting,536,84.88,,428.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,315.74,50,,252.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.61,75,,378.89,percent of total billed charges,75% of total billed charges for outpatient setting,442.04,70,,353.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.08,12.84,,64.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.18,80,,404.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.08,12.84,,64.86,percent of total billed charges,12.84% of total billed charges,81.08,12.84,,64.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,410.46,65,,328.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.02,35,,176.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,568.33,90,,454.66,percent of total billed charges,90% of total billed charges for outpatient setting,81.08,568.33,
ROD 3.5X120MM CAPITOL CRV 111.920,69162678,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X25MM CAPITOL / 111.825,1451471,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 3.5X30MM CAPITOL / 111.830,69162672,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 3.5X35MM CAPITOL / 111.835,69169290,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X40MM CAPITOL / 111.840,69162619,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X45MM ELLIPSE / 111.845,69162383,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 3.5X50MM CAPITOL CRV / 111.850,70000110,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X55MM CAPITOL CRV / 111.855,69162647,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 3.5X60MM CAPITOL CRV / 111.860,69162648,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X60MM CAPITOL CRV / 111.865,69169565,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 3.5X80MM CAPITOL CRV / 111.880,1660425,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 3.5X85MM CAPITOL CRV / 111.885,1451431,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 30MM THREADED / 4933-1-030,70000781,CDM,278,RC,C1713,HCPCS,Outpatient,,,241.4,241.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.84,60,,115.87,percent of total billed charges,60% of total Billed charges for outpatient setting,204.9,84.88,,163.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.05,75,,144.84,percent of total billed charges,75% of total billed charges for outpatient setting,120.7,50,,96.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.12,80,,154.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,241.4,65,,193.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.49,35,,67.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144.84,60,,115.87,percent of total billed charges,60% of total billed charges for outpatient setting,31,241.4,
ROD 40MM REVOLVE / 132.140,605590,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 45MM CREO / 1119.7045,69161733,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 45MM REVOLVE / 132.145,69162385,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 5.5x12MM OFFSET / 1175.2551,69169377,CDM,278,RC,C1713,HCPCS,Outpatient,,,2646,2646,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.6,60,,1270.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2245.92,84.88,,1796.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,75,,1587.6,percent of total billed charges,75% of total billed charges for outpatient setting,1323,50,,1058.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2116.8,80,,1693.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2778.3,105,,2222.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.1,35,,740.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1587.6,60,,1270.08,percent of total billed charges,60% of total billed charges for outpatient setting,339.75,2778.3,
ROD 5.5x150MM / 1119.5150,69162650,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 5.5x200MM HEX END / 1119.6200,1432774,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 5.5x300MM HEX END / 1119.6300,69162728,CDM,278,RC,C1713,HCPCS,Outpatient,,,2161.38,2161.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.83,60,,1037.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1834.58,84.88,,1467.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1621.04,75,,1296.83,percent of total billed charges,75% of total billed charges for outpatient setting,1080.69,50,,864.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.52,12.84,,222.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1729.1,80,,1383.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.52,12.84,,222.02,percent of total billed charges,12.84% of total billed charges,277.52,12.84,,222.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2269.45,105,,1815.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.48,35,,605.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296.83,60,,1037.46,percent of total billed charges,60% of total billed charges for outpatient setting,277.52,2269.45,
ROD 5.5x45MM  /PR5545,69169280,CDM,278,RC,C1713,HCPCS,Outpatient,,,1014.3,1014.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.58,60,,486.86,percent of total billed charges,60% of total Billed charges for outpatient setting,860.94,84.88,,688.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.73,75,,608.58,percent of total billed charges,75% of total billed charges for outpatient setting,507.15,50,,405.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.44,80,,649.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1014.3,65,,811.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.01,35,,284.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,608.58,60,,486.86,percent of total billed charges,60% of total billed charges for outpatient setting,130.24,1014.3,
ROD 5.5x45MM  STRAIGHT /SR5545,69169348,CDM,278,RC,C1713,HCPCS,Outpatient,,,1014.3,1014.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.58,60,,486.86,percent of total billed charges,60% of total Billed charges for outpatient setting,860.94,84.88,,688.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.73,75,,608.58,percent of total billed charges,75% of total billed charges for outpatient setting,507.15,50,,405.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.44,80,,649.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1014.3,65,,811.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.01,35,,284.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,608.58,60,,486.86,percent of total billed charges,60% of total billed charges for outpatient setting,130.24,1014.3,
ROD 5.5X45MM CONTOURED / 101-65545,69169159,CDM,278,RC,C1713,HCPCS,Outpatient,,,1044.73,1044.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.84,60,,501.47,percent of total billed charges,60% of total Billed charges for outpatient setting,886.77,84.88,,709.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.55,75,,626.84,percent of total billed charges,75% of total billed charges for outpatient setting,522.37,50,,417.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.78,80,,668.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1044.73,65,,835.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.66,35,,292.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,626.84,60,,501.47,percent of total billed charges,60% of total billed charges for outpatient setting,134.14,1044.73,
ROD 5.5x45MM STR HEAD / 1175.5511,69169170,CDM,278,RC,C1713,HCPCS,Outpatient,,,3804,3804,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2282.4,60,,1825.92,percent of total billed charges,60% of total Billed charges for outpatient setting,3228.84,84.88,,2583.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2853,75,,2282.4,percent of total billed charges,75% of total billed charges for outpatient setting,1902,50,,1521.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3043.2,80,,2434.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3994.2,105,,3195.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.4,35,,1065.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2282.4,60,,1825.92,percent of total billed charges,60% of total billed charges for outpatient setting,488.43,3994.2,
ROD 5.5X500MM HEX END / 1119.6500,69162685,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 5.5x50MM  STRAIGHT /SR5550,69169349,CDM,278,RC,C1713,HCPCS,Outpatient,,,1014.3,1014.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.58,60,,486.86,percent of total billed charges,60% of total Billed charges for outpatient setting,860.94,84.88,,688.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.73,75,,608.58,percent of total billed charges,75% of total billed charges for outpatient setting,507.15,50,,405.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.44,80,,649.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,130.24,12.84,,104.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1014.3,65,,811.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.01,35,,284.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,608.58,60,,486.86,percent of total billed charges,60% of total billed charges for outpatient setting,130.24,1014.3,
ROD 5.5X50MM CONTOURED / 101-65550,69169161,CDM,278,RC,C1713,HCPCS,Outpatient,,,1044.73,1044.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.84,60,,501.47,percent of total billed charges,60% of total Billed charges for outpatient setting,886.77,84.88,,709.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.55,75,,626.84,percent of total billed charges,75% of total billed charges for outpatient setting,522.37,50,,417.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.78,80,,668.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1044.73,65,,835.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.66,35,,292.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,626.84,60,,501.47,percent of total billed charges,60% of total billed charges for outpatient setting,134.14,1044.73,
ROD 5.5x50MM STR HEAD / 1175.5512,69169171,CDM,278,RC,C1713,HCPCS,Outpatient,,,3804,3804,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2282.4,60,,1825.92,percent of total billed charges,60% of total Billed charges for outpatient setting,3228.84,84.88,,2583.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2853,75,,2282.4,percent of total billed charges,75% of total billed charges for outpatient setting,1902,50,,1521.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3043.2,80,,2434.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3994.2,105,,3195.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.4,35,,1065.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2282.4,60,,1825.92,percent of total billed charges,60% of total billed charges for outpatient setting,488.43,3994.2,
ROD 5.5X55MM REVOLVE / 185.255,69162433,CDM,278,RC,C1713,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
ROD 5.5X58-70MM CREO CONNECT / 1119.0062,1401284,CDM,278,RC,C1713,HCPCS,Outpatient,,,2450,2450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470,60,,1176,percent of total billed charges,60% of total Billed charges for outpatient setting,2079.56,84.88,,1663.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1837.5,75,,1470,percent of total billed charges,75% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,80,,1568,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2572.5,105,,2058,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.5,35,,686,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1470,60,,1176,percent of total billed charges,60% of total billed charges for outpatient setting,314.58,2572.5,
ROD 5.5X65MM CONTOURED / 101-65565,69169146,CDM,278,RC,C1713,HCPCS,Outpatient,,,1044.73,1044.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.84,60,,501.47,percent of total billed charges,60% of total Billed charges for outpatient setting,886.77,84.88,,709.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.55,75,,626.84,percent of total billed charges,75% of total billed charges for outpatient setting,522.37,50,,417.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.78,80,,668.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,134.14,12.84,,107.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1044.73,65,,835.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.66,35,,292.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,626.84,60,,501.47,percent of total billed charges,60% of total billed charges for outpatient setting,134.14,1044.73,
ROD 5.5X65MM REVOLVE / 132.165,69162757,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 5.5X70MM REVOLVE / 132.170,69162371,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 5.5X70MM REVOLVE / 185.270,69162423,CDM,278,RC,C1713,HCPCS,Outpatient,,,2712.5,2712.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,60,,1302,percent of total billed charges,60% of total Billed charges for outpatient setting,2302.37,84.88,,1841.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034.38,75,,1627.5,percent of total billed charges,75% of total billed charges for outpatient setting,1356.25,50,,1085,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,80,,1736,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,348.29,12.84,,278.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2848.13,105,,2278.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.38,35,,759.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1627.5,60,,1302,percent of total billed charges,60% of total billed charges for outpatient setting,348.29,2848.13,
ROD 5.5x75MM SUP HEAD FL OFST/1175.5530,69169468,CDM,278,RC,C1713,HCPCS,Outpatient,,,3804,3804,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2282.4,60,,1825.92,percent of total billed charges,60% of total Billed charges for outpatient setting,3228.84,84.88,,2583.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2853,75,,2282.4,percent of total billed charges,75% of total billed charges for outpatient setting,1902,50,,1521.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3043.2,80,,2434.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3994.2,105,,3195.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.4,35,,1065.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2282.4,60,,1825.92,percent of total billed charges,60% of total billed charges for outpatient setting,488.43,3994.2,
ROD 5.5x75MM SUP HEAD OFFSET / 1175.5535,69169466,CDM,278,RC,C1713,HCPCS,Outpatient,,,3804,3804,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2282.4,60,,1825.92,percent of total billed charges,60% of total Billed charges for outpatient setting,3228.84,84.88,,2583.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2853,75,,2282.4,percent of total billed charges,75% of total billed charges for outpatient setting,1902,50,,1521.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3043.2,80,,2434.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,488.43,12.84,,390.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3994.2,105,,3195.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.4,35,,1065.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2282.4,60,,1825.92,percent of total billed charges,60% of total billed charges for outpatient setting,488.43,3994.2,
ROD 5.5X95MM REVOLVE / 132.195,69169143,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 50MM REVOLVE / 132.150,69162386,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 55MM REVOLVE / 132.155,69162306,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 6.0x12MM OFFSET / 1175.2601,69169378,CDM,278,RC,C1713,HCPCS,Outpatient,,,2646,2646,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.6,60,,1270.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2245.92,84.88,,1796.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.5,75,,1587.6,percent of total billed charges,75% of total billed charges for outpatient setting,1323,50,,1058.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2116.8,80,,1693.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,339.75,12.84,,271.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2778.3,105,,2222.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.1,35,,740.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1587.6,60,,1270.08,percent of total billed charges,60% of total billed charges for outpatient setting,339.75,2778.3,
ROD 60MM THREADED / 4933-1-060,70000784,CDM,278,RC,C1713,HCPCS,Outpatient,,,241.4,241.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.84,60,,115.87,percent of total billed charges,60% of total Billed charges for outpatient setting,204.9,84.88,,163.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.05,75,,144.84,percent of total billed charges,75% of total billed charges for outpatient setting,120.7,50,,96.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.12,80,,154.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,31,12.84,,24.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,241.4,65,,193.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.49,35,,67.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144.84,60,,115.87,percent of total billed charges,60% of total billed charges for outpatient setting,31,241.4,
ROD 80MM ELLIPSE / 182.801,70000028,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 80MM REVOLVE / 132.180,69162370,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 85MM CREO / 1119.7085,70000077,CDM,278,RC,C1713,HCPCS,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD 85MM REVOLVE / 132.185,69162304,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD 90MM CREO / 1119.7090,69161909,CDM,278,RC,C1713,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,60,,384,percent of total billed charges,60% of total Billed charges for outpatient setting,679.04,84.88,,543.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,480,percent of total billed charges,75% of total billed charges for outpatient setting,400,50,,320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640,80,,512,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,102.72,12.84,,82.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,800,65,,640,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,35,,224,percent of total billed charges,35% of total Billed charges for Outpatient Setting,480,60,,384,percent of total billed charges,60% of total billed charges for outpatient setting,102.72,800,
ROD CONNECTING 11X350MM / 4922-8-350,70000783,CDM,278,RC,C1713,HCPCS,Outpatient,,,1234.85,1234.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.91,60,,592.73,percent of total billed charges,60% of total Billed charges for outpatient setting,1048.14,84.88,,838.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.14,75,,740.91,percent of total billed charges,75% of total billed charges for outpatient setting,617.43,50,,493.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.55,12.84,,126.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.88,80,,790.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.55,12.84,,126.84,percent of total billed charges,12.84% of total billed charges,158.55,12.84,,126.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1234.85,65,,987.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.2,35,,345.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,740.91,60,,592.73,percent of total billed charges,60% of total billed charges for outpatient setting,158.55,1234.85,
ROD CRVD 5.5X60MM   132.160,69162442,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD CRVD 5.5X75MM / 132.175,69162424,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD STR 5.5X85MM  1119.5085,69162526,CDM,278,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,60,,415.3,percent of total billed charges,60% of total Billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,65,,692.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,519.12,60,,415.3,percent of total billed charges,60% of total billed charges for outpatient setting,111.09,865.2,
ROD W/ LINE 45MM / 1797-71-045,70000197,CDM,278,RC,C1713,HCPCS,Outpatient,,,1344.65,1344.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.79,60,,645.43,percent of total billed charges,60% of total Billed charges for outpatient setting,1141.34,84.88,,913.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.49,75,,806.79,percent of total billed charges,75% of total billed charges for outpatient setting,672.33,50,,537.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.72,80,,860.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1344.65,65,,1075.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.63,35,,376.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,806.79,60,,645.43,percent of total billed charges,60% of total billed charges for outpatient setting,172.65,1344.65,
ROD W/ LINE 75MM / 1797-71-075,70000494,CDM,278,RC,C1713,HCPCS,Outpatient,,,1344.65,1344.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.79,60,,645.43,percent of total billed charges,60% of total Billed charges for outpatient setting,1141.34,84.88,,913.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.49,75,,806.79,percent of total billed charges,75% of total billed charges for outpatient setting,672.33,50,,537.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.72,80,,860.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1344.65,65,,1075.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.63,35,,376.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,806.79,60,,645.43,percent of total billed charges,60% of total billed charges for outpatient setting,172.65,1344.65,
ROD W/ LINE PRE LORDOSED 55MM,70000451,CDM,278,RC,C1713,HCPCS,Outpatient,,,1344.65,1344.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.79,60,,645.43,percent of total billed charges,60% of total Billed charges for outpatient setting,1141.34,84.88,,913.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.49,75,,806.79,percent of total billed charges,75% of total billed charges for outpatient setting,672.33,50,,537.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.72,80,,860.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,172.65,12.84,,138.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1344.65,65,,1075.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.63,35,,376.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,806.79,60,,645.43,percent of total billed charges,60% of total billed charges for outpatient setting,172.65,1344.65,
ROFECOXIB (VIOXX) TAB: 12.5 MG,3301944,CDM,259,RC,,,Outpatient,,,7.14,7.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,6.06,84.88,,4.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.57,50,,2.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.36,75,,4.29,percent of total billed charges,75% of total billed charges for outpatient setting,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,80,,4.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.64,65,,3.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,35,,2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.43,90,,5.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.92,6.43,
ROFECOXIB (VIOXX) TAB: 12.5 MG   U/D,3301945,CDM,259,RC,,,Outpatient,,,6.81,6.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,70,,3.82,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,84.88,,4.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.41,50,,2.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.11,75,,4.09,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,70,,3.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.45,80,,4.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,0.87,12.84,,0.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.43,65,,3.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,35,,1.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.13,90,,4.9,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,6.13,
ROFECOXIB (VIOXX) TAB: 25 MG   U/D,3301943,CDM,259,RC,,,Outpatient,,,7.85,7.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,70,,4.4,percent of total billed charges,70% of total billed charges for outpatient setting,6.66,84.88,,5.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.93,50,,3.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.89,75,,4.71,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,70,,4.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.28,80,,5.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.1,65,,4.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,35,,2.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.07,90,,5.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.01,7.07,
ROLL 4X196IN FOAM RESTON / 1563L,71000227,CDM,272,RC,,,Outpatient,,,17.01,17.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,70,,9.53,percent of total billed charges,70% of total billed charges for outpatient setting,14.44,84.88,,11.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.51,50,,6.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.76,75,,10.21,percent of total billed charges,75% of total billed charges for outpatient setting,11.91,70,,9.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,80,,10.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,2.18,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.06,65,,8.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,35,,4.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.31,90,,12.25,percent of total billed charges,90% of total billed charges for outpatient setting,2.18,15.31,
ROLLER BALL / RB,6150603,CDM,270,RC,,,Outpatient,,,318.72,318.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.1,70,,178.48,percent of total billed charges,70% of total billed charges for outpatient setting,270.53,84.88,,216.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.36,50,,127.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.04,75,,191.23,percent of total billed charges,75% of total billed charges for outpatient setting,223.1,70,,178.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.92,12.84,,32.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.98,80,,203.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.92,12.84,,32.74,percent of total billed charges,12.84% of total billed charges,40.92,12.84,,32.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,207.17,65,,165.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.55,35,,89.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.85,90,,229.48,percent of total billed charges,90% of total billed charges for outpatient setting,40.92,286.85,
ROPINIROLE (REQUIP) 1 MG TAB:,3301946,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ROPINIROLE (REQUIP) 5 MG TAB:,3301947,CDM,259,RC,,,Outpatient,,,5.73,5.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,70,,3.21,percent of total billed charges,70% of total billed charges for outpatient setting,4.86,84.88,,3.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.87,50,,2.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.3,75,,3.44,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,70,,3.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.58,80,,3.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.72,65,,2.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,35,,1.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.16,90,,4.13,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.16,
ROPINIROLE genericREQUIP 0.25MG TAB,3303342,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
ROPIVACAINE (NAROPIN) 0.5% 30ML:INJ,3303220,CDM,250,RC,,,Outpatient,,,68.72,68.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.1,70,,38.48,percent of total billed charges,70% of total billed charges for outpatient setting,58.33,84.88,,46.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.36,50,,27.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.54,75,,41.23,percent of total billed charges,75% of total billed charges for outpatient setting,48.1,70,,38.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,12.84,,7.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.98,80,,43.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,12.84,,7.06,percent of total billed charges,12.84% of total billed charges,8.82,12.84,,7.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.67,65,,35.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,35,,19.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,61.85,90,,49.48,percent of total billed charges,90% of total billed charges for outpatient setting,8.82,61.85,
ROPIVACAINE (PAIN CASSETTE) 0.1%:250ML,3307971,CDM,250,RC,,,Outpatient,,,288.53,288.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.97,70,,161.58,percent of total billed charges,70% of total billed charges for outpatient setting,244.9,84.88,,195.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,144.27,50,,115.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.4,75,,173.12,percent of total billed charges,75% of total billed charges for outpatient setting,201.97,70,,161.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.05,12.84,,29.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.82,80,,184.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.05,12.84,,29.64,percent of total billed charges,12.84% of total billed charges,37.05,12.84,,29.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,187.54,65,,150.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.99,35,,80.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.68,90,,207.74,percent of total billed charges,90% of total billed charges for outpatient setting,37.05,259.68,
ROPIVACAINE 0.2%(NAROPIN)  200ML,3306714,CDM,250,RC,,,Outpatient,,,247.75,247.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.43,70,,138.74,percent of total billed charges,70% of total billed charges for outpatient setting,210.29,84.88,,168.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.88,50,,99.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.81,75,,148.65,percent of total billed charges,75% of total billed charges for outpatient setting,173.43,70,,138.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,12.84,,25.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.2,80,,158.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,12.84,,25.45,percent of total billed charges,12.84% of total billed charges,31.81,12.84,,25.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.04,65,,128.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.71,35,,69.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,222.98,90,,178.38,percent of total billed charges,90% of total billed charges for outpatient setting,31.81,222.98,
ROPIVACAINE 0.2%(NAROPIN) 100ML,3307055,CDM,636,RC,J2795,HCPCS,Outpatient,,,148.62,148.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.03,70,,83.22,percent of total billed charges,70% of total billed charges for outpatient setting,126.15,84.88,,100.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.08,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,111.47,75,,89.18,percent of total billed charges,75% of total billed charges for outpatient setting,104.03,70,,83.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,12.84,,15.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.9,80,,95.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,12.84,,15.26,percent of total billed charges,12.84% of total billed charges,19.08,12.84,,15.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.6,65,,77.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.08,100,,,Fee Schedule,100% of Custom Fee Schedule,133.76,90,,107.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.08,133.76,
ROPIVACAINE 0.2%(NAROPIN): 20 ML,3306719,CDM,250,RC,,,Outpatient,,,36.77,36.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,31.21,84.88,,24.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.39,50,,14.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.58,75,,22.06,percent of total billed charges,75% of total billed charges for outpatient setting,25.74,70,,20.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,12.84,,3.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,80,,23.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.72,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,4.72,12.84,,3.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.9,65,,19.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.87,35,,10.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.09,90,,26.47,percent of total billed charges,90% of total billed charges for outpatient setting,4.72,33.09,
ROPIVACAINE 0.2%(NAROPIN): 600ML,3309101,CDM,250,RC,,,Outpatient,,,260.07,260.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.05,70,,145.64,percent of total billed charges,70% of total billed charges for outpatient setting,220.75,84.88,,176.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.04,50,,104.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.05,75,,156.04,percent of total billed charges,75% of total billed charges for outpatient setting,182.05,70,,145.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,12.84,,26.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.06,80,,166.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,12.84,,26.71,percent of total billed charges,12.84% of total billed charges,33.39,12.84,,26.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,169.05,65,,135.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.02,35,,72.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,234.06,90,,187.25,percent of total billed charges,90% of total billed charges for outpatient setting,33.39,234.06,
ROPIVACAINE 0.5% (NAROPIN) 30ML,3306720,CDM,250,RC,,,Outpatient,,,40.82,40.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,34.65,84.88,,27.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.41,50,,16.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.62,75,,24.5,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.66,80,,26.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.53,65,,21.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.29,35,,11.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.74,90,,29.39,percent of total billed charges,90% of total billed charges for outpatient setting,5.24,36.74,
ROSA PINS AND NAVITRACKER / 98000600055,71000314,CDM,272,RC,,,Outpatient,,,1750,1750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225,70,,980,percent of total billed charges,70% of total billed charges for outpatient setting,1485.4,84.88,,1188.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,875,50,,700,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1312.5,75,,1050,percent of total billed charges,75% of total billed charges for outpatient setting,1225,70,,980,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,80,,1120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,224.7,12.84,,179.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1137.5,65,,910,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.5,35,,490,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1575,90,,1260,percent of total billed charges,90% of total billed charges for outpatient setting,224.7,1575,
ROSA ROBOTIC DRAPE / 20802008000,71000315,CDM,272,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,169.76,84.88,,135.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,100,50,,80,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,75,,120,percent of total billed charges,75% of total billed charges for outpatient setting,140,70,,112,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,80,,128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,130,65,,104,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,35,,56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,90,,144,percent of total billed charges,90% of total billed charges for outpatient setting,25.68,180,
ROSIGLITAZONE (AVANDIA) TAB: 2 MG,3301948,CDM,259,RC,,,Outpatient,,,5.89,5.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.12,70,,3.3,percent of total billed charges,70% of total billed charges for outpatient setting,5,84.88,,4,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.95,50,,2.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.42,75,,3.54,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,70,,3.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,80,,3.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,0.76,12.84,,0.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.83,65,,3.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,35,,1.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.3,90,,4.24,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,5.3,
ROSIGLITAZONE (AVANDIA) TAB: 4 MG,3301949,CDM,259,RC,,,Outpatient,,,7.86,7.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,70,,4.4,percent of total billed charges,70% of total billed charges for outpatient setting,6.67,84.88,,5.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.93,50,,3.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.9,75,,4.72,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,70,,4.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,80,,5.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,1.01,12.84,,0.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.11,65,,4.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,35,,2.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.07,90,,5.66,percent of total billed charges,90% of total billed charges for outpatient setting,1.01,7.07,
ROSIGLITAZONE (AVANDIA) TAB: 8 MG,3302907,CDM,259,RC,,,Outpatient,,,24.1,24.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.87,70,,13.5,percent of total billed charges,70% of total billed charges for outpatient setting,20.46,84.88,,16.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.05,50,,9.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.08,75,,14.46,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,70,,13.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.28,80,,15.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,3.09,12.84,,2.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.67,65,,12.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,35,,6.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.69,90,,17.35,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,21.69,
ROSUVASTATIN CA(genericCRESTOR) 5MG TAB,3303222,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ROSUVASTATIN CA(genericCRESTOR)10MG TAB,3303164,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ROTATABLE SNARE OVAL 20MM / M00561831,6050109,CDM,272,RC,,,Outpatient,,,171.47,171.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.03,70,,96.02,percent of total billed charges,70% of total billed charges for outpatient setting,145.54,84.88,,116.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.74,50,,68.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.6,75,,102.88,percent of total billed charges,75% of total billed charges for outpatient setting,120.03,70,,96.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.02,12.84,,17.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.18,80,,109.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.02,12.84,,17.62,percent of total billed charges,12.84% of total billed charges,22.02,12.84,,17.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,65,,89.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.01,35,,48.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.32,90,,123.46,percent of total billed charges,90% of total billed charges for outpatient setting,22.02,154.32,
ROTAVIRUS,200562,CDM,306,RC,87425,HCPCS,Outpatient,,,53.91,48.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,45.76,84.88,,36.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.43,75,,32.34,percent of total billed charges,75% of total billed charges for outpatient setting,37.74,70,,30.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,80,,34.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,48.52,90,,38.82,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,48.52,
ROZEREM (RAMELTEON):8 mg TAB,3303176,CDM,259,RC,,,Outpatient,,,41.17,41.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.82,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,34.95,84.88,,27.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.59,50,,16.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.88,75,,24.7,percent of total billed charges,75% of total billed charges for outpatient setting,28.82,70,,23.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.94,80,,26.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,5.29,12.84,,4.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.76,65,,21.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,35,,11.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.05,90,,29.64,percent of total billed charges,90% of total billed charges for outpatient setting,5.29,37.05,
RPR / T PALLIDUM,220117,CDM,300,RC,86592,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,53.62,
RUBELLA AB IGG,220465,CDM,300,RC,86762,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,58.28,
RUBELLA AB IGM,220469,CDM,300,RC,86762,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,58.28,
"RUBEOLA / MEASLES TITER, IGG",220733,CDM,302,RC,86765,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
RUMI ARCH 3.0CM / KC-ARCH-30,69161402,CDM,272,RC,,,Outpatient,,,389.34,389.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,330.47,84.88,,264.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.67,50,,155.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.01,75,,233.61,percent of total billed charges,75% of total billed charges for outpatient setting,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,80,,249.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,35,,109.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.41,90,,280.33,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,350.41,
RUMI ARCH 3.5CM / KC-ARCH-35,69161403,CDM,272,RC,,,Outpatient,,,389.34,389.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,330.47,84.88,,264.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,194.67,50,,155.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.01,75,,233.61,percent of total billed charges,75% of total billed charges for outpatient setting,272.54,70,,218.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.47,80,,249.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,49.99,12.84,,39.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,253.07,65,,202.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.27,35,,109.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,350.41,90,,280.33,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,350.41,
RUMI II 2.5cm Koh-Eff   KC-RUMI-25,69161639,CDM,272,RC,,,Outpatient,,,401.02,401.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,340.39,84.88,,272.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.51,50,,160.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.77,75,,240.62,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.82,80,,256.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,65,,208.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.36,35,,112.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.92,90,,288.74,percent of total billed charges,90% of total billed charges for outpatient setting,51.49,360.92,
RUMI II 3.0cm Koh-Eff   KC-RUMI-30,69161640,CDM,272,RC,,,Outpatient,,,401.02,401.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,340.39,84.88,,272.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.51,50,,160.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.77,75,,240.62,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.82,80,,256.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,65,,208.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.36,35,,112.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.92,90,,288.74,percent of total billed charges,90% of total billed charges for outpatient setting,51.49,360.92,
RUMI II 3.5cm Koh-Eff   KC-RUMI-35,69161641,CDM,272,RC,,,Outpatient,,,401.02,401.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,340.39,84.88,,272.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.51,50,,160.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.77,75,,240.62,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.82,80,,256.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,65,,208.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.36,35,,112.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.92,90,,288.74,percent of total billed charges,90% of total billed charges for outpatient setting,51.49,360.92,
RUMI II 4.0cm Koh-Eff   KC-RUMI-40,69161642,CDM,272,RC,,,Outpatient,,,401.02,401.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,340.39,84.88,,272.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.51,50,,160.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.77,75,,240.62,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,70,,224.57,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.82,80,,256.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,51.49,12.84,,41.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,65,,208.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.36,35,,112.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.92,90,,288.74,percent of total billed charges,90% of total billed charges for outpatient setting,51.49,360.92,
RUMI TIP BLUE 6.7X8CM / UMB678,69161408,CDM,272,RC,,,Outpatient,,,211.6,211.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,179.61,84.88,,143.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.8,50,,84.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.7,75,,126.96,percent of total billed charges,75% of total billed charges for outpatient setting,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.28,80,,135.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.54,65,,110.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.06,35,,59.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.44,90,,152.35,percent of total billed charges,90% of total billed charges for outpatient setting,27.17,190.44,
RUMI TIP GREEN 6.7X10CM / UMG670,69161409,CDM,272,RC,,,Outpatient,,,211.6,211.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,179.61,84.88,,143.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.8,50,,84.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.7,75,,126.96,percent of total billed charges,75% of total billed charges for outpatient setting,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.28,80,,135.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.54,65,,110.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.06,35,,59.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.44,90,,152.35,percent of total billed charges,90% of total billed charges for outpatient setting,27.17,190.44,
RUMI TIP LAVENDER 5.1MM X 6CM / UML516,69161406,CDM,272,RC,,,Outpatient,,,207.45,207.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.22,70,,116.18,percent of total billed charges,70% of total billed charges for outpatient setting,176.08,84.88,,140.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.73,50,,82.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.59,75,,124.47,percent of total billed charges,75% of total billed charges for outpatient setting,145.22,70,,116.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,12.84,,21.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.96,80,,132.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,12.84,,21.31,percent of total billed charges,12.84% of total billed charges,26.64,12.84,,21.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.84,65,,107.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.61,35,,58.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,186.71,90,,149.37,percent of total billed charges,90% of total billed charges for outpatient setting,26.64,186.71,
RUMI TIP ORANGE 6.7MMX12CM / UMO672,69161410,CDM,272,RC,,,Outpatient,,,211.6,211.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,179.61,84.88,,143.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.8,50,,84.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.7,75,,126.96,percent of total billed charges,75% of total billed charges for outpatient setting,148.12,70,,118.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.28,80,,135.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,27.17,12.84,,21.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.54,65,,110.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.06,35,,59.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.44,90,,152.35,percent of total billed charges,90% of total billed charges for outpatient setting,27.17,190.44,
RUMI TIP WHITE 6.7MMX6CM / UMW676,69161407,CDM,272,RC,,,Outpatient,,,207.4,207.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.18,70,,116.14,percent of total billed charges,70% of total billed charges for outpatient setting,176.04,84.88,,140.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,103.7,50,,82.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.55,75,,124.44,percent of total billed charges,75% of total billed charges for outpatient setting,145.18,70,,116.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.63,12.84,,21.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.92,80,,132.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.63,12.84,,21.3,percent of total billed charges,12.84% of total billed charges,26.63,12.84,,21.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,134.81,65,,107.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.59,35,,58.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,186.66,90,,149.33,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,186.66,
RUMI TIP YELLOW 5.1X3.75CM / UMY514,69161405,CDM,272,RC,,,Outpatient,,,246.74,246.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.72,70,,138.18,percent of total billed charges,70% of total billed charges for outpatient setting,209.43,84.88,,167.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.37,50,,98.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.06,75,,148.05,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,70,,138.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,12.84,,25.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.39,80,,157.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,12.84,,25.34,percent of total billed charges,12.84% of total billed charges,31.68,12.84,,25.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,160.38,65,,128.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.36,35,,69.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,222.07,90,,177.66,percent of total billed charges,90% of total billed charges for outpatient setting,31.68,222.07,
"RUSSELL VIPER VENOM TIME, DILUTED",200714,CDM,305,RC,85613,HCPCS,Outpatient,,,43.11,38.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.18,70,,24.14,percent of total billed charges,70% of total billed charges for outpatient setting,36.59,84.88,,29.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,32.33,75,,25.86,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,70,,24.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.49,80,,27.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,100,,,Fee Schedule,100% of Custom Fee Schedule,38.8,90,,31.04,percent of total billed charges,90% of total billed charges for outpatient setting,9.58,38.8,
S&I INJ PULM/GRAFT,2200660,CDM,481,RC,93556,HCPCS,Outpatient,,,2045.47,2045.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.83,70,,1145.46,percent of total billed charges,70% of total billed charges for outpatient setting,1736.19,84.88,,1388.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,1022.74,50,,818.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1534.1,75,,1227.28,percent of total billed charges,75% of total billed charges for outpatient setting,1431.83,70,,1145.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.64,12.84,,210.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.38,80,,1309.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.64,12.84,,210.11,percent of total billed charges,12.84% of total billed charges,262.64,12.84,,210.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.91,35,,572.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1840.92,90,,1472.74,percent of total billed charges,90% of total billed charges for outpatient setting,262.64,1840.92,
SABRE 30 W/ICW / AC4330-01,69160870,CDM,272,RC,,,Outpatient,,,2062.2,2062.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.54,70,,1154.83,percent of total billed charges,70% of total billed charges for outpatient setting,1750.4,84.88,,1400.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,1031.1,50,,824.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1546.65,75,,1237.32,percent of total billed charges,75% of total billed charges for outpatient setting,1443.54,70,,1154.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.79,12.84,,211.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1649.76,80,,1319.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.79,12.84,,211.83,percent of total billed charges,12.84% of total billed charges,264.79,12.84,,211.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1340.43,65,,1072.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.77,35,,577.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1855.98,90,,1484.78,percent of total billed charges,90% of total billed charges for outpatient setting,264.79,1855.98,
SACCHAROMYCES BOULARDII (FLORASTOR)250MG,3313916,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SACROCOLPOPEXY TIP LG / SACRO-1,69162665,CDM,272,RC,,,Outpatient,,,288.37,288.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.86,70,,161.49,percent of total billed charges,70% of total billed charges for outpatient setting,244.77,84.88,,195.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,144.19,50,,115.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.28,75,,173.02,percent of total billed charges,75% of total billed charges for outpatient setting,201.86,70,,161.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.7,80,,184.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,187.44,65,,149.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.93,35,,80.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.53,90,,207.62,percent of total billed charges,90% of total billed charges for outpatient setting,37.03,259.53,
SACROCOLPOPEXY TIP SMALL / SACRO-1S,69162666,CDM,272,RC,,,Outpatient,,,288.37,288.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.86,70,,161.49,percent of total billed charges,70% of total billed charges for outpatient setting,244.77,84.88,,195.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,144.19,50,,115.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.28,75,,173.02,percent of total billed charges,75% of total billed charges for outpatient setting,201.86,70,,161.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.7,80,,184.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,37.03,12.84,,29.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,187.44,65,,149.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.93,35,,80.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.53,90,,207.62,percent of total billed charges,90% of total billed charges for outpatient setting,37.03,259.53,
SACROILIAC JNTS 3+ VWS,2400280,CDM,320,RC,72202,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SACROILIAC JNTS LESS THAN 3 VWS,2400275,CDM,320,RC,72200,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SACROILIAC JOINT ARTHROGRAPHY,2400335,CDM,322,RC,,,Outpatient,,,1051.42,788.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.99,70,,588.79,percent of total billed charges,70% of total billed charges for outpatient setting,892.45,84.88,,713.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,525.71,50,,420.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,788.57,75,,630.86,percent of total billed charges,75% of total billed charges for outpatient setting,735.99,70,,588.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,12.84,,108,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.14,80,,672.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,12.84,,108,percent of total billed charges,12.84% of total billed charges,135,12.84,,108,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368,35,,294.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,946.28,90,,757.02,percent of total billed charges,90% of total billed charges for outpatient setting,128,946.28,
SACRUM AND COCCYX,2400285,CDM,320,RC,72220,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SACUBITRIL/VALSARTAN (ENTRESTO)24-26MG,3314309,CDM,259,RC,,,Outpatient,,,72.87,72.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.01,70,,40.81,percent of total billed charges,70% of total billed charges for outpatient setting,61.85,84.88,,49.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.44,50,,29.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.65,75,,43.72,percent of total billed charges,75% of total billed charges for outpatient setting,51.01,70,,40.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,12.84,,7.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.3,80,,46.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,12.84,,7.49,percent of total billed charges,12.84% of total billed charges,9.36,12.84,,7.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.37,65,,37.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.5,35,,20.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,65.58,90,,52.46,percent of total billed charges,90% of total billed charges for outpatient setting,9.36,65.58,
"SAFEGUARD KNIFE, CARPAL TUNNEL 08-0003",69161600,CDM,272,RC,,,Outpatient,,,935.72,935.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655,70,,524,percent of total billed charges,70% of total billed charges for outpatient setting,794.24,84.88,,635.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,467.86,50,,374.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,701.79,75,,561.43,percent of total billed charges,75% of total billed charges for outpatient setting,655,70,,524,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.15,12.84,,96.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.58,80,,598.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.15,12.84,,96.12,percent of total billed charges,12.84% of total billed charges,120.15,12.84,,96.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,608.22,65,,486.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.5,35,,262,percent of total billed charges,35% of total Billed charges for Outpatient Setting,842.15,90,,673.72,percent of total billed charges,90% of total billed charges for outpatient setting,120.15,842.15,
SALINE IRRG 1000ML BAG / 2B7124X,6150078,CDM,272,RC,,,Outpatient,,,25.45,25.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.82,70,,14.26,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,84.88,,17.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.73,50,,10.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.09,75,,15.27,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,70,,14.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,80,,16.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,3.27,12.84,,2.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.54,65,,13.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.91,35,,7.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.91,90,,18.33,percent of total billed charges,90% of total billed charges for outpatient setting,3.27,22.91,
SALINE IRRG 500ML BOTTLE / 2F7123,5050041,CDM,258,RC,,,Outpatient,,,18.6,18.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.02,70,,10.42,percent of total billed charges,70% of total billed charges for outpatient setting,15.79,84.88,,12.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.3,50,,7.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.95,75,,11.16,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,70,,10.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,80,,11.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.09,65,,9.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.51,35,,5.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.74,90,,13.39,percent of total billed charges,90% of total billed charges for outpatient setting,2.39,16.74,
SALINE IRRIG 1000ML BOTTLE / 2F7124,6150110,CDM,272,RC,,,Outpatient,,,21.6,21.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,18.33,84.88,,14.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.8,50,,8.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,75,,12.96,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,80,,13.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.04,65,,11.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,35,,6.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.44,90,,15.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.77,19.44,
SALINE IRRIG 3000ML BAG / 2B7477,6150079,CDM,272,RC,,,Outpatient,,,52.99,52.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,44.98,84.88,,35.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.5,50,,21.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.74,75,,31.79,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,70,,29.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.39,80,,33.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.44,65,,27.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,35,,14.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.69,90,,38.15,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.69,
SALINE IRRIG 5000ML BAG / 2B7479,69160088,CDM,272,RC,,,Outpatient,,,87.43,87.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,70,,48.96,percent of total billed charges,70% of total billed charges for outpatient setting,74.21,84.88,,59.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.72,50,,34.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.57,75,,52.46,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,70,,48.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.94,80,,55.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,11.23,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.83,65,,45.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.6,35,,24.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.69,90,,62.95,percent of total billed charges,90% of total billed charges for outpatient setting,11.23,78.69,
SALIVARY GLAND FOR CALCULUS,2400140,CDM,320,RC,70380,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SALIVARY GLAND FUNCTION STUDY,3000305,CDM,341,RC,78232,HCPCS,Outpatient,,,811.23,608.42,,540.47,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,688.57,84.88,,550.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,486,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,608.42,75,,486.74,percent of total billed charges,75% of total billed charges for outpatient setting,567.86,70,,454.29,percent of total billed charges,70% of total billed charges for outpatient setting,574.25,170,,,Fee Schedule,170% of Medicare OPPS rate,726.25,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,104.16,12.84,,83.328,percent of total billed charges,12.84% of total billed charges,591.14,175,,,Fee Schedule,175% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,648.98,80,,519.18,percent of total billed charges,80% of total billed charges for outpatient setting,472.91,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,422.24,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,104.16,12.84,,83.33,percent of total billed charges,12.84% of total billed charges,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,774,100,,,Case rate,pays based on fixed rate ,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,337.79,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,385.16,100,,,Fee Schedule,100% of Custom Fee Schedule,730.11,90,,584.09,percent of total billed charges,90% of total billed charges for outpatient setting,104.16,774,
SALMETEROL (SEREVENT) DISKUS: 50 MCG,3301951,CDM,259,RC,,,Outpatient,,,202.21,202.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.55,70,,113.24,percent of total billed charges,70% of total billed charges for outpatient setting,171.64,84.88,,137.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.11,50,,80.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.66,75,,121.33,percent of total billed charges,75% of total billed charges for outpatient setting,141.55,70,,113.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.96,12.84,,20.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.77,80,,129.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.96,12.84,,20.77,percent of total billed charges,12.84% of total billed charges,25.96,12.84,,20.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.44,65,,105.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.77,35,,56.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.99,90,,145.59,percent of total billed charges,90% of total billed charges for outpatient setting,25.96,181.99,
SALMETEROL (SEREVENT)6.5GM INH:21MCG,3301950,CDM,259,RC,,,Outpatient,,,144.73,144.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.31,70,,81.05,percent of total billed charges,70% of total billed charges for outpatient setting,122.85,84.88,,98.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.37,50,,57.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.55,75,,86.84,percent of total billed charges,75% of total billed charges for outpatient setting,101.31,70,,81.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,12.84,,14.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.78,80,,92.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.58,12.84,,14.86,percent of total billed charges,12.84% of total billed charges,18.58,12.84,,14.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.07,65,,75.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.66,35,,40.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.26,90,,104.21,percent of total billed charges,90% of total billed charges for outpatient setting,18.58,130.26,
SALSALATE (DISALCID) TAB : 500 MG,3301952,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SAMPLINGS GAS DISPOSABLE / WHSA30MM,6150847,CDM,271,RC,,,Outpatient,,,7.78,7.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.45,70,,4.36,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,84.88,,5.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.89,50,,3.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.84,75,,4.67,percent of total billed charges,75% of total billed charges for outpatient setting,5.45,70,,4.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.22,80,,4.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.06,65,,4.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,35,,2.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7,90,,5.6,percent of total billed charges,90% of total billed charges for outpatient setting,1,7,
SANDOSTATIN LAR 1MG IM INJ (OCTREOTIDE),3304531,CDM,250,RC,J2353,HCPCS,Outpatient,,,406.09,406.09,,331.13,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,284.26,70,,227.41,percent of total billed charges,70% of total billed charges for outpatient setting,344.69,84.88,,275.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.22,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,304.57,75,,243.66,percent of total billed charges,75% of total billed charges for outpatient setting,284.26,70,,227.41,percent of total billed charges,70% of total billed charges for outpatient setting,351.83,170,,,Fee Schedule,170% of Medicare OPPS rate,444.96,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,52.14,12.84,,41.712,percent of total billed charges,12.84% of total billed charges,362.18,175,,,Fee Schedule,175% of Medicare OPPS rate,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,324.87,80,,259.9,percent of total billed charges,80% of total billed charges for outpatient setting,289.74,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,258.7,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,52.14,12.84,,41.71,percent of total billed charges,12.84% of total billed charges,52.14,12.84,,41.71,percent of total billed charges,12.84% of total billed charges,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,263.96,65,,211.17,percent of total billed charges,65% of total billed charges for outpatient setting,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.96,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,163.31,100,,,Fee Schedule,100% of Custom Fee Schedule,365.48,90,,292.38,percent of total billed charges,90% of total billed charges for outpatient setting,52.14,444.96,
SAVI PREP CATHETER  SPC-01,69160888,CDM,272,RC,,,Outpatient,,,886.25,886.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.38,70,,496.3,percent of total billed charges,70% of total billed charges for outpatient setting,752.25,84.88,,601.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,443.13,50,,354.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.69,75,,531.75,percent of total billed charges,75% of total billed charges for outpatient setting,620.38,70,,496.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.79,12.84,,91.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709,80,,567.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.79,12.84,,91.03,percent of total billed charges,12.84% of total billed charges,113.79,12.84,,91.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,576.06,65,,460.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.19,35,,248.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,797.63,90,,638.1,percent of total billed charges,90% of total billed charges for outpatient setting,113.79,797.63,
SAVI6 1 6 CATHETER,69160884,CDM,272,RC,C1728,HCPCS,Outpatient,,,5500,5500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3850,70,,3080,percent of total billed charges,70% of total billed charges for outpatient setting,4668.4,84.88,,3734.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4125,75,,3300,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.2,12.84,,564.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4400,80,,3520,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.2,12.84,,564.96,percent of total billed charges,12.84% of total billed charges,706.2,12.84,,564.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3575,65,,2860,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1925,35,,1540,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4950,90,,3960,percent of total billed charges,90% of total billed charges for outpatient setting,706.2,4950,
SAVORY CLEANING BRUSH S/S /SCB-1,6051201,CDM,270,RC,,,Outpatient,,,230.09,230.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.06,70,,128.85,percent of total billed charges,70% of total billed charges for outpatient setting,195.3,84.88,,156.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.05,50,,92.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.57,75,,138.06,percent of total billed charges,75% of total billed charges for outpatient setting,161.06,70,,128.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.54,12.84,,23.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.07,80,,147.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.54,12.84,,23.63,percent of total billed charges,12.84% of total billed charges,29.54,12.84,,23.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.56,65,,119.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.53,35,,64.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.08,90,,165.66,percent of total billed charges,90% of total billed charges for outpatient setting,29.54,207.08,
SAW BLADE DEPUY KNEE,69161989,CDM,272,RC,,,Outpatient,,,526.91,526.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.84,70,,295.07,percent of total billed charges,70% of total billed charges for outpatient setting,447.24,84.88,,357.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,263.46,50,,210.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.18,75,,316.14,percent of total billed charges,75% of total billed charges for outpatient setting,368.84,70,,295.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.66,12.84,,54.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.53,80,,337.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.66,12.84,,54.13,percent of total billed charges,12.84% of total billed charges,67.66,12.84,,54.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,342.49,65,,273.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.42,35,,147.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,474.22,90,,379.38,percent of total billed charges,90% of total billed charges for outpatient setting,67.66,474.22,
SAW BLADE OSC.  1.27 X 25MM WIDE,69161649,CDM,272,RC,,,Outpatient,,,507.96,507.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.57,70,,284.46,percent of total billed charges,70% of total billed charges for outpatient setting,431.16,84.88,,344.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,253.98,50,,203.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.97,75,,304.78,percent of total billed charges,75% of total billed charges for outpatient setting,355.57,70,,284.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.22,12.84,,52.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.37,80,,325.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.22,12.84,,52.18,percent of total billed charges,12.84% of total billed charges,65.22,12.84,,52.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,330.17,65,,264.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.79,35,,142.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,457.16,90,,365.73,percent of total billed charges,90% of total billed charges for outpatient setting,65.22,457.16,
SC AMNIOCENTESIS,2600499,CDM,360,RC,,,Outpatient,,,513.16,513.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.21,70,,287.37,percent of total billed charges,70% of total billed charges for outpatient setting,435.57,84.88,,348.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,256.58,50,,205.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,384.87,75,,307.9,percent of total billed charges,75% of total billed charges for outpatient setting,359.21,70,,287.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.89,12.84,,52.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.53,80,,328.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.89,12.84,,52.71,percent of total billed charges,12.84% of total billed charges,65.89,12.84,,52.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.61,35,,143.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,461.84,90,,369.47,percent of total billed charges,90% of total billed charges for outpatient setting,65.89,461.84,
SC ASP ABS/CYST SKIN,2600500,CDM,360,RC,,,Outpatient,,,412.1,412.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.47,70,,230.78,percent of total billed charges,70% of total billed charges for outpatient setting,349.79,84.88,,279.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,206.05,50,,164.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.08,75,,247.26,percent of total billed charges,75% of total billed charges for outpatient setting,288.47,70,,230.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.91,12.84,,42.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.68,80,,263.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.91,12.84,,42.33,percent of total billed charges,12.84% of total billed charges,52.91,12.84,,42.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.24,35,,115.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,370.89,90,,296.71,percent of total billed charges,90% of total billed charges for outpatient setting,52.91,370.89,
SC ASP CYST BREAST ADDL,2600504,CDM,360,RC,,,Outpatient,,,964.45,964.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,818.63,84.88,,654.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,482.23,50,,385.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.34,75,,578.67,percent of total billed charges,75% of total billed charges for outpatient setting,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.56,80,,617.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.56,35,,270.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.01,90,,694.41,percent of total billed charges,90% of total billed charges for outpatient setting,123.84,868.01,
SC ASP CYST BREAST INI,2600505,CDM,360,RC,,,Outpatient,,,964.45,964.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,818.63,84.88,,654.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,482.23,50,,385.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.34,75,,578.67,percent of total billed charges,75% of total billed charges for outpatient setting,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.56,80,,617.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.56,35,,270.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.01,90,,694.41,percent of total billed charges,90% of total billed charges for outpatient setting,123.84,868.01,
SC ASP/INJ CYST REN/PEL,2300219,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BIOPSY LIVER NEEDLE PERC,2700055,CDM,320,RC,47000,HCPCS,Outpatient,,,2036.1,1527.08,,2017.34,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1425.27,70,,1140.22,percent of total billed charges,70% of total billed charges for outpatient setting,1728.24,84.88,,1382.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,1837.34,50,,1469.87,percent of total billed charges,50% of total Billed charges for outpatient setting,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1527.08,75,,1221.66,percent of total billed charges,75% of total billed charges for outpatient setting,1425.27,70,,1140.22,percent of total billed charges,70% of total billed charges for outpatient setting,2143.42,170,,,Fee Schedule,170% of Medicare OPPS rate,2710.8,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,261.44,12.84,,209.152,percent of total billed charges,12.84% of total billed charges,2206.46,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1628.88,80,,1303.1,percent of total billed charges,80% of total billed charges for outpatient setting,1765.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1576.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,261.44,12.84,,209.15,percent of total billed charges,12.84% of total billed charges,261.44,12.84,,209.15,percent of total billed charges,12.84% of total billed charges,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.83,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,901.42,100,,,Fee Schedule,100% of Custom Fee Schedule,1832.49,90,,1465.99,percent of total billed charges,90% of total billed charges for outpatient setting,128,2710.8,
SC BX ABD/RETROPERITO,2300211,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BX BONE DEEP,2300212,CDM,360,RC,,,Outpatient,,,1621.31,1621.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.92,70,,907.94,percent of total billed charges,70% of total billed charges for outpatient setting,1376.17,84.88,,1100.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,810.66,50,,648.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1215.98,75,,972.78,percent of total billed charges,75% of total billed charges for outpatient setting,1134.92,70,,907.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.18,12.84,,166.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1297.05,80,,1037.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.18,12.84,,166.54,percent of total billed charges,12.84% of total billed charges,208.18,12.84,,166.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.46,35,,453.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1459.18,90,,1167.34,percent of total billed charges,90% of total billed charges for outpatient setting,208.18,1459.18,
SC BX BONE SUPERFICIAL,2300213,CDM,360,RC,,,Outpatient,,,1621.31,1621.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.92,70,,907.94,percent of total billed charges,70% of total billed charges for outpatient setting,1376.17,84.88,,1100.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,810.66,50,,648.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1215.98,75,,972.78,percent of total billed charges,75% of total billed charges for outpatient setting,1134.92,70,,907.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.18,12.84,,166.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1297.05,80,,1037.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.18,12.84,,166.54,percent of total billed charges,12.84% of total billed charges,208.18,12.84,,166.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.46,35,,453.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1459.18,90,,1167.34,percent of total billed charges,90% of total billed charges for outpatient setting,208.18,1459.18,
SC BX BREAST NDL CORE,2600501,CDM,360,RC,,,Outpatient,,,1574.87,1574.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.41,70,,881.93,percent of total billed charges,70% of total billed charges for outpatient setting,1336.75,84.88,,1069.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,787.44,50,,629.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1181.15,75,,944.92,percent of total billed charges,75% of total billed charges for outpatient setting,1102.41,70,,881.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.21,12.84,,161.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1259.9,80,,1007.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.21,12.84,,161.77,percent of total billed charges,12.84% of total billed charges,202.21,12.84,,161.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.2,35,,440.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1417.38,90,,1133.9,percent of total billed charges,90% of total billed charges for outpatient setting,202.21,1417.38,
SC BX FNA US GUIDED (OTHER THAN BREAST),2600512,CDM,360,RC,,,Outpatient,,,964.45,964.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,818.63,84.88,,654.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,482.23,50,,385.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.34,75,,578.67,percent of total billed charges,75% of total billed charges for outpatient setting,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.56,80,,617.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.56,35,,270.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.01,90,,694.41,percent of total billed charges,90% of total billed charges for outpatient setting,123.84,868.01,
SC BX LIVER,2600502,CDM,360,RC,,,Outpatient,,,412.1,412.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.47,70,,230.78,percent of total billed charges,70% of total billed charges for outpatient setting,349.79,84.88,,279.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,206.05,50,,164.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.08,75,,247.26,percent of total billed charges,75% of total billed charges for outpatient setting,288.47,70,,230.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.91,12.84,,42.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.68,80,,263.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.91,12.84,,42.33,percent of total billed charges,12.84% of total billed charges,52.91,12.84,,42.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.24,35,,115.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,370.89,90,,296.71,percent of total billed charges,90% of total billed charges for outpatient setting,52.91,370.89,
SC BX LIVER,2300214,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BX LUNG PERC,2300215,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BX LUNG/MEDIASTINUM CT PERC NEEDLE,2300300,CDM,360,RC,32405,HCPCS,Outpatient,,,2405.52,2405.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1683.86,70,,1347.09,percent of total billed charges,70% of total billed charges for outpatient setting,2041.81,84.88,,1633.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1202.76,50,,962.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1804.14,75,,1443.31,percent of total billed charges,75% of total billed charges for outpatient setting,1683.86,70,,1347.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.87,12.84,,247.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1924.42,80,,1539.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.87,12.84,,247.1,percent of total billed charges,12.84% of total billed charges,308.87,12.84,,247.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,901.42,100,,,Fee Schedule,100% of Custom Fee Schedule,2164.97,90,,1731.98,percent of total billed charges,90% of total billed charges for outpatient setting,308.87,2164.97,
SC BX MUSCLE PERC,2300216,CDM,360,RC,,,Outpatient,,,1565.8,1565.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.06,70,,876.85,percent of total billed charges,70% of total billed charges for outpatient setting,1329.05,84.88,,1063.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,782.9,50,,626.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1174.35,75,,939.48,percent of total billed charges,75% of total billed charges for outpatient setting,1096.06,70,,876.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.05,12.84,,160.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.64,80,,1002.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.05,12.84,,160.84,percent of total billed charges,12.84% of total billed charges,201.05,12.84,,160.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.03,35,,438.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1409.22,90,,1127.38,percent of total billed charges,90% of total billed charges for outpatient setting,201.05,1409.22,
SC BX PANCREAS,2300217,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BX PAROTID,2600513,CDM,360,RC,,,Outpatient,,,964.45,964.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,818.63,84.88,,654.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,482.23,50,,385.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.34,75,,578.67,percent of total billed charges,75% of total billed charges for outpatient setting,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.56,80,,617.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.56,35,,270.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.01,90,,694.41,percent of total billed charges,90% of total billed charges for outpatient setting,123.84,868.01,
SC BX RENAL,2300218,CDM,360,RC,,,Outpatient,,,3073.34,3073.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151.34,70,,1721.07,percent of total billed charges,70% of total billed charges for outpatient setting,2608.65,84.88,,2086.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,1536.67,50,,1229.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2305.01,75,,1844.01,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2458.67,80,,1966.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,394.62,12.84,,315.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.67,35,,860.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2766.01,90,,2212.81,percent of total billed charges,90% of total billed charges for outpatient setting,394.62,2766.01,
SC BX THYROID,2600503,CDM,360,RC,,,Outpatient,,,964.45,964.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,818.63,84.88,,654.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,482.23,50,,385.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.34,75,,578.67,percent of total billed charges,75% of total billed charges for outpatient setting,675.12,70,,540.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.56,80,,617.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,123.84,12.84,,99.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.56,35,,270.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,868.01,90,,694.41,percent of total billed charges,90% of total billed charges for outpatient setting,123.84,868.01,
SC CTH HYSTEROSALPING,2401011,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC EXCHG CATH ABS/CYS,2300220,CDM,360,RC,,,Outpatient,,,7306.56,7306.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5114.59,70,,4091.67,percent of total billed charges,70% of total billed charges for outpatient setting,6201.81,84.88,,4961.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,3653.28,50,,2922.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5479.92,75,,4383.94,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.16,12.84,,750.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5845.25,80,,4676.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.16,12.84,,750.53,percent of total billed charges,12.84% of total billed charges,938.16,12.84,,750.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.3,35,,2045.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6575.9,90,,5260.72,percent of total billed charges,90% of total billed charges for outpatient setting,938.16,6575.9,
SC INJ ARTHRO ANKLE,2401000,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO ELBOW,2401001,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO HIP W/ANS,2401003,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO HIP W/O AN,2401002,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO KNEE,2401004,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO SHOULDER TRAY,2401005,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO TMJ,2401006,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ARTHRO WRIST,2401007,CDM,272,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.75,65,,331,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ CATH ABS/CYST,2300221,CDM,360,RC,,,Outpatient,,,860.88,860.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.62,70,,482.1,percent of total billed charges,70% of total billed charges for outpatient setting,730.71,84.88,,584.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,430.44,50,,344.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,645.66,75,,516.53,percent of total billed charges,75% of total billed charges for outpatient setting,602.62,70,,482.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,12.84,,88.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.7,80,,550.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.54,12.84,,88.43,percent of total billed charges,12.84% of total billed charges,110.54,12.84,,88.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.31,35,,241.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,774.79,90,,619.83,percent of total billed charges,90% of total billed charges for outpatient setting,110.54,774.79,
SC INJ CHOLANGIO T-TUBE,2401008,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ CYSTO/URETH,2401010,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ ILEAL CONDUIT,2401012,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ LYMPHANGIOGRAM,2401014,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ MYELOGRAM SPINE,2401015,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ NEPHROSTOGRAM,2402001,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC INJ PROC PERCU TX PSEUDOANEURYSM EXTR,2600525,CDM,760,RC,36002,HCPCS,Outpatient,,,1107.25,1107.25,,774.99,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,775.08,70,,620.06,percent of total billed charges,70% of total billed charges for outpatient setting,939.83,84.88,,751.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,851.96,50,,681.57,percent of total billed charges,50% of total Billed charges for outpatient setting,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,830.44,75,,664.35,percent of total billed charges,75% of total billed charges for outpatient setting,775.08,70,,620.06,percent of total billed charges,70% of total billed charges for outpatient setting,823.42,170,,,Fee Schedule,170% of Medicare OPPS rate,1041.39,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,142.17,12.84,,113.736,percent of total billed charges,12.84% of total billed charges,847.64,175,,,Fee Schedule,175% of Medicare OPPS rate,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,885.8,80,,708.64,percent of total billed charges,80% of total billed charges for outpatient setting,678.11,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,605.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,142.17,12.84,,113.74,percent of total billed charges,12.84% of total billed charges,142.17,12.84,,113.74,percent of total billed charges,12.84% of total billed charges,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,719.71,65,,575.77,percent of total billed charges,65% of total billed charges for outpatient setting,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,484.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,996.53,90,,797.22,percent of total billed charges,90% of total billed charges for outpatient setting,142.17,1041.39,
SC INJ PYELOGR THR TB,2401016,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ SHUNTOGRAM,2401018,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ SINUS TRACT DX,2401019,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ URETER,2401020,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ URETHROCYST RET,2401009,CDM,360,RC,,,Outpatient,,,469,469,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,398.09,84.88,,318.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,234.5,50,,187.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.75,75,,281.4,percent of total billed charges,75% of total billed charges for outpatient setting,328.3,70,,262.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.2,80,,300.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,60.22,12.84,,48.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,35,,131.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,422.1,90,,337.68,percent of total billed charges,90% of total billed charges for outpatient setting,60.22,422.1,
SC INJ VENOGRAM,2401021,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
S-C JOINTS,2400195,CDM,320,RC,71130,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SC PARACENTESIS,2300222,CDM,360,RC,,,Outpatient,,,1729.43,1729.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1210.6,70,,968.48,percent of total billed charges,70% of total billed charges for outpatient setting,1467.94,84.88,,1174.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,864.72,50,,691.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.07,75,,1037.66,percent of total billed charges,75% of total billed charges for outpatient setting,1210.6,70,,968.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.06,12.84,,177.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1383.54,80,,1106.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.06,12.84,,177.65,percent of total billed charges,12.84% of total billed charges,222.06,12.84,,177.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.3,35,,484.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1556.49,90,,1245.19,percent of total billed charges,90% of total billed charges for outpatient setting,222.06,1556.49,
SC PARACENTESIS INI,2600506,CDM,360,RC,,,Outpatient,,,1792.78,1792.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,1521.71,84.88,,1217.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,896.39,50,,717.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1344.59,75,,1075.67,percent of total billed charges,75% of total billed charges for outpatient setting,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.22,80,,1147.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.47,35,,501.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1613.5,90,,1290.8,percent of total billed charges,90% of total billed charges for outpatient setting,230.19,1613.5,
SC PARACENTESIS SUBS,2600507,CDM,360,RC,,,Outpatient,,,1792.78,1792.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,1521.71,84.88,,1217.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,896.39,50,,717.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1344.59,75,,1075.67,percent of total billed charges,75% of total billed charges for outpatient setting,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.22,80,,1147.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.47,35,,501.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1613.5,90,,1290.8,percent of total billed charges,90% of total billed charges for outpatient setting,230.19,1613.5,
SC PLC NDL PROSTATE,2600508,CDM,360,RC,,,Outpatient,,,810.13,810.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.09,70,,453.67,percent of total billed charges,70% of total billed charges for outpatient setting,687.64,84.88,,550.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,405.07,50,,324.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,607.6,75,,486.08,percent of total billed charges,75% of total billed charges for outpatient setting,567.09,70,,453.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.02,12.84,,83.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.1,80,,518.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.02,12.84,,83.22,percent of total billed charges,12.84% of total billed charges,104.02,12.84,,83.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.55,35,,226.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,729.12,90,,583.3,percent of total billed charges,90% of total billed charges for outpatient setting,104.02,729.12,
SC PLC WIRE BREAST,2600511,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC PLC WIRE BREAST ADDL,2600510,CDM,360,RC,,,Outpatient,,,636.54,636.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,540.3,84.88,,432.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.27,50,,254.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.41,75,,381.93,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,70,,356.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.23,80,,407.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,81.73,12.84,,65.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.79,35,,178.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.89,90,,458.31,percent of total billed charges,90% of total billed charges for outpatient setting,81.73,572.89,
SC PLC WIRE BRST,2700081,CDM,360,RC,,,Outpatient,,,426.27,426.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.39,70,,238.71,percent of total billed charges,70% of total billed charges for outpatient setting,361.82,84.88,,289.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,213.14,50,,170.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.7,75,,255.76,percent of total billed charges,75% of total billed charges for outpatient setting,298.39,70,,238.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.73,12.84,,43.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.02,80,,272.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.73,12.84,,43.78,percent of total billed charges,12.84% of total billed charges,54.73,12.84,,43.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.19,35,,119.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,383.64,90,,306.91,percent of total billed charges,90% of total billed charges for outpatient setting,54.73,383.64,
SC PLC WIRE BRST ADDL,2700080,CDM,360,RC,,,Outpatient,,,426.27,426.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.39,70,,238.71,percent of total billed charges,70% of total billed charges for outpatient setting,361.82,84.88,,289.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,213.14,50,,170.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.7,75,,255.76,percent of total billed charges,75% of total billed charges for outpatient setting,298.39,70,,238.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.73,12.84,,43.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.02,80,,272.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.73,12.84,,43.78,percent of total billed charges,12.84% of total billed charges,54.73,12.84,,43.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.19,35,,119.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,383.64,90,,306.91,percent of total billed charges,90% of total billed charges for outpatient setting,54.73,383.64,
SC PROSTATE PLACEMENT OF MARKERS,2600190,CDM,360,RC,,,Outpatient,,,2082.91,2082.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1458.04,70,,1166.43,percent of total billed charges,70% of total billed charges for outpatient setting,1767.97,84.88,,1414.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,1041.46,50,,833.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1562.18,75,,1249.74,percent of total billed charges,75% of total billed charges for outpatient setting,1458.04,70,,1166.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.45,12.84,,213.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1666.33,80,,1333.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.45,12.84,,213.96,percent of total billed charges,12.84% of total billed charges,267.45,12.84,,213.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.02,35,,583.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1874.62,90,,1499.7,percent of total billed charges,90% of total billed charges for outpatient setting,267.45,1874.62,
SC PUNCTURE LUMBAR DX,2401013,CDM,360,RC,,,Outpatient,,,1407.48,1407.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.24,70,,788.19,percent of total billed charges,70% of total billed charges for outpatient setting,1194.67,84.88,,955.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,703.74,50,,562.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1055.61,75,,844.49,percent of total billed charges,75% of total billed charges for outpatient setting,985.24,70,,788.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.72,12.84,,144.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.98,80,,900.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.72,12.84,,144.58,percent of total billed charges,12.84% of total billed charges,180.72,12.84,,144.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.62,35,,394.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1266.73,90,,1013.38,percent of total billed charges,90% of total billed charges for outpatient setting,180.72,1266.73,
SC REPOSITION GI TUBE,2401017,CDM,360,RC,,,Outpatient,,,733.06,733.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.14,70,,410.51,percent of total billed charges,70% of total billed charges for outpatient setting,622.22,84.88,,497.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,366.53,50,,293.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.8,75,,439.84,percent of total billed charges,75% of total billed charges for outpatient setting,513.14,70,,410.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.12,12.84,,75.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.45,80,,469.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.12,12.84,,75.3,percent of total billed charges,12.84% of total billed charges,94.12,12.84,,75.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.57,35,,205.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,659.75,90,,527.8,percent of total billed charges,90% of total billed charges for outpatient setting,94.12,659.75,
SC THORACENTESIS,2300223,CDM,360,RC,,,Outpatient,,,1729.43,1729.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1210.6,70,,968.48,percent of total billed charges,70% of total billed charges for outpatient setting,1467.94,84.88,,1174.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,864.72,50,,691.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.07,75,,1037.66,percent of total billed charges,75% of total billed charges for outpatient setting,1210.6,70,,968.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.06,12.84,,177.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1383.54,80,,1106.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.06,12.84,,177.65,percent of total billed charges,12.84% of total billed charges,222.06,12.84,,177.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.3,35,,484.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1556.49,90,,1245.19,percent of total billed charges,90% of total billed charges for outpatient setting,222.06,1556.49,
SC THORACENTESIS,2600509,CDM,360,RC,,,Outpatient,,,1792.78,1792.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,1521.71,84.88,,1217.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,896.39,50,,717.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1344.59,75,,1075.67,percent of total billed charges,75% of total billed charges for outpatient setting,1254.95,70,,1003.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.22,80,,1147.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,230.19,12.84,,184.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.47,35,,501.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1613.5,90,,1290.8,percent of total billed charges,90% of total billed charges for outpatient setting,230.19,1613.5,
SCALPEL  #11 DISPOSABLE / 371611,69169117,CDM,272,RC,,,Outpatient,,,5.5,5.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,70,,3.08,percent of total billed charges,70% of total billed charges for outpatient setting,4.67,84.88,,3.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.75,50,,2.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.13,75,,3.3,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,70,,3.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.4,80,,3.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,0.71,12.84,,0.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.58,65,,2.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,35,,1.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.95,90,,3.96,percent of total billed charges,90% of total billed charges for outpatient setting,0.71,4.95,
SCALPEL SPEEDRELEASE / SN20,7667097,CDM,278,RC,C1713,HCPCS,Outpatient,,,1400,1400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,60,,672,percent of total billed charges,60% of total Billed charges for outpatient setting,1188.32,84.88,,950.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,75,,840,percent of total billed charges,75% of total billed charges for outpatient setting,700,50,,560,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,80,,896,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1400,65,,1120,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490,35,,392,percent of total billed charges,35% of total Billed charges for Outpatient Setting,840,60,,672,percent of total billed charges,60% of total billed charges for outpatient setting,179.76,1400,
SCAPULA COMP LEFT,2400476,CDM,320,RC,73010,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SCAPULA COMP RIGHT,2400475,CDM,320,RC,73010,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SCD SLEEVES CALF MED / 9529,6150677,CDM,270,RC,,,Outpatient,,,116.8,116.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.76,70,,65.41,percent of total billed charges,70% of total billed charges for outpatient setting,99.14,84.88,,79.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.4,50,,46.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.6,75,,70.08,percent of total billed charges,75% of total billed charges for outpatient setting,81.76,70,,65.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,12.84,,12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.44,80,,74.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,12.84,,12,percent of total billed charges,12.84% of total billed charges,15,12.84,,12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.92,65,,60.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.88,35,,32.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.12,90,,84.1,percent of total billed charges,90% of total billed charges for outpatient setting,15,105.12,
SCD SLEEVES CALF MED / 9529B,69162895,CDM,270,RC,,,Outpatient,,,62.93,62.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.05,70,,35.24,percent of total billed charges,70% of total billed charges for outpatient setting,53.41,84.88,,42.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.47,50,,25.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.2,75,,37.76,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,70,,35.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,12.84,,6.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.34,80,,40.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,12.84,,6.46,percent of total billed charges,12.84% of total billed charges,8.08,12.84,,6.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.9,65,,32.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.03,35,,17.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.64,90,,45.31,percent of total billed charges,90% of total billed charges for outpatient setting,8.08,56.64,
SCD SLEEVES XLG CALF / 9790B,69160971,CDM,270,RC,,,Outpatient,,,100.86,100.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.6,70,,56.48,percent of total billed charges,70% of total billed charges for outpatient setting,85.61,84.88,,68.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.43,50,,40.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.65,75,,60.52,percent of total billed charges,75% of total billed charges for outpatient setting,70.6,70,,56.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,12.84,,10.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.69,80,,64.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.95,12.84,,10.36,percent of total billed charges,12.84% of total billed charges,12.95,12.84,,10.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.56,65,,52.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.3,35,,28.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.77,90,,72.62,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,90.77,
SCISSOR 2.6MM 165CM ENSIZOR / ES26165,71000256,CDM,272,RC,,,Outpatient,,,1300,1300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,1103.44,84.88,,882.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,650,50,,520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,75,,780,percent of total billed charges,75% of total billed charges for outpatient setting,910,70,,728,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1040,80,,832,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,166.92,12.84,,133.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,845,65,,676,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,35,,364,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1170,90,,936,percent of total billed charges,90% of total billed charges for outpatient setting,166.92,1170,
SCISSOR ENDO 5MM CURVED / 5DCS,6150159,CDM,272,RC,,,Outpatient,,,197.9,197.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.53,70,,110.82,percent of total billed charges,70% of total billed charges for outpatient setting,167.98,84.88,,134.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.95,50,,79.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.43,75,,118.74,percent of total billed charges,75% of total billed charges for outpatient setting,138.53,70,,110.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,12.84,,20.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.32,80,,126.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,12.84,,20.33,percent of total billed charges,12.84% of total billed charges,25.41,12.84,,20.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128.64,65,,102.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.27,35,,55.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,178.11,90,,142.49,percent of total billed charges,90% of total billed charges for outpatient setting,25.41,178.11,
SCLERAL TISSUE - HALF SHELL,69169190,CDM,278,RC,C1762,HCPCS,Outpatient,,,2081.89,2081.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.13,60,,999.3,percent of total billed charges,60% of total Billed charges for outpatient setting,1767.11,84.88,,1413.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1561.42,75,,1249.14,percent of total billed charges,75% of total billed charges for outpatient setting,1040.95,50,,832.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.31,12.84,,213.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1665.51,80,,1332.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.31,12.84,,213.85,percent of total billed charges,12.84% of total billed charges,267.31,12.84,,213.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2081.89,65,,1665.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.66,35,,582.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1249.13,60,,999.3,percent of total billed charges,60% of total billed charges for outpatient setting,267.31,2081.89,
SCLERAL TISSUE - QUARTER SHELL,69169540,CDM,278,RC,C1762,HCPCS,Outpatient,,,1260,1260,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,60,,604.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1069.49,84.88,,855.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,75,,756,percent of total billed charges,75% of total billed charges for outpatient setting,630,50,,504,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.78,12.84,,129.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,80,,806.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.78,12.84,,129.42,percent of total billed charges,12.84% of total billed charges,161.78,12.84,,129.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1260,65,,1008,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,35,,352.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,756,60,,604.8,percent of total billed charges,60% of total billed charges for outpatient setting,161.78,1260,
SCLERAL TISSUE - QUARTER SHELL,69169664,CDM,278,RC,C1762,HCPCS,Outpatient,,,2081.89,2081.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.13,60,,999.3,percent of total billed charges,60% of total Billed charges for outpatient setting,1767.11,84.88,,1413.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1561.42,75,,1249.14,percent of total billed charges,75% of total billed charges for outpatient setting,1040.95,50,,832.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.31,12.84,,213.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1665.51,80,,1332.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.31,12.84,,213.85,percent of total billed charges,12.84% of total billed charges,267.31,12.84,,213.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2081.89,65,,1665.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.66,35,,582.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1249.13,60,,999.3,percent of total billed charges,60% of total billed charges for outpatient setting,267.31,2081.89,
SCLERODERMA AB SCL-70,220862,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
SCOPE MOUTH WASH: 44ML,3303346,CDM,259,RC,,,Outpatient,,,9.74,9.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,8.27,84.88,,6.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.87,50,,3.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.31,75,,5.85,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,70,,5.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,80,,6.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,1.25,12.84,,1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.33,65,,5.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,35,,2.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.77,90,,7.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.25,8.77,
SCOPE MOUTHWASH ORIG MINT:44ML,3303780,CDM,259,RC,,,Outpatient,,,9.95,9.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.97,70,,5.58,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,84.88,,6.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.98,50,,3.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.46,75,,5.97,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,70,,5.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.96,80,,6.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.47,65,,5.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.48,35,,2.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.96,90,,7.17,percent of total billed charges,90% of total billed charges for outpatient setting,1.28,8.96,
"SCOPE SEAL, MYOSURE",69161785,CDM,272,RC,,,Outpatient,,,77.97,77.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.58,70,,43.66,percent of total billed charges,70% of total billed charges for outpatient setting,66.18,84.88,,52.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.99,50,,31.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.48,75,,46.78,percent of total billed charges,75% of total billed charges for outpatient setting,54.58,70,,43.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,12.84,,8.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.38,80,,49.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,12.84,,8.01,percent of total billed charges,12.84% of total billed charges,10.01,12.84,,8.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.68,65,,40.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.29,35,,21.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.17,90,,56.14,percent of total billed charges,90% of total billed charges for outpatient setting,10.01,70.17,
SCOPOLAMINE (ISOPT HYOSC) 0.25% DRP:5ML,3301953,CDM,259,RC,,,Outpatient,,,56.34,56.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,70,,31.55,percent of total billed charges,70% of total billed charges for outpatient setting,47.82,84.88,,38.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.17,50,,22.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.26,75,,33.81,percent of total billed charges,75% of total billed charges for outpatient setting,39.44,70,,31.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.23,12.84,,5.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.07,80,,36.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.23,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,7.23,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.62,65,,29.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,35,,15.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.71,90,,40.57,percent of total billed charges,90% of total billed charges for outpatient setting,7.23,50.71,
SCOPOLAMINE(TRANSDERM SCOP) 1.5MG PATCH,3301954,CDM,259,RC,,,Outpatient,,,44.52,44.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,37.79,84.88,,30.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.26,50,,17.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.39,75,,26.71,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,12.84,,4.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.62,80,,28.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,5.72,12.84,,4.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.94,65,,23.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.58,35,,12.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.07,90,,32.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.72,40.07,
SCORPION NEEDLE / AR-13990N,69160856,CDM,272,RC,,,Outpatient,,,636.29,636.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.4,70,,356.32,percent of total billed charges,70% of total billed charges for outpatient setting,540.08,84.88,,432.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.15,50,,254.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.22,75,,381.78,percent of total billed charges,75% of total billed charges for outpatient setting,445.4,70,,356.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.03,80,,407.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.59,65,,330.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.7,35,,178.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.66,90,,458.13,percent of total billed charges,90% of total billed charges for outpatient setting,81.7,572.66,
SCORPION NEEDLE MULTIFIRE / AR-13995N,69169783,CDM,272,RC,,,Outpatient,,,714,714,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.8,70,,399.84,percent of total billed charges,70% of total billed charges for outpatient setting,606.04,84.88,,484.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,357,50,,285.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.5,75,,428.4,percent of total billed charges,75% of total billed charges for outpatient setting,499.8,70,,399.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.2,80,,456.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,91.68,12.84,,73.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,464.1,65,,371.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,35,,199.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642.6,90,,514.08,percent of total billed charges,90% of total billed charges for outpatient setting,91.68,642.6,
SCORPION NEEDLE SUREFIRE/ AR-13991N,69160552,CDM,272,RC,,,Outpatient,,,636.29,636.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.4,70,,356.32,percent of total billed charges,70% of total billed charges for outpatient setting,540.08,84.88,,432.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,318.15,50,,254.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.22,75,,381.78,percent of total billed charges,75% of total billed charges for outpatient setting,445.4,70,,356.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.03,80,,407.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,81.7,12.84,,65.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,413.59,65,,330.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.7,35,,178.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.66,90,,458.13,percent of total billed charges,90% of total billed charges for outpatient setting,81.7,572.66,
SCOTCHCAST 4IN 4YD BLUE / 82004B,71000638,CDM,272,RC,,,Outpatient,,,32.4,32.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,27.5,84.88,,22,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.2,50,,12.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,75,,19.44,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,80,,20.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.06,65,,16.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,35,,9.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.16,90,,23.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,29.16,
SCOTCHCAST 4IN 4YD WHITE / 82004,71000639,CDM,272,RC,,,Outpatient,,,30.56,30.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,70,,17.11,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,84.88,,20.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.28,50,,12.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.92,75,,18.34,percent of total billed charges,75% of total billed charges for outpatient setting,21.39,70,,17.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,12.84,,3.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,80,,19.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,3.92,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.86,65,,15.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.7,35,,8.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.5,90,,22,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,27.5,
SCREENING 3D TOMOSYNTHESIS BIL,2710101,CDM,403,RC,77063,HCPCS,Outpatient,,,301.5,301.5,,34.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,72.23,170,,,Fee Schedule,170% of Medicare OPPS rate,45.95,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,37.4,175,,,Fee Schedule,175% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,26.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.39,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,21.37,271.35,
SCREENING 3D TOMOSYNTHESIS BIL,2710106,CDM,403,RC,77063,HCPCS,Outpatient,,,301.5,301.5,,34.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,255.91,84.88,,204.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,226.13,75,,180.9,percent of total billed charges,75% of total billed charges for outpatient setting,211.05,70,,168.84,percent of total billed charges,70% of total billed charges for outpatient setting,72.23,170,,,Fee Schedule,170% of Medicare OPPS rate,45.95,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,38.71,12.84,,30.968,percent of total billed charges,12.84% of total billed charges,37.4,175,,,Fee Schedule,175% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,241.2,80,,192.96,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,26.71,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,38.71,12.84,,30.97,percent of total billed charges,12.84% of total billed charges,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,214,100,,,Case rate,pays based on fixed rate ,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,21.37,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,55.39,100,,,Fee Schedule,100% of Custom Fee Schedule,271.35,90,,217.08,percent of total billed charges,90% of total billed charges for outpatient setting,21.37,271.35,
SCREW 1.5X10MM STARDRIVE / 02.214.110,69169254,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 1.5X11MM STARDRIVE / 02.214.111,69169255,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 1.5X13MM STARDRIVE / 02.214.113,69169257,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 1.5X8MM STARDRIVE / 02.214.108,69169253,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 1.5X9MM STARDRIVE / 02.214.109,69169256,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 1.7X8MM  / 58-17008E,69162677,CDM,278,RC,C1713,HCPCS,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW 1.7X8MM STRYKER / 58-17009,69162021,CDM,278,RC,,,Outpatient,,,474.13,474.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.48,60,,227.58,percent of total billed charges,60% of total Billed charges for outpatient setting,402.44,84.88,,321.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,237.07,50,,189.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,355.6,75,,284.48,percent of total billed charges,75% of total billed charges for outpatient setting,237.07,50,,189.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.88,12.84,,48.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.3,80,,303.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.88,12.84,,48.7,percent of total billed charges,12.84% of total billed charges,60.88,12.84,,48.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,474.13,65,,379.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.95,35,,132.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,284.48,60,,227.58,percent of total billed charges,60% of total billed charges for outpatient setting,60.88,474.13,
SCREW 1.7X9MM STRYKER / 58-17009E,69161970,CDM,278,RC,,,Outpatient,,,463.4,463.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.04,60,,222.43,percent of total billed charges,60% of total Billed charges for outpatient setting,393.33,84.88,,314.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.55,75,,278.04,percent of total billed charges,75% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.72,80,,296.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,463.4,65,,370.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,35,,129.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,278.04,60,,222.43,percent of total billed charges,60% of total billed charges for outpatient setting,59.5,463.4,
SCREW 10X23MM INTRFERNCE BIOCMP AR-1400C,69162527,CDM,278,RC,,,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 10X25 COMPOSITE ACL / 231025M5,69161667,CDM,272,RC,,,Outpatient,,,1049.53,1049.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.67,70,,587.74,percent of total billed charges,70% of total billed charges for outpatient setting,890.84,84.88,,712.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,524.77,50,,419.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.15,75,,629.72,percent of total billed charges,75% of total billed charges for outpatient setting,734.67,70,,587.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.76,12.84,,107.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.62,80,,671.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.76,12.84,,107.81,percent of total billed charges,12.84% of total billed charges,134.76,12.84,,107.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,682.19,65,,545.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.34,35,,293.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,944.58,90,,755.66,percent of total billed charges,90% of total billed charges for outpatient setting,134.76,944.58,
SCREW 10X28MM INTERFERENCE AR-5028C-10,69161805,CDM,278,RC,,,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 10X30MM SI-LOK HA / 139.502S,69162469,CDM,278,RC,C1713,HCPCS,Outpatient,,,6650,6650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3990,60,,3192,percent of total billed charges,60% of total Billed charges for outpatient setting,5644.52,84.88,,4515.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4987.5,75,,3990,percent of total billed charges,75% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5320,80,,4256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6982.5,105,,5586,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.5,35,,1862,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3990,60,,3192,percent of total billed charges,60% of total billed charges for outpatient setting,853.86,6982.5,
SCREW 10X30MM VENTED / AR-4030C-10,71000367,CDM,278,RC,C1713,HCPCS,Outpatient,,,1180,1180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708,60,,566.4,percent of total billed charges,60% of total Billed charges for outpatient setting,1001.58,84.88,,801.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885,75,,708,percent of total billed charges,75% of total billed charges for outpatient setting,590,50,,472,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944,80,,755.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1180,65,,944,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,35,,330.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,708,60,,566.4,percent of total billed charges,60% of total billed charges for outpatient setting,151.51,1180,
SCREW 10X35MM SI-LOK HA / 139.503S,69162452,CDM,278,RC,,,Outpatient,,,6650,6650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3990,60,,3192,percent of total billed charges,60% of total Billed charges for outpatient setting,5644.52,84.88,,4515.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4987.5,75,,3990,percent of total billed charges,75% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5320,80,,4256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6982.5,105,,5586,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.5,35,,1862,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3990,60,,3192,percent of total billed charges,60% of total billed charges for outpatient setting,853.86,6982.5,
SCREW 10X40MM SI-LOK HA / 139.504S,69162453,CDM,278,RC,,,Outpatient,,,6650,6650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3990,60,,3192,percent of total billed charges,60% of total Billed charges for outpatient setting,5644.52,84.88,,4515.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4987.5,75,,3990,percent of total billed charges,75% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5320,80,,4256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6982.5,105,,5586,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.5,35,,1862,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3990,60,,3192,percent of total billed charges,60% of total billed charges for outpatient setting,853.86,6982.5,
SCREW 10X45MM SI-LOK HA / 139.505S,69162468,CDM,278,RC,,,Outpatient,,,6650,6650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3990,60,,3192,percent of total billed charges,60% of total Billed charges for outpatient setting,5644.52,84.88,,4515.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4987.5,75,,3990,percent of total billed charges,75% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5320,80,,4256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6982.5,105,,5586,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.5,35,,1862,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3990,60,,3192,percent of total billed charges,60% of total billed charges for outpatient setting,853.86,6982.5,
SCREW 11X135MM FEMORAL ECHO / 192011,71000049,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SCREW 11X28MM INTERF RD / AR-5028C-11,69162565,CDM,278,RC,C1713,HCPCS,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 11X30MM VENTED / AR-4030C-11,71000800,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 12MM  189-07-012,69161771,CDM,278,RC,,,Outpatient,,,2241.82,2241.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.09,60,,1076.07,percent of total billed charges,60% of total Billed charges for outpatient setting,1902.86,84.88,,1522.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,1120.91,50,,896.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1681.37,75,,1345.1,percent of total billed charges,75% of total billed charges for outpatient setting,1120.91,50,,896.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.85,12.84,,230.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1793.46,80,,1434.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.85,12.84,,230.28,percent of total billed charges,12.84% of total billed charges,287.85,12.84,,230.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2353.91,105,,1883.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.64,35,,627.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1345.09,60,,1076.07,percent of total billed charges,60% of total billed charges for outpatient setting,287.85,2353.91,
SCREW 12MM ELLIPSE / 182.312,69162381,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 12MM VARIABLE / 13-16-012,69169318,CDM,278,RC,C1713,HCPCS,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,60,,302.4,percent of total billed charges,60% of total Billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,630,65,,504,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378,60,,302.4,percent of total billed charges,60% of total billed charges for outpatient setting,80.89,630,
SCREW 12MM XTEND / 161.012,69161740,CDM,278,RC,,,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 12X3.6MM / 184.152,69162196,CDM,278,RC,,,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 14MM ELLIPSE / 182.314,70000025,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 14MM RESCUE LG / 1868-54-014,69169135,CDM,278,RC,C1713,HCPCS,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.68,60,,622.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1297.8,65,,1038.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,60,,622.94,percent of total billed charges,60% of total billed charges for outpatient setting,166.64,1297.8,
SCREW 14MM VARIABLE / 13-16-014,69169302,CDM,278,RC,C1713,HCPCS,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,60,,302.4,percent of total billed charges,60% of total Billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,630,65,,504,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378,60,,302.4,percent of total billed charges,60% of total billed charges for outpatient setting,80.89,630,
SCREW 2.00X16MM LOCKING / 5201020016,71000361,CDM,278,RC,C1713,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.8,60,,349.44,percent of total billed charges,60% of total Billed charges for outpatient setting,617.93,84.88,,494.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,75,,436.8,percent of total billed charges,75% of total billed charges for outpatient setting,364,50,,291.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.48,12.84,,74.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.4,80,,465.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.48,12.84,,74.78,percent of total billed charges,12.84% of total billed charges,93.48,12.84,,74.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,728,65,,582.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.8,35,,203.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,436.8,60,,349.44,percent of total billed charges,60% of total billed charges for outpatient setting,93.48,728,
SCREW 2.0X10MM CORTEX / 201.360.97,69162714,CDM,278,RC,C1713,HCPCS,Outpatient,,,232.95,232.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.77,60,,111.82,percent of total billed charges,60% of total Billed charges for outpatient setting,197.73,84.88,,158.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.71,75,,139.77,percent of total billed charges,75% of total billed charges for outpatient setting,116.48,50,,93.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.36,80,,149.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.95,65,,186.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,35,,65.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.77,60,,111.82,percent of total billed charges,60% of total billed charges for outpatient setting,29.91,232.95,
SCREW 2.0X10MM CORTEX / A-5400.10/1,69169703,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X10MM LOCK / 201.880,69162715,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0X11MM CORTEX / 201.361.97,69169401,CDM,278,RC,C1713,HCPCS,Outpatient,,,259.56,259.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.74,60,,124.59,percent of total billed charges,60% of total Billed charges for outpatient setting,220.31,84.88,,176.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,75,,155.74,percent of total billed charges,75% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,80,,166.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.56,65,,207.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,35,,72.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,60,,124.59,percent of total billed charges,60% of total billed charges for outpatient setting,33.33,259.56,
SCREW 2.0X11MM CORTEX / 201.881,69169403,CDM,278,RC,C1713,HCPCS,Outpatient,,,552.22,552.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.33,60,,265.06,percent of total billed charges,60% of total Billed charges for outpatient setting,468.72,84.88,,374.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.17,75,,331.34,percent of total billed charges,75% of total billed charges for outpatient setting,276.11,50,,220.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,12.84,,56.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.78,80,,353.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,12.84,,56.73,percent of total billed charges,12.84% of total billed charges,70.91,12.84,,56.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,552.22,65,,441.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.28,35,,154.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,331.33,60,,265.06,percent of total billed charges,60% of total billed charges for outpatient setting,70.91,552.22,
SCREW 2.0X11MM CORTEX / A-5400.11/1,69169704,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X12MM CORTEX / 201.362.97,69162929,CDM,278,RC,C1713,HCPCS,Outpatient,,,177.15,177.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.29,60,,85.03,percent of total billed charges,60% of total Billed charges for outpatient setting,150.36,84.88,,120.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.86,75,,106.29,percent of total billed charges,75% of total billed charges for outpatient setting,88.58,50,,70.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.72,80,,113.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.15,65,,141.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62,35,,49.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.29,60,,85.03,percent of total billed charges,60% of total billed charges for outpatient setting,22.75,177.15,
SCREW 2.0X12MM CORTEX / A-5400.12/1,69169705,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X12MM CORTEX / A-5400.14/1,69169706,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X12MM LOCK / 201.882,69162716,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0X13MM CORTEX / 201.363.97,69162930,CDM,278,RC,C1713,HCPCS,Outpatient,,,189.04,189.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.42,60,,90.74,percent of total billed charges,60% of total Billed charges for outpatient setting,160.46,84.88,,128.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.78,75,,113.42,percent of total billed charges,75% of total billed charges for outpatient setting,94.52,50,,75.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.23,80,,120.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.04,65,,151.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.16,35,,52.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.42,60,,90.74,percent of total billed charges,60% of total billed charges for outpatient setting,24.27,189.04,
SCREW 2.0X13MM LOCKING / 201.883,134239,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0X14MM CORTEX / 201.364.97,69162710,CDM,278,RC,C1713,HCPCS,Outpatient,,,177.15,177.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.29,60,,85.03,percent of total billed charges,60% of total Billed charges for outpatient setting,150.36,84.88,,120.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.86,75,,106.29,percent of total billed charges,75% of total billed charges for outpatient setting,88.58,50,,70.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.72,80,,113.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.15,65,,141.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62,35,,49.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.29,60,,85.03,percent of total billed charges,60% of total billed charges for outpatient setting,22.75,177.15,
SCREW 2.0X14MM LOCK / 201.884,69162712,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0X16MM CORTEX / 201.886,69169402,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0X16MM CORTEX/ 201.366.97,69162713,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 2.0X16MM STARDRIVE / 201.766,69169249,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.0X18MM CORTEX / 201.368.97,69162711,CDM,278,RC,C1713,HCPCS,Outpatient,,,177.15,177.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.29,60,,85.03,percent of total billed charges,60% of total Billed charges for outpatient setting,150.36,84.88,,120.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.86,75,,106.29,percent of total billed charges,75% of total billed charges for outpatient setting,88.58,50,,70.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.72,80,,113.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,22.75,12.84,,18.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.15,65,,141.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62,35,,49.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,106.29,60,,85.03,percent of total billed charges,60% of total billed charges for outpatient setting,22.75,177.15,
SCREW 2.0X18MM STARDRIVE / 201.768,69169247,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.0X20MM LOCKING / 201.890,116262,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.0x24MM HEADLESS / 141-2024,69169358,CDM,278,RC,C1713,HCPCS,Outpatient,,,915.52,915.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.31,60,,439.45,percent of total billed charges,60% of total Billed charges for outpatient setting,777.09,84.88,,621.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.64,75,,549.31,percent of total billed charges,75% of total billed charges for outpatient setting,457.76,50,,366.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.55,12.84,,94.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.42,80,,585.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.55,12.84,,94.04,percent of total billed charges,12.84% of total billed charges,117.55,12.84,,94.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,915.52,65,,732.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.43,35,,256.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,549.31,60,,439.45,percent of total billed charges,60% of total billed charges for outpatient setting,117.55,915.52,
SCREW 2.0X6MM CORTEX / 201.356.97,812708,CDM,278,RC,C1713,HCPCS,Outpatient,,,232.95,232.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.77,60,,111.82,percent of total billed charges,60% of total Billed charges for outpatient setting,197.73,84.88,,158.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.71,75,,139.77,percent of total billed charges,75% of total billed charges for outpatient setting,116.48,50,,93.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.36,80,,149.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.95,65,,186.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,35,,65.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.77,60,,111.82,percent of total billed charges,60% of total billed charges for outpatient setting,29.91,232.95,
SCREW 2.0X7MM CORTEX / 201.357.97,1116222,CDM,278,RC,C1713,HCPCS,Outpatient,,,232.95,232.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.77,60,,111.82,percent of total billed charges,60% of total Billed charges for outpatient setting,197.73,84.88,,158.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.71,75,,139.77,percent of total billed charges,75% of total billed charges for outpatient setting,116.48,50,,93.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.36,80,,149.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.95,65,,186.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,35,,65.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.77,60,,111.82,percent of total billed charges,60% of total billed charges for outpatient setting,29.91,232.95,
SCREW 2.0X8MM CORTEX / 201.358.97,70000364,CDM,278,RC,C1713,HCPCS,Outpatient,,,213.15,213.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.89,60,,102.31,percent of total billed charges,60% of total Billed charges for outpatient setting,180.92,84.88,,144.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.86,75,,127.89,percent of total billed charges,75% of total billed charges for outpatient setting,106.58,50,,85.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.37,12.84,,21.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.52,80,,136.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.37,12.84,,21.9,percent of total billed charges,12.84% of total billed charges,27.37,12.84,,21.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,213.15,65,,170.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.6,35,,59.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.89,60,,102.31,percent of total billed charges,60% of total billed charges for outpatient setting,27.37,213.15,
SCREW 2.0X8MM CORTEX / A-5400.08/1,69169701,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X8MM LOCK STARDRIVE / 201.878,70000363,CDM,278,RC,C1713,HCPCS,Outpatient,,,552.22,552.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.33,60,,265.06,percent of total billed charges,60% of total Billed charges for outpatient setting,468.72,84.88,,374.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.17,75,,331.34,percent of total billed charges,75% of total billed charges for outpatient setting,276.11,50,,220.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,12.84,,56.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.78,80,,353.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,12.84,,56.73,percent of total billed charges,12.84% of total billed charges,70.91,12.84,,56.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,552.22,65,,441.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.28,35,,154.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,331.33,60,,265.06,percent of total billed charges,60% of total billed charges for outpatient setting,70.91,552.22,
SCREW 2.0X9MM CORTEX / 201.359.97,70000630,CDM,278,RC,C1713,HCPCS,Outpatient,,,189.04,189.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.42,60,,90.74,percent of total billed charges,60% of total Billed charges for outpatient setting,160.46,84.88,,128.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.78,75,,113.42,percent of total billed charges,75% of total billed charges for outpatient setting,94.52,50,,75.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.23,80,,120.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.04,65,,151.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.16,35,,52.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.42,60,,90.74,percent of total billed charges,60% of total billed charges for outpatient setting,24.27,189.04,
SCREW 2.0X9MM CORTEX / 201.359.97,70000361,CDM,278,RC,C1713,HCPCS,Outpatient,,,232.95,232.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.77,60,,111.82,percent of total billed charges,60% of total Billed charges for outpatient setting,197.73,84.88,,158.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.71,75,,139.77,percent of total billed charges,75% of total billed charges for outpatient setting,116.48,50,,93.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.36,80,,149.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,29.91,12.84,,23.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.95,65,,186.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,35,,65.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.77,60,,111.82,percent of total billed charges,60% of total billed charges for outpatient setting,29.91,232.95,
SCREW 2.0X9MM CORTEX / A-5400.09/1,69169702,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.0X9MM LOCK STARDRIVE / 201.879,70000362,CDM,278,RC,C1713,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,60,,220.32,percent of total billed charges,60% of total Billed charges for outpatient setting,389.6,84.88,,311.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,75,,275.4,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,50,,183.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,80,,293.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,58.94,12.84,,47.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,459,65,,367.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,35,,128.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,275.4,60,,220.32,percent of total billed charges,60% of total billed charges for outpatient setting,58.94,459,
SCREW 2.3 x 12MM LOCKING 53-23612E,69162621,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3 x 16MM / 53-23216E,69162507,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.3 x 22MM LOCKING 53-23622E,69162510,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X11MM VARIAX / 663811,7053242,CDM,278,RC,C1713,HCPCS,Outpatient,,,351.36,351.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.82,60,,168.66,percent of total billed charges,60% of total Billed charges for outpatient setting,298.23,84.88,,238.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,75,,210.82,percent of total billed charges,75% of total billed charges for outpatient setting,175.68,50,,140.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.09,80,,224.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.36,65,,281.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.98,35,,98.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.82,60,,168.66,percent of total billed charges,60% of total billed charges for outpatient setting,45.11,351.36,
SCREW 2.3X13MM VARIAX / 663813,7053844,CDM,278,RC,C1713,HCPCS,Outpatient,,,351.36,351.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.82,60,,168.66,percent of total billed charges,60% of total Billed charges for outpatient setting,298.23,84.88,,238.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,75,,210.82,percent of total billed charges,75% of total billed charges for outpatient setting,175.68,50,,140.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.09,80,,224.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.36,65,,281.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.98,35,,98.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.82,60,,168.66,percent of total billed charges,60% of total billed charges for outpatient setting,45.11,351.36,
SCREW 2.3X14MM / 53-23214E,69162506,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.3X14MM LOCKING / 53-23614E,70000154,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X15MM VARIAX / 663815,7053842,CDM,278,RC,C1713,HCPCS,Outpatient,,,351.36,351.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.82,60,,168.66,percent of total billed charges,60% of total Billed charges for outpatient setting,298.23,84.88,,238.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,75,,210.82,percent of total billed charges,75% of total billed charges for outpatient setting,175.68,50,,140.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.09,80,,224.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.36,65,,281.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.98,35,,98.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.82,60,,168.66,percent of total billed charges,60% of total billed charges for outpatient setting,45.11,351.36,
SCREW 2.3X16MM LOCKING / 53-23616E,70000173,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X18MM LOCKING / 53-23618E,69162511,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X20MM LOCKING / 53-23610E,69162509,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X20MM LOCKING / 53-23620E,69162508,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X26MM TIT CORT / CO-N2326,696074,CDM,278,RC,C1713,HCPCS,Outpatient,,,344,344,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.4,60,,165.12,percent of total billed charges,60% of total Billed charges for outpatient setting,291.99,84.88,,233.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,75,,206.4,percent of total billed charges,75% of total billed charges for outpatient setting,172,50,,137.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.17,12.84,,35.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.2,80,,220.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.17,12.84,,35.34,percent of total billed charges,12.84% of total billed charges,44.17,12.84,,35.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344,65,,275.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.4,35,,96.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.4,60,,165.12,percent of total billed charges,60% of total billed charges for outpatient setting,44.17,344,
SCREW 2.3X30MM LOCKING / 53-23630E,70000456,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X34MM LOCKING / 53-23634E,70000455,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.3X36MM T7 / 53-23236E,70000454,CDM,278,RC,C1713,HCPCS,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.3X8MM VARIAX / 663808,7053245,CDM,278,RC,C1713,HCPCS,Outpatient,,,351.36,351.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.82,60,,168.66,percent of total billed charges,60% of total Billed charges for outpatient setting,298.23,84.88,,238.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,75,,210.82,percent of total billed charges,75% of total billed charges for outpatient setting,175.68,50,,140.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.09,80,,224.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,45.11,12.84,,36.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.36,65,,281.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.98,35,,98.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210.82,60,,168.66,percent of total billed charges,60% of total billed charges for outpatient setting,45.11,351.36,
SCREW 2.40X10MM LOCKING / 5201024010,71000358,CDM,278,RC,C1713,HCPCS,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,60,,443.52,percent of total billed charges,60% of total Billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,924,65,,739.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,554.4,60,,443.52,percent of total billed charges,60% of total billed charges for outpatient setting,118.64,924,
SCREW 2.40X10MM NONLOCK / 5201124010,383692,CDM,278,RC,C1713,HCPCS,Outpatient,,,470,470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282,60,,225.6,percent of total billed charges,60% of total Billed charges for outpatient setting,398.94,84.88,,319.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.5,75,,282,percent of total billed charges,75% of total billed charges for outpatient setting,235,50,,188,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.35,12.84,,48.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376,80,,300.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.35,12.84,,48.28,percent of total billed charges,12.84% of total billed charges,60.35,12.84,,48.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,470,65,,376,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.5,35,,131.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,282,60,,225.6,percent of total billed charges,60% of total billed charges for outpatient setting,60.35,470,
SCREW 2.40X12MM LOCKING / 5201024012,71000356,CDM,278,RC,C1713,HCPCS,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,60,,443.52,percent of total billed charges,60% of total Billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,924,65,,739.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,554.4,60,,443.52,percent of total billed charges,60% of total billed charges for outpatient setting,118.64,924,
SCREW 2.40X12MM NONLOCK / 5201124012,71000359,CDM,278,RC,C1713,HCPCS,Outpatient,,,292,292,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.2,60,,140.16,percent of total billed charges,60% of total Billed charges for outpatient setting,247.85,84.88,,198.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219,75,,175.2,percent of total billed charges,75% of total billed charges for outpatient setting,146,50,,116.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,12.84,,29.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.6,80,,186.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,12.84,,29.99,percent of total billed charges,12.84% of total billed charges,37.49,12.84,,29.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,292,65,,233.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.2,35,,81.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,175.2,60,,140.16,percent of total billed charges,60% of total billed charges for outpatient setting,37.49,292,
SCREW 2.40X14MM LOCKING / 5201024014,411093,CDM,278,RC,C1713,HCPCS,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,60,,443.52,percent of total billed charges,60% of total Billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,924,65,,739.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,554.4,60,,443.52,percent of total billed charges,60% of total billed charges for outpatient setting,118.64,924,
SCREW 2.40X14MM NONLOCK / 5201124014,71000360,CDM,278,RC,C1713,HCPCS,Outpatient,,,376,376,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.6,60,,180.48,percent of total billed charges,60% of total Billed charges for outpatient setting,319.15,84.88,,255.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282,75,,225.6,percent of total billed charges,75% of total billed charges for outpatient setting,188,50,,150.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.28,12.84,,38.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.8,80,,240.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.28,12.84,,38.62,percent of total billed charges,12.84% of total billed charges,48.28,12.84,,38.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,376,65,,300.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.6,35,,105.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,225.6,60,,180.48,percent of total billed charges,60% of total billed charges for outpatient setting,48.28,376,
SCREW 2.40X16MM LOCKING / 5201024016,71000357,CDM,278,RC,C1713,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.8,60,,349.44,percent of total billed charges,60% of total Billed charges for outpatient setting,617.93,84.88,,494.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,75,,436.8,percent of total billed charges,75% of total billed charges for outpatient setting,364,50,,291.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.48,12.84,,74.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.4,80,,465.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.48,12.84,,74.78,percent of total billed charges,12.84% of total billed charges,93.48,12.84,,74.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,728,65,,582.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.8,35,,203.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,436.8,60,,349.44,percent of total billed charges,60% of total billed charges for outpatient setting,93.48,728,
SCREW 2.4MMX10MM LOCKING / 212.810,70000571,CDM,278,RC,C1713,HCPCS,Outpatient,,,468,468,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.8,60,,224.64,percent of total billed charges,60% of total Billed charges for outpatient setting,397.24,84.88,,317.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,75,,280.8,percent of total billed charges,75% of total billed charges for outpatient setting,234,50,,187.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,80,,299.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,468,65,,374.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,35,,131.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,280.8,60,,224.64,percent of total billed charges,60% of total billed charges for outpatient setting,60.09,468,
SCREW 2.4X10MM CORTEX TI / 401.760,69162812,CDM,278,RC,,,Outpatient,,,238.5,238.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,60,,114.48,percent of total billed charges,60% of total Billed charges for outpatient setting,202.44,84.88,,161.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.25,50,,95.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.88,75,,143.1,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,50,,95.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,12.84,,24.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.8,80,,152.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,12.84,,24.5,percent of total billed charges,12.84% of total billed charges,30.62,12.84,,24.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,238.5,65,,190.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.48,35,,66.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.1,60,,114.48,percent of total billed charges,60% of total billed charges for outpatient setting,30.62,238.5,
SCREW 2.4X10MM CRTX T8 / 201.760,70000303,CDM,278,RC,C1713,HCPCS,Outpatient,,,288.92,288.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.35,60,,138.68,percent of total billed charges,60% of total Billed charges for outpatient setting,245.24,84.88,,196.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.69,75,,173.35,percent of total billed charges,75% of total billed charges for outpatient setting,144.46,50,,115.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.14,80,,184.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,288.92,65,,231.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.12,35,,80.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.35,60,,138.68,percent of total billed charges,60% of total billed charges for outpatient setting,37.1,288.92,
SCREW 2.4X10MM LCKNG TI / 412.810,69162814,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X11MM CRTX T8 / 201.761,70000572,CDM,278,RC,C1713,HCPCS,Outpatient,,,270.69,270.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.41,60,,129.93,percent of total billed charges,60% of total Billed charges for outpatient setting,229.76,84.88,,183.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.02,75,,162.42,percent of total billed charges,75% of total billed charges for outpatient setting,135.35,50,,108.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.76,12.84,,27.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.55,80,,173.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.76,12.84,,27.81,percent of total billed charges,12.84% of total billed charges,34.76,12.84,,27.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,270.69,65,,216.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.74,35,,75.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,162.41,60,,129.93,percent of total billed charges,60% of total billed charges for outpatient setting,34.76,270.69,
SCREW 2.4X12MM CRTX T8 / 201.762,70000304,CDM,278,RC,C1713,HCPCS,Outpatient,,,288.92,288.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.35,60,,138.68,percent of total billed charges,60% of total Billed charges for outpatient setting,245.24,84.88,,196.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.69,75,,173.35,percent of total billed charges,75% of total billed charges for outpatient setting,144.46,50,,115.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.14,80,,184.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,37.1,12.84,,29.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,288.92,65,,231.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.12,35,,80.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.35,60,,138.68,percent of total billed charges,60% of total billed charges for outpatient setting,37.1,288.92,
SCREW 2.4X12MM LCKNG TI / 412.812,69162813,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X12MM LOCKING / 212.812,69162212,CDM,278,RC,C1713,HCPCS,Outpatient,,,602.32,602.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.39,60,,289.11,percent of total billed charges,60% of total Billed charges for outpatient setting,511.25,84.88,,409,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.74,75,,361.39,percent of total billed charges,75% of total billed charges for outpatient setting,301.16,50,,240.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.34,12.84,,61.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.86,80,,385.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.34,12.84,,61.87,percent of total billed charges,12.84% of total billed charges,77.34,12.84,,61.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.32,65,,481.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.81,35,,168.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.39,60,,289.11,percent of total billed charges,60% of total billed charges for outpatient setting,77.34,602.32,
SCREW 2.4X12MM STARDRIVE / 02.210.112,70000305,CDM,278,RC,C1713,HCPCS,Outpatient,,,622.16,622.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.3,60,,298.64,percent of total billed charges,60% of total Billed charges for outpatient setting,528.09,84.88,,422.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.62,75,,373.3,percent of total billed charges,75% of total billed charges for outpatient setting,311.08,50,,248.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.73,80,,398.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,622.16,65,,497.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.76,35,,174.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.3,60,,298.64,percent of total billed charges,60% of total billed charges for outpatient setting,79.89,622.16,
SCREW 2.4X13MM CRTX T8 / 201.763,128925,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.4X13MM LOCKING / 212.813,128944,CDM,278,RC,C1713,HCPCS,Outpatient,,,563.01,563.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.81,60,,270.25,percent of total billed charges,60% of total Billed charges for outpatient setting,477.88,84.88,,382.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.26,75,,337.81,percent of total billed charges,75% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.41,80,,360.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,563.01,65,,450.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,35,,157.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.81,60,,270.25,percent of total billed charges,60% of total billed charges for outpatient setting,72.29,563.01,
SCREW 2.4X14MM CRTX T8 / 201.764,69169139,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.4X14MM LCKNG TI / 412.814,69162431,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X14MM LOCKING / 212.814,69160442,CDM,278,RC,,,Outpatient,,,563.01,563.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.81,60,,270.25,percent of total billed charges,60% of total Billed charges for outpatient setting,477.88,84.88,,382.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422.26,75,,337.81,percent of total billed charges,75% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.41,80,,360.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,563.01,65,,450.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,35,,157.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.81,60,,270.25,percent of total billed charges,60% of total billed charges for outpatient setting,72.29,563.01,
SCREW 2.4X14MM STARDRIVE  / 02.210.114,68702,CDM,278,RC,C1713,HCPCS,Outpatient,,,622.16,622.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.3,60,,298.64,percent of total billed charges,60% of total Billed charges for outpatient setting,528.09,84.88,,422.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.62,75,,373.3,percent of total billed charges,75% of total billed charges for outpatient setting,311.08,50,,248.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.73,80,,398.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,622.16,65,,497.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.76,35,,174.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.3,60,,298.64,percent of total billed charges,60% of total billed charges for outpatient setting,79.89,622.16,
SCREW 2.4X14MM VAL CRTX / AR-8916VNC-14,71000665,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 2.4X16MM CORTEX TI  401.766,69162426,CDM,278,RC,,,Outpatient,,,238.5,238.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,60,,114.48,percent of total billed charges,60% of total Billed charges for outpatient setting,202.44,84.88,,161.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,119.25,50,,95.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.88,75,,143.1,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,50,,95.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,12.84,,24.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.8,80,,152.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,12.84,,24.5,percent of total billed charges,12.84% of total billed charges,30.62,12.84,,24.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,238.5,65,,190.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.48,35,,66.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,143.1,60,,114.48,percent of total billed charges,60% of total billed charges for outpatient setting,30.62,238.5,
SCREW 2.4X16MM KREULOCK / AR-8724VCL-16,71000415,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.4X16MM LCKNG TI / 412.816,69162430,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X16MM LOCKING / 212.816,69160440,CDM,278,RC,C1713,HCPCS,Outpatient,,,602.32,602.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.39,60,,289.11,percent of total billed charges,60% of total Billed charges for outpatient setting,511.25,84.88,,409,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.74,75,,361.39,percent of total billed charges,75% of total billed charges for outpatient setting,301.16,50,,240.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.34,12.84,,61.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.86,80,,385.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.34,12.84,,61.87,percent of total billed charges,12.84% of total billed charges,77.34,12.84,,61.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.32,65,,481.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.81,35,,168.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.39,60,,289.11,percent of total billed charges,60% of total billed charges for outpatient setting,77.34,602.32,
SCREW 2.4X16MM TI / AR-8724V-16,70000546,CDM,278,RC,C1713,HCPCS,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,60,,290.7,percent of total billed charges,60% of total Billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,605.64,65,,484.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.38,60,,290.7,percent of total billed charges,60% of total billed charges for outpatient setting,77.76,605.64,
SCREW 2.4X16MM VA LOCKING / 04.210.116,69162459,CDM,278,RC,C1713,HCPCS,Outpatient,,,569.82,569.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.89,60,,273.51,percent of total billed charges,60% of total Billed charges for outpatient setting,483.66,84.88,,386.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.37,75,,341.9,percent of total billed charges,75% of total billed charges for outpatient setting,284.91,50,,227.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.86,80,,364.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.82,65,,455.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.44,35,,159.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.89,60,,273.51,percent of total billed charges,60% of total billed charges for outpatient setting,73.16,569.82,
SCREW 2.4X16MM VAL CRTX / AR-8916VNC-16,71000666,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 2.4X18MM CRTX TI / AR-8916VNC-18,70000538,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 2.4X18MM KREULOCK / AR-8724VCL-18,71000661,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.4X18MM LCKNG TI / 412.818,69162427,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X18MM LCKNG TI / 412.820,69162428,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X18MM LOCKING / 212.818,69169655,CDM,278,RC,C1713,HCPCS,Outpatient,,,563.01,563.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.81,60,,270.25,percent of total billed charges,60% of total Billed charges for outpatient setting,477.88,84.88,,382.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.26,75,,337.81,percent of total billed charges,75% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.41,80,,360.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,563.01,65,,450.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,35,,157.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.81,60,,270.25,percent of total billed charges,60% of total billed charges for outpatient setting,72.29,563.01,
SCREW 2.4X18MM STARDRIVE  / 02.210.118,70000308,CDM,278,RC,C1713,HCPCS,Outpatient,,,622.16,622.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.3,60,,298.64,percent of total billed charges,60% of total Billed charges for outpatient setting,528.09,84.88,,422.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.62,75,,373.3,percent of total billed charges,75% of total billed charges for outpatient setting,311.08,50,,248.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.73,80,,398.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,622.16,65,,497.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.76,35,,174.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.3,60,,298.64,percent of total billed charges,60% of total billed charges for outpatient setting,79.89,622.16,
SCREW 2.4X18MM TI / AR-8724V-18,70000531,CDM,278,RC,C1713,HCPCS,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,60,,290.7,percent of total billed charges,60% of total Billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,605.64,65,,484.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.38,60,,290.7,percent of total billed charges,60% of total billed charges for outpatient setting,77.76,605.64,
SCREW 2.4X18MM VA LOCKING/ 04.210.118,69162458,CDM,278,RC,,,Outpatient,,,569.82,569.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.89,60,,273.51,percent of total billed charges,60% of total Billed charges for outpatient setting,483.66,84.88,,386.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.91,50,,227.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.37,75,,341.9,percent of total billed charges,75% of total billed charges for outpatient setting,284.91,50,,227.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.86,80,,364.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.82,65,,455.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.44,35,,159.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.89,60,,273.51,percent of total billed charges,60% of total billed charges for outpatient setting,73.16,569.82,
SCREW 2.4X20MM CORTEX / AR-8916CX24-20,71000664,CDM,278,RC,C1713,HCPCS,Outpatient,,,462,462,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.2,60,,221.76,percent of total billed charges,60% of total Billed charges for outpatient setting,392.15,84.88,,313.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.5,75,,277.2,percent of total billed charges,75% of total billed charges for outpatient setting,231,50,,184.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.32,12.84,,47.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.6,80,,295.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.32,12.84,,47.46,percent of total billed charges,12.84% of total billed charges,59.32,12.84,,47.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,462,65,,369.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.7,35,,129.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,277.2,60,,221.76,percent of total billed charges,60% of total billed charges for outpatient setting,59.32,462,
SCREW 2.4X20MM KREULOCK / AR-8724VCL-20,71000433,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.4X20MM STARDRIVE/ 02.210.120,70000306,CDM,278,RC,C1713,HCPCS,Outpatient,,,622.16,622.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.3,60,,298.64,percent of total billed charges,60% of total Billed charges for outpatient setting,528.09,84.88,,422.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.62,75,,373.3,percent of total billed charges,75% of total billed charges for outpatient setting,311.08,50,,248.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.73,80,,398.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,79.89,12.84,,63.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,622.16,65,,497.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.76,35,,174.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.3,60,,298.64,percent of total billed charges,60% of total billed charges for outpatient setting,79.89,622.16,
SCREW 2.4X20MM VA LOCKING/ 04.210.120,69162457,CDM,278,RC,,,Outpatient,,,569.82,569.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.89,60,,273.51,percent of total billed charges,60% of total Billed charges for outpatient setting,483.66,84.88,,386.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.91,50,,227.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.37,75,,341.9,percent of total billed charges,75% of total billed charges for outpatient setting,284.91,50,,227.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.86,80,,364.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,73.16,12.84,,58.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.82,65,,455.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.44,35,,159.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.89,60,,273.51,percent of total billed charges,60% of total billed charges for outpatient setting,73.16,569.82,
SCREW 2.4X20MM VAL CRTX / AR-8916VNC-20,71000667,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 2.4X20MM VAL TI / AR-8724V-20,70000532,CDM,278,RC,C1713,HCPCS,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,60,,290.7,percent of total billed charges,60% of total Billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,605.64,65,,484.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.38,60,,290.7,percent of total billed charges,60% of total billed charges for outpatient setting,77.76,605.64,
SCREW 2.4X22MM  LOCKING / 656022,1627051,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.72,594.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,60,,285.46,percent of total billed charges,60% of total Billed charges for outpatient setting,504.8,84.88,,403.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.04,75,,356.83,percent of total billed charges,75% of total billed charges for outpatient setting,297.36,50,,237.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.78,80,,380.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.72,65,,475.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.15,35,,166.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.83,60,,285.46,percent of total billed charges,60% of total billed charges for outpatient setting,76.36,594.72,
SCREW 2.4X22MM STARDRIVE  / 02.210.122,70000307,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.42,579.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.65,60,,278.12,percent of total billed charges,60% of total Billed charges for outpatient setting,491.81,84.88,,393.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.57,75,,347.66,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,50,,231.77,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.4,12.84,,59.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.54,80,,370.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.4,12.84,,59.52,percent of total billed charges,12.84% of total billed charges,74.4,12.84,,59.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.42,65,,463.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.8,35,,162.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.65,60,,278.12,percent of total billed charges,60% of total billed charges for outpatient setting,74.4,579.42,
SCREW 2.4X24MM  LOCKING / 656024,69169735,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.72,594.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,60,,285.46,percent of total billed charges,60% of total Billed charges for outpatient setting,504.8,84.88,,403.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.04,75,,356.83,percent of total billed charges,75% of total billed charges for outpatient setting,297.36,50,,237.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.78,80,,380.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.72,65,,475.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.15,35,,166.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.83,60,,285.46,percent of total billed charges,60% of total billed charges for outpatient setting,76.36,594.72,
SCREW 2.4X24MM KREULOCK / AR-8724VCL-24,71000662,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.4X24MM LCKNG TI  412.824,69162429,CDM,278,RC,,,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW 2.4X24MM TI / AR-8724V-22,70000547,CDM,278,RC,C1713,HCPCS,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,60,,290.7,percent of total billed charges,60% of total Billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,605.64,65,,484.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.38,60,,290.7,percent of total billed charges,60% of total billed charges for outpatient setting,77.76,605.64,
SCREW 2.4X28MM KREULOCK / AR-8724VCL-28,71000663,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.4X6MM CRTX T8 / 201.756,662119,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.4X9MM CRTX T8 / 201.759,128922,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.8,257.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.68,60,,123.74,percent of total billed charges,60% of total Billed charges for outpatient setting,218.82,84.88,,175.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.35,75,,154.68,percent of total billed charges,75% of total billed charges for outpatient setting,128.9,50,,103.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,80,,164.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,33.1,12.84,,26.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.8,65,,206.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,35,,72.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.68,60,,123.74,percent of total billed charges,60% of total billed charges for outpatient setting,33.1,257.8,
SCREW 2.4X9MM LOCKING / 212.809,116279,CDM,278,RC,C1713,HCPCS,Outpatient,,,468,468,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.8,60,,224.64,percent of total billed charges,60% of total Billed charges for outpatient setting,397.24,84.88,,317.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,75,,280.8,percent of total billed charges,75% of total billed charges for outpatient setting,234,50,,187.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,80,,299.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,60.09,12.84,,48.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,468,65,,374.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,35,,131.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,280.8,60,,224.64,percent of total billed charges,60% of total billed charges for outpatient setting,60.09,468,
SCREW 2.50X38MM CANN T9 / IC2538,2312660,CDM,278,RC,C1713,HCPCS,Outpatient,,,860,860,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,60,,412.8,percent of total billed charges,60% of total Billed charges for outpatient setting,729.97,84.88,,583.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645,75,,516,percent of total billed charges,75% of total billed charges for outpatient setting,430,50,,344,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688,80,,550.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,860,65,,688,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301,35,,240.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,516,60,,412.8,percent of total billed charges,60% of total billed charges for outpatient setting,110.42,860,
SCREW 2.5X10MM LOCKING / A-5750.10/1,69169672,CDM,278,RC,C1713,HCPCS,Outpatient,,,1061.76,1061.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.06,60,,509.65,percent of total billed charges,60% of total Billed charges for outpatient setting,901.22,84.88,,720.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,75,,637.06,percent of total billed charges,75% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.41,80,,679.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1061.76,65,,849.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.62,35,,297.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,637.06,60,,509.65,percent of total billed charges,60% of total billed charges for outpatient setting,136.33,1061.76,
SCREW 2.5X12MM CORTEX / A-5700.12/1,69169670,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X12MM LOCKING / A-5750.12/1,69169673,CDM,278,RC,C1713,HCPCS,Outpatient,,,1061.76,1061.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.06,60,,509.65,percent of total billed charges,60% of total Billed charges for outpatient setting,901.22,84.88,,720.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,75,,637.06,percent of total billed charges,75% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.41,80,,679.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1061.76,65,,849.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.62,35,,297.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,637.06,60,,509.65,percent of total billed charges,60% of total billed charges for outpatient setting,136.33,1061.76,
SCREW 2.5X14MM CORTEX / A-5700.14/1,69169709,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X14MM LOCKING / A-5750.14/1,69169674,CDM,278,RC,,,Outpatient,,,1061.76,1061.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.06,60,,509.65,percent of total billed charges,60% of total Billed charges for outpatient setting,901.22,84.88,,720.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,796.32,75,,637.06,percent of total billed charges,75% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.41,80,,679.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1061.76,65,,849.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.62,35,,297.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,637.06,60,,509.65,percent of total billed charges,60% of total billed charges for outpatient setting,136.33,1061.76,
SCREW 2.5X16MM CORTEX / A-5700.16/1,69169710,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X16MM CORTEX / A-5700.16/1,69169829,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X16MM LOCKING / A-5750.16/1,69169675,CDM,278,RC,C1713,HCPCS,Outpatient,,,1061.76,1061.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.06,60,,509.65,percent of total billed charges,60% of total Billed charges for outpatient setting,901.22,84.88,,720.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,75,,637.06,percent of total billed charges,75% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.41,80,,679.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1061.76,65,,849.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.62,35,,297.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,637.06,60,,509.65,percent of total billed charges,60% of total billed charges for outpatient setting,136.33,1061.76,
SCREW 2.5X18MM LOCKING / A-5750.18/1,69169676,CDM,278,RC,C1713,HCPCS,Outpatient,,,1061.76,1061.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637.06,60,,509.65,percent of total billed charges,60% of total Billed charges for outpatient setting,901.22,84.88,,720.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,75,,637.06,percent of total billed charges,75% of total billed charges for outpatient setting,530.88,50,,424.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.41,80,,679.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,136.33,12.84,,109.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1061.76,65,,849.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.62,35,,297.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,637.06,60,,509.65,percent of total billed charges,60% of total billed charges for outpatient setting,136.33,1061.76,
SCREW 2.5X22MM CORTEX / A-5700.22/1,69169711,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X24MM CORTEX / A-5700.24/1,69169830,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X25MM HEX HEAD / 42-5099-025-25,69169392,CDM,272,RC,C1713,HCPCS,Outpatient,,,739.2,739.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.44,70,,413.95,percent of total billed charges,70% of total billed charges for outpatient setting,627.43,84.88,,501.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,75,,443.52,percent of total billed charges,75% of total billed charges for outpatient setting,517.44,70,,413.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.91,12.84,,75.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.36,80,,473.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.91,12.84,,75.93,percent of total billed charges,12.84% of total billed charges,94.91,12.84,,75.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480.48,65,,384.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.72,35,,206.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,665.28,90,,532.22,percent of total billed charges,90% of total billed charges for outpatient setting,94.91,665.28,
SCREW 2.5X26MM CANN / 04.333.126,7171297,CDM,278,RC,C1713,HCPCS,Outpatient,,,1762.95,1762.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.77,60,,846.22,percent of total billed charges,60% of total Billed charges for outpatient setting,1496.39,84.88,,1197.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1322.21,75,,1057.77,percent of total billed charges,75% of total billed charges for outpatient setting,881.48,50,,705.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.36,12.84,,181.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410.36,80,,1128.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.36,12.84,,181.09,percent of total billed charges,12.84% of total billed charges,226.36,12.84,,181.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1762.95,65,,1410.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.03,35,,493.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1057.77,60,,846.22,percent of total billed charges,60% of total billed charges for outpatient setting,226.36,1762.95,
SCREW 2.5X26MM CORTEX / A-5700.26/1,69169831,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.48,648.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.09,60,,311.27,percent of total billed charges,60% of total Billed charges for outpatient setting,550.43,84.88,,440.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.36,75,,389.09,percent of total billed charges,75% of total billed charges for outpatient setting,324.24,50,,259.39,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.78,80,,415.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,83.26,12.84,,66.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.48,65,,518.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.97,35,,181.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.09,60,,311.27,percent of total billed charges,60% of total billed charges for outpatient setting,83.26,648.48,
SCREW 2.5X28MM COMPR FT / AR-8725-28H,71000552,CDM,278,RC,C1713,HCPCS,Outpatient,,,1470,1470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,60,,705.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1247.74,84.88,,998.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,75,,882,percent of total billed charges,75% of total billed charges for outpatient setting,735,50,,588,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,80,,940.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1470,65,,1176,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,35,,411.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,882,60,,705.6,percent of total billed charges,60% of total billed charges for outpatient setting,188.75,1470,
SCREW 2.5X30MM AUTOFIX COMPRS 141-2530,69162731,CDM,278,RC,C1713,HCPCS,Outpatient,,,1051.65,1051.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.99,60,,504.79,percent of total billed charges,60% of total Billed charges for outpatient setting,892.64,84.88,,714.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.74,75,,630.99,percent of total billed charges,75% of total billed charges for outpatient setting,525.83,50,,420.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.03,12.84,,108.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.32,80,,673.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.03,12.84,,108.02,percent of total billed charges,12.84% of total billed charges,135.03,12.84,,108.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1051.65,65,,841.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.08,35,,294.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,630.99,60,,504.79,percent of total billed charges,60% of total billed charges for outpatient setting,135.03,1051.65,
SCREW 2.5X30MM COMPR FT / AR-8725-30H,69169659,CDM,278,RC,C1713,HCPCS,Outpatient,,,1470,1470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,60,,705.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1247.74,84.88,,998.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,75,,882,percent of total billed charges,75% of total billed charges for outpatient setting,735,50,,588,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,80,,940.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1470,65,,1176,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,35,,411.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,882,60,,705.6,percent of total billed charges,60% of total billed charges for outpatient setting,188.75,1470,
SCREW 2.5X32MM COMPR / AR-8725-32H,71000574,CDM,278,RC,C1713,HCPCS,Outpatient,,,1470,1470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,60,,705.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1247.74,84.88,,998.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,75,,882,percent of total billed charges,75% of total billed charges for outpatient setting,735,50,,588,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,80,,940.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1470,65,,1176,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,35,,411.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,882,60,,705.6,percent of total billed charges,60% of total billed charges for outpatient setting,188.75,1470,
SCREW 2.7 x 24MM  53-27224E,69162504,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7MM CORTEX 14MM / 202.814,6152784,CDM,278,RC,,,Outpatient,,,180.08,180.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.05,60,,86.44,percent of total billed charges,60% of total Billed charges for outpatient setting,152.85,84.88,,122.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.04,50,,72.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.06,75,,108.05,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,50,,72.03,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.12,12.84,,18.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.06,80,,115.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.12,12.84,,18.5,percent of total billed charges,12.84% of total billed charges,23.12,12.84,,18.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.08,65,,144.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.03,35,,50.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108.05,60,,86.44,percent of total billed charges,60% of total billed charges for outpatient setting,23.12,180.08,
SCREW 2.7MM CORTEX 16MM / 202.816,6152785,CDM,278,RC,,,Outpatient,,,180.08,180.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.05,60,,86.44,percent of total billed charges,60% of total Billed charges for outpatient setting,152.85,84.88,,122.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,90.04,50,,72.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.06,75,,108.05,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,50,,72.03,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.12,12.84,,18.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.06,80,,115.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.12,12.84,,18.5,percent of total billed charges,12.84% of total billed charges,23.12,12.84,,18.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,180.08,65,,144.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.03,35,,50.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108.05,60,,86.44,percent of total billed charges,60% of total billed charges for outpatient setting,23.12,180.08,
SCREW 2.7MM HIGH PITCH / SD21,7621838,CDM,278,RC,C1713,HCPCS,Outpatient,,,1912,1912,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.2,60,,917.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1622.91,84.88,,1298.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434,75,,1147.2,percent of total billed charges,75% of total billed charges for outpatient setting,956,50,,764.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1529.6,80,,1223.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1912,65,,1529.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.2,35,,535.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1147.2,60,,917.76,percent of total billed charges,60% of total billed charges for outpatient setting,245.5,1912,
SCREW 2.7MM LONG HIGH PITCH / SD21,7417800,CDM,278,RC,C1713,HCPCS,Outpatient,,,1912,1912,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.2,60,,917.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1622.91,84.88,,1298.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434,75,,1147.2,percent of total billed charges,75% of total billed charges for outpatient setting,956,50,,764.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1529.6,80,,1223.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1912,65,,1529.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.2,35,,535.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1147.2,60,,917.76,percent of total billed charges,60% of total billed charges for outpatient setting,245.5,1912,
SCREW 2.7MM T8 FULL THREAD / 656418,70000673,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7mm x 18mm Stryker  614718,69161550,CDM,278,RC,,,Outpatient,,,471.43,471.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.86,60,,226.29,percent of total billed charges,60% of total Billed charges for outpatient setting,400.15,84.88,,320.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,235.72,50,,188.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.57,75,,282.86,percent of total billed charges,75% of total billed charges for outpatient setting,235.72,50,,188.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,12.84,,48.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.14,80,,301.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,12.84,,48.42,percent of total billed charges,12.84% of total billed charges,60.53,12.84,,48.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,471.43,65,,377.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165,35,,132,percent of total billed charges,35% of total Billed charges for Outpatient Setting,282.86,60,,226.29,percent of total billed charges,60% of total billed charges for outpatient setting,60.53,471.43,
SCREW 2.7X10MM / 53-27210E,70000057,CDM,278,RC,C1713,HCPCS,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7X10MM CORTEX STR / 202.870,662211,CDM,278,RC,C1713,HCPCS,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.49,60,,105.19,percent of total billed charges,60% of total Billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.15,65,,175.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,60,,105.19,percent of total billed charges,60% of total billed charges for outpatient setting,28.14,219.15,
SCREW 2.7X10MM KREULOCK / AR-8827CL-10,71000533,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.7X10MM LCKING / 02.211.010,69169453,CDM,278,RC,C1713,HCPCS,Outpatient,,,685.78,685.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.47,60,,329.18,percent of total billed charges,60% of total Billed charges for outpatient setting,582.09,84.88,,465.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.34,75,,411.47,percent of total billed charges,75% of total billed charges for outpatient setting,342.89,50,,274.31,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.05,12.84,,70.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.62,80,,438.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.05,12.84,,70.44,percent of total billed charges,12.84% of total billed charges,88.05,12.84,,70.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,685.78,65,,548.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.02,35,,192.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,411.47,60,,329.18,percent of total billed charges,60% of total billed charges for outpatient setting,88.05,685.78,
SCREW 2.7X10MM LOCKING / 202.210,69169276,CDM,278,RC,C1769,HCPCS,Outpatient,,,211.05,211.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.63,60,,101.3,percent of total billed charges,60% of total Billed charges for outpatient setting,179.14,84.88,,143.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.29,75,,126.63,percent of total billed charges,75% of total billed charges for outpatient setting,105.53,50,,84.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.84,80,,135.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,211.05,65,,168.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.87,35,,59.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.63,60,,101.3,percent of total billed charges,60% of total billed charges for outpatient setting,27.1,211.05,
SCREW 2.7X10MM LOCKING / 53-27610E,70000059,CDM,278,RC,C1713,HCPCS,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.7X10MM NON LOCKING / 656410,1627089,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7X10MM T8 LOCKING / 656310,69169325,CDM,278,RC,C1713,HCPCS,Outpatient,,,566.4,566.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.84,60,,271.87,percent of total billed charges,60% of total Billed charges for outpatient setting,480.76,84.88,,384.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.8,75,,339.84,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,50,,226.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,12.84,,58.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.12,80,,362.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,12.84,,58.18,percent of total billed charges,12.84% of total billed charges,72.73,12.84,,58.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,566.4,65,,453.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,35,,158.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,339.84,60,,271.87,percent of total billed charges,60% of total billed charges for outpatient setting,72.73,566.4,
SCREW 2.7X12MM / 53-27212E,69161624,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7X12MM CORTEX STARDR 402.872,69162456,CDM,278,RC,,,Outpatient,,,202.08,202.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.25,60,,97,percent of total billed charges,60% of total Billed charges for outpatient setting,171.53,84.88,,137.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.56,75,,121.25,percent of total billed charges,75% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.66,80,,129.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,202.08,65,,161.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.73,35,,56.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.25,60,,97,percent of total billed charges,60% of total billed charges for outpatient setting,25.95,202.08,
SCREW 2.7X12MM CORTEX STR / 202.872,69169181,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.61,263.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.17,60,,126.54,percent of total billed charges,60% of total Billed charges for outpatient setting,223.75,84.88,,179,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.71,75,,158.17,percent of total billed charges,75% of total billed charges for outpatient setting,131.81,50,,105.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.89,80,,168.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.61,65,,210.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.26,35,,73.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,158.17,60,,126.54,percent of total billed charges,60% of total billed charges for outpatient setting,33.85,263.61,
SCREW 2.7X12MM KREULOCK / AR-8827CL-12,71000534,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.7X12MM LOCK / 131227112,69169570,CDM,278,RC,C1713,HCPCS,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
SCREW 2.7X12MM LOCKING / 02.211.012,69169178,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X12MM LOCKING / 202.212,69161800,CDM,278,RC,C1769,HCPCS,Outpatient,,,633.15,633.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.89,60,,303.91,percent of total billed charges,60% of total Billed charges for outpatient setting,537.42,84.88,,429.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.86,75,,379.89,percent of total billed charges,75% of total billed charges for outpatient setting,316.58,50,,253.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.52,80,,405.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,633.15,65,,506.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.6,35,,177.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.89,60,,303.91,percent of total billed charges,60% of total billed charges for outpatient setting,81.3,633.15,
SCREW 2.7X12MM LOCKING / 52-27612,70000567,CDM,278,RC,C1713,HCPCS,Outpatient,,,753.81,753.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.29,60,,361.83,percent of total billed charges,60% of total Billed charges for outpatient setting,639.83,84.88,,511.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.36,75,,452.29,percent of total billed charges,75% of total billed charges for outpatient setting,376.91,50,,301.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.05,80,,482.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,753.81,65,,603.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.83,35,,211.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.29,60,,361.83,percent of total billed charges,60% of total billed charges for outpatient setting,96.79,753.81,
SCREW 2.7X12MM LOCKING / 53-27612E,69161623,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.7X12MM LOCKING / 657012,1627126,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 2.7X12MM LOCKING / 657112,1627135,CDM,278,RC,C1713,HCPCS,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 2.7x12MM LOCKING / AR-8827L-12,69162689,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 2.7X12MM NON LOCKING / 656412,69169442,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7X12MM NONLK / 131227212,69169610,CDM,278,RC,C1713,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,60,,100.8,percent of total billed charges,60% of total Billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,210,65,,168,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126,60,,100.8,percent of total billed charges,60% of total billed charges for outpatient setting,26.96,210,
SCREW 2.7X12MM NON-LOCKING / 52-27212,70000565,CDM,278,RC,C1713,HCPCS,Outpatient,,,580.99,580.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.59,60,,278.87,percent of total billed charges,60% of total Billed charges for outpatient setting,493.14,84.88,,394.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.74,75,,348.59,percent of total billed charges,75% of total billed charges for outpatient setting,290.5,50,,232.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.79,80,,371.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580.99,65,,464.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.35,35,,162.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348.59,60,,278.87,percent of total billed charges,60% of total billed charges for outpatient setting,74.6,580.99,
SCREW 2.7X12MM T8 LOCKING / 656312,70000609,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X14MM / 53-27214E,70000058,CDM,278,RC,C1713,HCPCS,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7X14MM CORTEX / 402.874,69161507,CDM,278,RC,,,Outpatient,,,202.08,202.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.25,60,,97,percent of total billed charges,60% of total Billed charges for outpatient setting,171.53,84.88,,137.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.56,75,,121.25,percent of total billed charges,75% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.66,80,,129.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,202.08,65,,161.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.73,35,,56.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.25,60,,97,percent of total billed charges,60% of total billed charges for outpatient setting,25.95,202.08,
SCREW 2.7X14MM KREULOCK / AR-8827CL-14,71000535,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.7X14MM LOCK / 131227114,69169608,CDM,278,RC,C1713,HCPCS,Outpatient,,,415.8,415.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.48,60,,199.58,percent of total billed charges,60% of total Billed charges for outpatient setting,352.93,84.88,,282.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.85,75,,249.48,percent of total billed charges,75% of total billed charges for outpatient setting,207.9,50,,166.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.64,80,,266.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,53.39,12.84,,42.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.8,65,,332.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,35,,116.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.48,60,,199.58,percent of total billed charges,60% of total billed charges for outpatient setting,53.39,415.8,
SCREW 2.7X14MM LOCK / AR-8827L-14,70000502,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 2.7X14MM LOCKING / 02.211.014,69169179,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X14MM LOCKING / 202.214,69160919,CDM,278,RC,C1769,HCPCS,Outpatient,,,543.08,543.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.85,60,,260.68,percent of total billed charges,60% of total Billed charges for outpatient setting,460.97,84.88,,368.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.31,75,,325.85,percent of total billed charges,75% of total billed charges for outpatient setting,271.54,50,,217.23,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.73,12.84,,55.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.46,80,,347.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.73,12.84,,55.78,percent of total billed charges,12.84% of total billed charges,69.73,12.84,,55.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,543.08,65,,434.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.08,35,,152.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.85,60,,260.68,percent of total billed charges,60% of total billed charges for outpatient setting,69.73,543.08,
SCREW 2.7X14MM LOCKING / 53-27614E,69162505,CDM,278,RC,,,Outpatient,,,372.2,372.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.32,60,,178.66,percent of total billed charges,60% of total Billed charges for outpatient setting,315.92,84.88,,252.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.15,75,,223.32,percent of total billed charges,75% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,80,,238.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.2,65,,297.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.27,35,,104.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.32,60,,178.66,percent of total billed charges,60% of total billed charges for outpatient setting,47.79,372.2,
SCREW 2.7X14MM NON LOCKING / 656414,69162843,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7X14MM NONLK / 131227214,69169743,CDM,278,RC,C1713,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,60,,100.8,percent of total billed charges,60% of total Billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,210,65,,168,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126,60,,100.8,percent of total billed charges,60% of total billed charges for outpatient setting,26.96,210,
SCREW 2.7X14MM NON-LOCKING / 52-27214,70000566,CDM,278,RC,C1713,HCPCS,Outpatient,,,580.99,580.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.59,60,,278.87,percent of total billed charges,60% of total Billed charges for outpatient setting,493.14,84.88,,394.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.74,75,,348.59,percent of total billed charges,75% of total billed charges for outpatient setting,290.5,50,,232.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.79,80,,371.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,74.6,12.84,,59.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580.99,65,,464.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.35,35,,162.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348.59,60,,278.87,percent of total billed charges,60% of total billed charges for outpatient setting,74.6,580.99,
SCREW 2.7X14MM T8 LOCKING / 656314,70000613,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X16MM / 53-27216E,69162503,CDM,278,RC,,,Outpatient,,,278.71,278.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.23,60,,133.78,percent of total billed charges,60% of total Billed charges for outpatient setting,236.57,84.88,,189.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,139.36,50,,111.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.03,75,,167.22,percent of total billed charges,75% of total billed charges for outpatient setting,139.36,50,,111.49,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.79,12.84,,28.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.97,80,,178.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.79,12.84,,28.63,percent of total billed charges,12.84% of total billed charges,35.79,12.84,,28.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,278.71,65,,222.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.55,35,,78.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.23,60,,133.78,percent of total billed charges,60% of total billed charges for outpatient setting,35.79,278.71,
SCREW 2.7X16MM CORTEX / 402.876,69161505,CDM,278,RC,,,Outpatient,,,257.88,257.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.73,60,,123.78,percent of total billed charges,60% of total Billed charges for outpatient setting,218.89,84.88,,175.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.94,50,,103.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.41,75,,154.73,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,50,,103.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.11,12.84,,26.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.3,80,,165.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.11,12.84,,26.49,percent of total billed charges,12.84% of total billed charges,33.11,12.84,,26.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.88,65,,206.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.26,35,,72.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.73,60,,123.78,percent of total billed charges,60% of total billed charges for outpatient setting,33.11,257.88,
SCREW 2.7X16MM CORTEX STR / 202.876,69169182,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.61,263.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.17,60,,126.54,percent of total billed charges,60% of total Billed charges for outpatient setting,223.75,84.88,,179,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.71,75,,158.17,percent of total billed charges,75% of total billed charges for outpatient setting,131.81,50,,105.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.89,80,,168.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.61,65,,210.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.26,35,,73.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,158.17,60,,126.54,percent of total billed charges,60% of total billed charges for outpatient setting,33.85,263.61,
SCREW 2.7X16MM KREULOCK / AR-8827CL-16,71000583,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 2.7X16MM LCKING / 202.216,69160917,CDM,278,RC,C1769,HCPCS,Outpatient,,,570.23,570.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.14,60,,273.71,percent of total billed charges,60% of total Billed charges for outpatient setting,484.01,84.88,,387.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.67,75,,342.14,percent of total billed charges,75% of total billed charges for outpatient setting,285.12,50,,228.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,12.84,,58.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.18,80,,364.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,12.84,,58.58,percent of total billed charges,12.84% of total billed charges,73.22,12.84,,58.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,570.23,65,,456.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,35,,159.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,342.14,60,,273.71,percent of total billed charges,60% of total billed charges for outpatient setting,73.22,570.23,
SCREW 2.7X16MM LOCK / AR-8827L-16,69162479,CDM,278,RC,,,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 2.7X16MM LOCKING / 02.211.016,69169180,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X16MM LOCKING / 52-27614,70000569,CDM,278,RC,C1713,HCPCS,Outpatient,,,753.81,753.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.29,60,,361.83,percent of total billed charges,60% of total Billed charges for outpatient setting,639.83,84.88,,511.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.36,75,,452.29,percent of total billed charges,75% of total billed charges for outpatient setting,376.91,50,,301.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.05,80,,482.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,753.81,65,,603.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.83,35,,211.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.29,60,,361.83,percent of total billed charges,60% of total billed charges for outpatient setting,96.79,753.81,
SCREW 2.7X16MM LOCKING / 52-27616,70000568,CDM,278,RC,C1713,HCPCS,Outpatient,,,753.81,753.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.29,60,,361.83,percent of total billed charges,60% of total Billed charges for outpatient setting,639.83,84.88,,511.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.36,75,,452.29,percent of total billed charges,75% of total billed charges for outpatient setting,376.91,50,,301.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.05,80,,482.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,96.79,12.84,,77.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,753.81,65,,603.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.83,35,,211.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,452.29,60,,361.83,percent of total billed charges,60% of total billed charges for outpatient setting,96.79,753.81,
SCREW 2.7X16MM LOCKING / 53-27616E,69161622,CDM,278,RC,,,Outpatient,,,372.2,372.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.32,60,,178.66,percent of total billed charges,60% of total Billed charges for outpatient setting,315.92,84.88,,252.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.15,75,,223.32,percent of total billed charges,75% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,80,,238.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.2,65,,297.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.27,35,,104.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.32,60,,178.66,percent of total billed charges,60% of total billed charges for outpatient setting,47.79,372.2,
SCREW 2.7X16MM LOCKING / AR-8827-16,71000504,CDM,278,RC,C1713,HCPCS,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,60,,113.4,percent of total billed charges,60% of total Billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.25,65,,189,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,60,,113.4,percent of total billed charges,60% of total billed charges for outpatient setting,30.33,236.25,
SCREW 2.7X16MM NON LOCKING / 656416,70000607,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7X16MM T8 LOCKING / 656316,70000611,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X18MM / 53-27218E,70000117,CDM,278,RC,C1713,HCPCS,Outpatient,,,278.71,278.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.23,60,,133.78,percent of total billed charges,60% of total Billed charges for outpatient setting,236.57,84.88,,189.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.03,75,,167.22,percent of total billed charges,75% of total billed charges for outpatient setting,139.36,50,,111.49,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.79,12.84,,28.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.97,80,,178.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.79,12.84,,28.63,percent of total billed charges,12.84% of total billed charges,35.79,12.84,,28.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,278.71,65,,222.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.55,35,,78.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.23,60,,133.78,percent of total billed charges,60% of total billed charges for outpatient setting,35.79,278.71,
SCREW 2.7X18MM CORTEX 202.818,69169440,CDM,278,RC,,,Outpatient,,,211.05,211.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.63,60,,101.3,percent of total billed charges,60% of total Billed charges for outpatient setting,179.14,84.88,,143.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.53,50,,84.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.29,75,,126.63,percent of total billed charges,75% of total billed charges for outpatient setting,105.53,50,,84.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.84,80,,135.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,27.1,12.84,,21.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,211.05,65,,168.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.87,35,,59.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.63,60,,101.3,percent of total billed charges,60% of total billed charges for outpatient setting,27.1,211.05,
SCREW 2.7X18MM CORTEX STR / 202.878,69169451,CDM,278,RC,C1713,HCPCS,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.49,60,,105.19,percent of total billed charges,60% of total Billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.15,65,,175.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,60,,105.19,percent of total billed charges,60% of total billed charges for outpatient setting,28.14,219.15,
SCREW 2.7X18MM CORTEX TI  402.878,69161506,CDM,278,RC,,,Outpatient,,,202.08,202.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.25,60,,97,percent of total billed charges,60% of total Billed charges for outpatient setting,171.53,84.88,,137.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.56,75,,121.25,percent of total billed charges,75% of total billed charges for outpatient setting,101.04,50,,80.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.66,80,,129.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,25.95,12.84,,20.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,202.08,65,,161.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.73,35,,56.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.25,60,,97,percent of total billed charges,60% of total billed charges for outpatient setting,25.95,202.08,
SCREW 2.7X18MM LCKING / 202.218,69161428,CDM,278,RC,C1769,HCPCS,Outpatient,,,570.23,570.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.14,60,,273.71,percent of total billed charges,60% of total Billed charges for outpatient setting,484.01,84.88,,387.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.67,75,,342.14,percent of total billed charges,75% of total billed charges for outpatient setting,285.12,50,,228.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,12.84,,58.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.18,80,,364.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,12.84,,58.58,percent of total billed charges,12.84% of total billed charges,73.22,12.84,,58.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,570.23,65,,456.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,35,,159.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,342.14,60,,273.71,percent of total billed charges,60% of total billed charges for outpatient setting,73.22,570.23,
SCREW 2.7X18MM LOCK /AR-8827L-18,69162480,CDM,278,RC,,,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 2.7X18MM LOCKING / 02.211.018,69169189,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X18MM LOCKING / 53-27618E,69161621,CDM,278,RC,,,Outpatient,,,372.2,372.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.32,60,,178.66,percent of total billed charges,60% of total Billed charges for outpatient setting,315.92,84.88,,252.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.15,75,,223.32,percent of total billed charges,75% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,80,,238.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.2,65,,297.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.27,35,,104.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.32,60,,178.66,percent of total billed charges,60% of total billed charges for outpatient setting,47.79,372.2,
SCREW 2.7X18MM LOCKING / AR-8827-18,71000508,CDM,278,RC,C1713,HCPCS,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,60,,113.4,percent of total billed charges,60% of total Billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.25,65,,189,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,60,,113.4,percent of total billed charges,60% of total billed charges for outpatient setting,30.33,236.25,
SCREW 2.7X18MM MTPHSL / 02.118.518,1178507,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.68,209.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.81,60,,100.65,percent of total billed charges,60% of total Billed charges for outpatient setting,177.98,84.88,,142.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.26,75,,125.81,percent of total billed charges,75% of total billed charges for outpatient setting,104.84,50,,83.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.74,80,,134.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.68,65,,167.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.39,35,,58.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.81,60,,100.65,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,209.68,
SCREW 2.7X18MM NONLK / 131227218,71000106,CDM,278,RC,C1713,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,60,,96,percent of total billed charges,60% of total Billed charges for outpatient setting,169.76,84.88,,135.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150,75,,120,percent of total billed charges,75% of total billed charges for outpatient setting,100,50,,80,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,80,,128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,25.68,12.84,,20.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,200,65,,160,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,35,,56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120,60,,96,percent of total billed charges,60% of total billed charges for outpatient setting,25.68,200,
SCREW 2.7X18MM T8 LOCKING / 656318,70000612,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X20MM / 53-27220E,69161625,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7X20MM CORTEX 202.820,69162294,CDM,278,RC,C1713,HCPCS,Outpatient,,,227.44,227.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.46,60,,109.17,percent of total billed charges,60% of total Billed charges for outpatient setting,193.05,84.88,,154.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.58,75,,136.46,percent of total billed charges,75% of total billed charges for outpatient setting,113.72,50,,90.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.95,80,,145.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,227.44,65,,181.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.6,35,,63.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.46,60,,109.17,percent of total billed charges,60% of total billed charges for outpatient setting,29.2,227.44,
SCREW 2.7X20MM CORTEX STR / 202.880,69169449,CDM,278,RC,C1713,HCPCS,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.49,60,,105.19,percent of total billed charges,60% of total Billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.15,65,,175.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,60,,105.19,percent of total billed charges,60% of total billed charges for outpatient setting,28.14,219.15,
SCREW 2.7X20MM LCK STAR / 02.211.020,69169433,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X20MM LOCK /AR-8827L-20,69162481,CDM,278,RC,,,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 2.7X20MM LOCKING / 202.220,69161799,CDM,278,RC,C1769,HCPCS,Outpatient,,,505.8,505.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.48,60,,242.78,percent of total billed charges,60% of total Billed charges for outpatient setting,429.32,84.88,,343.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.35,75,,303.48,percent of total billed charges,75% of total billed charges for outpatient setting,252.9,50,,202.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.64,80,,323.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.8,65,,404.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.03,35,,141.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.48,60,,242.78,percent of total billed charges,60% of total billed charges for outpatient setting,64.94,505.8,
SCREW 2.7X20MM LOCKING / 53-27620E,69161620,CDM,278,RC,,,Outpatient,,,372.2,372.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.32,60,,178.66,percent of total billed charges,60% of total Billed charges for outpatient setting,315.92,84.88,,252.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.15,75,,223.32,percent of total billed charges,75% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,80,,238.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.2,65,,297.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.27,35,,104.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.32,60,,178.66,percent of total billed charges,60% of total billed charges for outpatient setting,47.79,372.2,
SCREW 2.7X20MM LOCKING / AR-8827-20,71000505,CDM,278,RC,C1713,HCPCS,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,60,,113.4,percent of total billed charges,60% of total Billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.25,65,,189,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,60,,113.4,percent of total billed charges,60% of total billed charges for outpatient setting,30.33,236.25,
SCREW 2.7X20MM MTPHSL / 02.118.520,1154883,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.68,209.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.81,60,,100.65,percent of total billed charges,60% of total Billed charges for outpatient setting,177.98,84.88,,142.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.26,75,,125.81,percent of total billed charges,75% of total billed charges for outpatient setting,104.84,50,,83.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.74,80,,134.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.68,65,,167.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.39,35,,58.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.81,60,,100.65,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,209.68,
SCREW 2.7X20MM NONLK / 131227220,69169609,CDM,278,RC,C1713,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,60,,100.8,percent of total billed charges,60% of total Billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,210,65,,168,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126,60,,100.8,percent of total billed charges,60% of total billed charges for outpatient setting,26.96,210,
SCREW 2.7X20MM T8 LOCKING / 656320,70000610,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X20MM T8 LOCKING / 656420,70000608,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.72,302.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.63,60,,145.3,percent of total billed charges,60% of total Billed charges for outpatient setting,256.95,84.88,,205.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,75,,181.63,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,50,,121.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.18,80,,193.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,38.87,12.84,,31.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.72,65,,242.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.95,35,,84.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.63,60,,145.3,percent of total billed charges,60% of total billed charges for outpatient setting,38.87,302.72,
SCREW 2.7X22MM CORTEX 202.822,6152788,CDM,278,RC,,,Outpatient,,,227.44,227.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.46,60,,109.17,percent of total billed charges,60% of total Billed charges for outpatient setting,193.05,84.88,,154.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.72,50,,90.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.58,75,,136.46,percent of total billed charges,75% of total billed charges for outpatient setting,113.72,50,,90.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.95,80,,145.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,29.2,12.84,,23.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,227.44,65,,181.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.6,35,,63.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,136.46,60,,109.17,percent of total billed charges,60% of total billed charges for outpatient setting,29.2,227.44,
SCREW 2.7X22MM LCK STAR / 02.211.022,66799,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X22MM LCKING / 202.222,69162435,CDM,278,RC,C1769,HCPCS,Outpatient,,,505.8,505.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.48,60,,242.78,percent of total billed charges,60% of total Billed charges for outpatient setting,429.32,84.88,,343.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.35,75,,303.48,percent of total billed charges,75% of total billed charges for outpatient setting,252.9,50,,202.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.64,80,,323.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.8,65,,404.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.03,35,,141.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.48,60,,242.78,percent of total billed charges,60% of total billed charges for outpatient setting,64.94,505.8,
SCREW 2.7X22MM LOCKING / 53-27622E,70000200,CDM,278,RC,C1713,HCPCS,Outpatient,,,372.2,372.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.32,60,,178.66,percent of total billed charges,60% of total Billed charges for outpatient setting,315.92,84.88,,252.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.15,75,,223.32,percent of total billed charges,75% of total billed charges for outpatient setting,186.1,50,,148.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,80,,238.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,47.79,12.84,,38.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,372.2,65,,297.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.27,35,,104.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.32,60,,178.66,percent of total billed charges,60% of total billed charges for outpatient setting,47.79,372.2,
SCREW 2.7X22MM LOCKING / 657022,69169275,CDM,278,RC,C1713,HCPCS,Outpatient,,,635.63,635.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.38,60,,305.1,percent of total billed charges,60% of total Billed charges for outpatient setting,539.52,84.88,,431.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.72,75,,381.38,percent of total billed charges,75% of total billed charges for outpatient setting,317.82,50,,254.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.5,80,,406.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.63,65,,508.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.47,35,,177.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.38,60,,305.1,percent of total billed charges,60% of total billed charges for outpatient setting,81.61,635.63,
SCREW 2.7X22MM METAPHYSEAL / 02.118.522,1154884,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.68,209.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.81,60,,100.65,percent of total billed charges,60% of total Billed charges for outpatient setting,177.98,84.88,,142.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.26,75,,125.81,percent of total billed charges,75% of total billed charges for outpatient setting,104.84,50,,83.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.74,80,,134.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.68,65,,167.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.39,35,,58.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.81,60,,100.65,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,209.68,
SCREW 2.7X22MM NON LOCKING / 656422,1627095,CDM,278,RC,C1713,HCPCS,Outpatient,,,330.24,330.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.14,60,,158.51,percent of total billed charges,60% of total Billed charges for outpatient setting,280.31,84.88,,224.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.68,75,,198.14,percent of total billed charges,75% of total billed charges for outpatient setting,165.12,50,,132.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.19,80,,211.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,330.24,65,,264.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.58,35,,92.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198.14,60,,158.51,percent of total billed charges,60% of total billed charges for outpatient setting,42.4,330.24,
SCREW 2.7X22MM T8 LOCKING / 656322,69162844,CDM,278,RC,C1713,HCPCS,Outpatient,,,519.2,519.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,60,,249.22,percent of total billed charges,60% of total Billed charges for outpatient setting,440.7,84.88,,352.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.4,75,,311.52,percent of total billed charges,75% of total billed charges for outpatient setting,259.6,50,,207.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.36,80,,332.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,66.67,12.84,,53.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,519.2,65,,415.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.72,35,,145.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.52,60,,249.22,percent of total billed charges,60% of total billed charges for outpatient setting,66.67,519.2,
SCREW 2.7X24MM CORTEX 202.824,6152789,CDM,278,RC,,,Outpatient,,,229.7,229.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.82,60,,110.26,percent of total billed charges,60% of total Billed charges for outpatient setting,194.97,84.88,,155.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.85,50,,91.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.28,75,,137.82,percent of total billed charges,75% of total billed charges for outpatient setting,114.85,50,,91.88,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,12.84,,23.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.76,80,,147.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.49,12.84,,23.59,percent of total billed charges,12.84% of total billed charges,29.49,12.84,,23.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,229.7,65,,183.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.4,35,,64.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.82,60,,110.26,percent of total billed charges,60% of total billed charges for outpatient setting,29.49,229.7,
SCREW 2.7X24MM CORTEX 402.824,69169246,CDM,278,RC,,,Outpatient,,,233.1,233.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.86,60,,111.89,percent of total billed charges,60% of total Billed charges for outpatient setting,197.86,84.88,,158.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.55,50,,93.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.83,75,,139.86,percent of total billed charges,75% of total billed charges for outpatient setting,116.55,50,,93.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.93,12.84,,23.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.48,80,,149.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.93,12.84,,23.94,percent of total billed charges,12.84% of total billed charges,29.93,12.84,,23.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,233.1,65,,186.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.59,35,,65.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.86,60,,111.89,percent of total billed charges,60% of total billed charges for outpatient setting,29.93,233.1,
SCREW 2.7X24MM CORTEX STR / 202.884,662217,CDM,278,RC,C1713,HCPCS,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.49,60,,105.19,percent of total billed charges,60% of total Billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.15,65,,175.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,60,,105.19,percent of total billed charges,60% of total billed charges for outpatient setting,28.14,219.15,
SCREW 2.7X24MM LCK STAR / 02.211.024,69169431,CDM,278,RC,C1713,HCPCS,Outpatient,,,789.52,789.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.71,60,,378.97,percent of total billed charges,60% of total Billed charges for outpatient setting,670.14,84.88,,536.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.14,75,,473.71,percent of total billed charges,75% of total billed charges for outpatient setting,394.76,50,,315.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,12.84,,81.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.62,80,,505.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,12.84,,81.1,percent of total billed charges,12.84% of total billed charges,101.37,12.84,,81.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,789.52,65,,631.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.33,35,,221.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.71,60,,378.97,percent of total billed charges,60% of total billed charges for outpatient setting,101.37,789.52,
SCREW 2.7X24MM LCKING / 202.224,69162436,CDM,278,RC,C1769,HCPCS,Outpatient,,,505.8,505.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.48,60,,242.78,percent of total billed charges,60% of total Billed charges for outpatient setting,429.32,84.88,,343.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.35,75,,303.48,percent of total billed charges,75% of total billed charges for outpatient setting,252.9,50,,202.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.64,80,,323.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,64.94,12.84,,51.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,505.8,65,,404.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.03,35,,141.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,303.48,60,,242.78,percent of total billed charges,60% of total billed charges for outpatient setting,64.94,505.8,
SCREW 2.7X24MM LOCKING / 53-27624E,69162759,CDM,278,RC,,,Outpatient,,,676.59,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.95,60,,324.76,percent of total billed charges,60% of total Billed charges for outpatient setting,574.29,84.88,,459.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.44,75,,405.95,percent of total billed charges,75% of total billed charges for outpatient setting,338.3,50,,270.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.27,80,,433.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,86.87,12.84,,69.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,676.59,65,,541.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.81,35,,189.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,405.95,60,,324.76,percent of total billed charges,60% of total billed charges for outpatient setting,86.87,676.59,
SCREW 2.7X24MM LOCKING / AR-8827-24,71000820,CDM,278,RC,C1713,HCPCS,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,60,,113.4,percent of total billed charges,60% of total Billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,236.25,65,,189,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,60,,113.4,percent of total billed charges,60% of total billed charges for outpatient setting,30.33,236.25,
SCREW 2.7X24MM NON LOCKING / 656424,1627096,CDM,278,RC,C1713,HCPCS,Outpatient,,,330.24,330.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.14,60,,158.51,percent of total billed charges,60% of total Billed charges for outpatient setting,280.31,84.88,,224.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.68,75,,198.14,percent of total billed charges,75% of total billed charges for outpatient setting,165.12,50,,132.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.19,80,,211.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,42.4,12.84,,33.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,330.24,65,,264.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.58,35,,92.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,198.14,60,,158.51,percent of total billed charges,60% of total billed charges for outpatient setting,42.4,330.24,
SCREW 2.7X24MM T8 LOCKING / 656324,69162868,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.72,594.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,60,,285.46,percent of total billed charges,60% of total Billed charges for outpatient setting,504.8,84.88,,403.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.04,75,,356.83,percent of total billed charges,75% of total billed charges for outpatient setting,297.36,50,,237.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.78,80,,380.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.72,65,,475.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.15,35,,166.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.83,60,,285.46,percent of total billed charges,60% of total billed charges for outpatient setting,76.36,594.72,
SCREW 2.7X26MM CORTEX STR / 202.886,69169452,CDM,278,RC,C1713,HCPCS,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.49,60,,105.19,percent of total billed charges,60% of total Billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,219.15,65,,175.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.49,60,,105.19,percent of total billed charges,60% of total billed charges for outpatient setting,28.14,219.15,
SCREW 2.7X26MM LOCK  / 40-27626,69162881,CDM,278,RC,C1713,HCPCS,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
SCREW 2.7X26MM LOCK / 02.211.026,66801,CDM,278,RC,C1713,HCPCS,Outpatient,,,653.12,653.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.87,60,,313.5,percent of total billed charges,60% of total Billed charges for outpatient setting,554.37,84.88,,443.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.84,75,,391.87,percent of total billed charges,75% of total billed charges for outpatient setting,326.56,50,,261.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,12.84,,67.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.5,80,,418,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,12.84,,67.09,percent of total billed charges,12.84% of total billed charges,83.86,12.84,,67.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,653.12,65,,522.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.59,35,,182.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,391.87,60,,313.5,percent of total billed charges,60% of total billed charges for outpatient setting,83.86,653.12,
SCREW 2.7X26MM T7 / 53-27226E,70000266,CDM,278,RC,C1713,HCPCS,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW 2.7X26MM T8 LOCKING / 656326,69162869,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.72,594.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,60,,285.46,percent of total billed charges,60% of total Billed charges for outpatient setting,504.8,84.88,,403.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.04,75,,356.83,percent of total billed charges,75% of total billed charges for outpatient setting,297.36,50,,237.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.78,80,,380.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.72,65,,475.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.15,35,,166.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.83,60,,285.46,percent of total billed charges,60% of total billed charges for outpatient setting,76.36,594.72,
SCREW 2.7X28MM CORTEX STR / 202.888,662219,CDM,278,RC,C1713,HCPCS,Outpatient,,,248.55,248.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.13,60,,119.3,percent of total billed charges,60% of total Billed charges for outpatient setting,210.97,84.88,,168.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.41,75,,149.13,percent of total billed charges,75% of total billed charges for outpatient setting,124.28,50,,99.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.91,12.84,,25.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.84,80,,159.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.91,12.84,,25.53,percent of total billed charges,12.84% of total billed charges,31.91,12.84,,25.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,248.55,65,,198.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.99,35,,69.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,149.13,60,,119.3,percent of total billed charges,60% of total billed charges for outpatient setting,31.91,248.55,
SCREW 2.7X28MM LCK STAR / 02.211.028,69169434,CDM,278,RC,C1713,HCPCS,Outpatient,,,724.6,724.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.76,60,,347.81,percent of total billed charges,60% of total Billed charges for outpatient setting,615.04,84.88,,492.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.45,75,,434.76,percent of total billed charges,75% of total billed charges for outpatient setting,362.3,50,,289.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.68,80,,463.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,93.04,12.84,,74.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.6,65,,579.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.61,35,,202.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,434.76,60,,347.81,percent of total billed charges,60% of total billed charges for outpatient setting,93.04,724.6,
SCREW 2.7X28MM LOCK  / 40-27628,69162880,CDM,278,RC,C1713,HCPCS,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
SCREW 2.7X28MM NON LOCKING / 656428,69169590,CDM,278,RC,C1713,HCPCS,Outpatient,,,342.27,342.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.36,60,,164.29,percent of total billed charges,60% of total Billed charges for outpatient setting,290.52,84.88,,232.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.7,75,,205.36,percent of total billed charges,75% of total billed charges for outpatient setting,171.14,50,,136.91,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.95,12.84,,35.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.82,80,,219.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.95,12.84,,35.16,percent of total billed charges,12.84% of total billed charges,43.95,12.84,,35.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,342.27,65,,273.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.79,35,,95.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,205.36,60,,164.29,percent of total billed charges,60% of total billed charges for outpatient setting,43.95,342.27,
SCREW 2.7X28MM T8 LOCKING / 656328,69169551,CDM,278,RC,C1713,HCPCS,Outpatient,,,569.94,569.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.96,60,,273.57,percent of total billed charges,60% of total Billed charges for outpatient setting,483.77,84.88,,387.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.46,75,,341.97,percent of total billed charges,75% of total billed charges for outpatient setting,284.97,50,,227.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.18,12.84,,58.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.95,80,,364.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.18,12.84,,58.54,percent of total billed charges,12.84% of total billed charges,73.18,12.84,,58.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.94,65,,455.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.48,35,,159.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.96,60,,273.57,percent of total billed charges,60% of total billed charges for outpatient setting,73.18,569.94,
SCREW 2.7X30MM T8 LOCKING / 656330,69169734,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.72,594.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,60,,285.46,percent of total billed charges,60% of total Billed charges for outpatient setting,504.8,84.88,,403.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.04,75,,356.83,percent of total billed charges,75% of total billed charges for outpatient setting,297.36,50,,237.89,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.78,80,,380.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,76.36,12.84,,61.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.72,65,,475.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.15,35,,166.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.83,60,,285.46,percent of total billed charges,60% of total billed charges for outpatient setting,76.36,594.72,
SCREW 2.7X32MM  / 40-27032,69162878,CDM,278,RC,C1713,HCPCS,Outpatient,,,283.13,283.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.88,60,,135.9,percent of total billed charges,60% of total Billed charges for outpatient setting,240.32,84.88,,192.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.35,75,,169.88,percent of total billed charges,75% of total billed charges for outpatient setting,141.57,50,,113.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.5,80,,181.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,283.13,65,,226.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.1,35,,79.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.88,60,,135.9,percent of total billed charges,60% of total billed charges for outpatient setting,36.35,283.13,
SCREW 2.7X32MM CORTEX STR / 202.892,69169450,CDM,278,RC,C1713,HCPCS,Outpatient,,,263.61,263.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.17,60,,126.54,percent of total billed charges,60% of total Billed charges for outpatient setting,223.75,84.88,,179,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.71,75,,158.17,percent of total billed charges,75% of total billed charges for outpatient setting,131.81,50,,105.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.89,80,,168.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,33.85,12.84,,27.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.61,65,,210.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.26,35,,73.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,158.17,60,,126.54,percent of total billed charges,60% of total billed charges for outpatient setting,33.85,263.61,
SCREW 2.7X32MM LOCK  / 40-27632,69162879,CDM,278,RC,C1713,HCPCS,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
SCREW 2.7X34MM LCK STAR / 02.211.034,69169432,CDM,278,RC,C1713,HCPCS,Outpatient,,,789.52,789.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.71,60,,378.97,percent of total billed charges,60% of total Billed charges for outpatient setting,670.14,84.88,,536.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.14,75,,473.71,percent of total billed charges,75% of total billed charges for outpatient setting,394.76,50,,315.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,12.84,,81.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.62,80,,505.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,12.84,,81.1,percent of total billed charges,12.84% of total billed charges,101.37,12.84,,81.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,789.52,65,,631.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.33,35,,221.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,473.71,60,,378.97,percent of total billed charges,60% of total billed charges for outpatient setting,101.37,789.52,
SCREW 2.7X36MM  / 40-27036,69162877,CDM,278,RC,C1713,HCPCS,Outpatient,,,283.13,283.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.88,60,,135.9,percent of total billed charges,60% of total Billed charges for outpatient setting,240.32,84.88,,192.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.35,75,,169.88,percent of total billed charges,75% of total billed charges for outpatient setting,141.57,50,,113.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.5,80,,181.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,36.35,12.84,,29.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,283.13,65,,226.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.1,35,,79.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.88,60,,135.9,percent of total billed charges,60% of total billed charges for outpatient setting,36.35,283.13,
SCREW 2.7X56MM METAPHYSEAL / 02.118.556,1178513,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.68,209.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.81,60,,100.65,percent of total billed charges,60% of total Billed charges for outpatient setting,177.98,84.88,,142.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.26,75,,125.81,percent of total billed charges,75% of total billed charges for outpatient setting,104.84,50,,83.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.74,80,,134.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.68,65,,167.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.39,35,,58.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.81,60,,100.65,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,209.68,
SCREW 2.7X60MM MTPHSL / 02.118.560,1170028,CDM,278,RC,C1713,HCPCS,Outpatient,,,209.68,209.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.81,60,,100.65,percent of total billed charges,60% of total Billed charges for outpatient setting,177.98,84.88,,142.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.26,75,,125.81,percent of total billed charges,75% of total billed charges for outpatient setting,104.84,50,,83.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.74,80,,134.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,26.92,12.84,,21.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.68,65,,167.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.39,35,,58.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.81,60,,100.65,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,209.68,
SCREW 2.7X62MM MTPHSL / 02.118.562,69169430,CDM,278,RC,C1713,HCPCS,Outpatient,,,255.53,255.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.32,60,,122.66,percent of total billed charges,60% of total Billed charges for outpatient setting,216.89,84.88,,173.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.65,75,,153.32,percent of total billed charges,75% of total billed charges for outpatient setting,127.77,50,,102.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.81,12.84,,26.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.42,80,,163.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.81,12.84,,26.25,percent of total billed charges,12.84% of total billed charges,32.81,12.84,,26.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,255.53,65,,204.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.44,35,,71.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.32,60,,122.66,percent of total billed charges,60% of total billed charges for outpatient setting,32.81,255.53,
SCREW 2.7X7MM LOCKING / 656307,7233818,CDM,278,RC,C1713,HCPCS,Outpatient,,,566.4,566.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.84,60,,271.87,percent of total billed charges,60% of total Billed charges for outpatient setting,480.76,84.88,,384.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.8,75,,339.84,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,50,,226.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,12.84,,58.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.12,80,,362.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,12.84,,58.18,percent of total billed charges,12.84% of total billed charges,72.73,12.84,,58.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,566.4,65,,453.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,35,,158.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,339.84,60,,271.87,percent of total billed charges,60% of total billed charges for outpatient setting,72.73,566.4,
SCREW 2.7X8MM LOCKING / 02.211.008,962048,CDM,278,RC,C1713,HCPCS,Outpatient,,,653.12,653.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.87,60,,313.5,percent of total billed charges,60% of total Billed charges for outpatient setting,554.37,84.88,,443.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.84,75,,391.87,percent of total billed charges,75% of total billed charges for outpatient setting,326.56,50,,261.25,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,12.84,,67.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.5,80,,418,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,12.84,,67.09,percent of total billed charges,12.84% of total billed charges,83.86,12.84,,67.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,653.12,65,,522.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.59,35,,182.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,391.87,60,,313.5,percent of total billed charges,60% of total billed charges for outpatient setting,83.86,653.12,
SCREW 2.7X8MM LOCKING / 202.208,69169462,CDM,278,RC,C1769,HCPCS,Outpatient,,,633.15,633.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.89,60,,303.91,percent of total billed charges,60% of total Billed charges for outpatient setting,537.42,84.88,,429.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.86,75,,379.89,percent of total billed charges,75% of total billed charges for outpatient setting,316.58,50,,253.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.52,80,,405.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,81.3,12.84,,65.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,633.15,65,,506.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.6,35,,177.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.89,60,,303.91,percent of total billed charges,60% of total billed charges for outpatient setting,81.3,633.15,
SCREW 26MM ELLIPSE / 182.426,70000027,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 3.0X12MM CANCLUS / AR-8830-12,71000536,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.0X14MM HEADLESS / 141-3014,69169127,CDM,278,RC,C1713,HCPCS,Outpatient,,,966.86,966.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.12,60,,464.1,percent of total billed charges,60% of total Billed charges for outpatient setting,820.67,84.88,,656.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.15,75,,580.12,percent of total billed charges,75% of total billed charges for outpatient setting,483.43,50,,386.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.14,12.84,,99.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.49,80,,618.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.14,12.84,,99.31,percent of total billed charges,12.84% of total billed charges,124.14,12.84,,99.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,966.86,65,,773.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.4,35,,270.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,580.12,60,,464.1,percent of total billed charges,60% of total billed charges for outpatient setting,124.14,966.86,
SCREW 3.0X14MM LOCKING /AR8933L-14,69162351,CDM,278,RC,C1713,HCPCS,Outpatient,,,416.38,416.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,60,,199.86,percent of total billed charges,60% of total Billed charges for outpatient setting,353.42,84.88,,282.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.29,75,,249.83,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,50,,166.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,80,,266.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416.38,65,,333.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.73,35,,116.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.83,60,,199.86,percent of total billed charges,60% of total billed charges for outpatient setting,53.46,416.38,
SCREW 3.0X16MM CANCLUS / AR-8830-16,71000821,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.0X16MM CORTICAL / AR-8933-16,71000929,CDM,278,RC,C1713,HCPCS,Outpatient,,,462,462,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.2,60,,221.76,percent of total billed charges,60% of total Billed charges for outpatient setting,392.15,84.88,,313.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.5,75,,277.2,percent of total billed charges,75% of total billed charges for outpatient setting,231,50,,184.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.32,12.84,,47.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.6,80,,295.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.32,12.84,,47.46,percent of total billed charges,12.84% of total billed charges,59.32,12.84,,47.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,462,65,,369.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.7,35,,129.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,277.2,60,,221.76,percent of total billed charges,60% of total billed charges for outpatient setting,59.32,462,
SCREW 3.0X16MM LOCKING /AR8933L-16,69162350,CDM,278,RC,C1713,HCPCS,Outpatient,,,416.38,416.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,60,,199.86,percent of total billed charges,60% of total Billed charges for outpatient setting,353.42,84.88,,282.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.29,75,,249.83,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,50,,166.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,80,,266.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416.38,65,,333.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.73,35,,116.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.83,60,,199.86,percent of total billed charges,60% of total billed charges for outpatient setting,53.46,416.38,
SCREW 3.0X18MM CORTICAL /AR8933-18,69162347,CDM,278,RC,C1713,HCPCS,Outpatient,,,416.38,416.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,60,,199.86,percent of total billed charges,60% of total Billed charges for outpatient setting,353.42,84.88,,282.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.29,75,,249.83,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,50,,166.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,80,,266.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416.38,65,,333.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.73,35,,116.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.83,60,,199.86,percent of total billed charges,60% of total billed charges for outpatient setting,53.46,416.38,
SCREW 3.0X18MM HEADLESS / 141-3018,69169126,CDM,278,RC,C1713,HCPCS,Outpatient,,,966.86,966.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.12,60,,464.1,percent of total billed charges,60% of total Billed charges for outpatient setting,820.67,84.88,,656.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.15,75,,580.12,percent of total billed charges,75% of total billed charges for outpatient setting,483.43,50,,386.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.14,12.84,,99.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.49,80,,618.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.14,12.84,,99.31,percent of total billed charges,12.84% of total billed charges,124.14,12.84,,99.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,966.86,65,,773.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.4,35,,270.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,580.12,60,,464.1,percent of total billed charges,60% of total billed charges for outpatient setting,124.14,966.86,
SCREW 3.0X20MM CORTICAL /AR8933-20,69162349,CDM,278,RC,C1713,HCPCS,Outpatient,,,416.38,416.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,60,,199.86,percent of total billed charges,60% of total Billed charges for outpatient setting,353.42,84.88,,282.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.29,75,,249.83,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,50,,166.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,80,,266.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416.38,65,,333.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.73,35,,116.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.83,60,,199.86,percent of total billed charges,60% of total billed charges for outpatient setting,53.46,416.38,
SCREW 3.0X24MM CORTICAL /AR8933-24,69162348,CDM,278,RC,C1713,HCPCS,Outpatient,,,416.38,416.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,60,,199.86,percent of total billed charges,60% of total Billed charges for outpatient setting,353.42,84.88,,282.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.29,75,,249.83,percent of total billed charges,75% of total billed charges for outpatient setting,208.19,50,,166.55,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,80,,266.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,53.46,12.84,,42.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,416.38,65,,333.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.73,35,,116.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,249.83,60,,199.86,percent of total billed charges,60% of total billed charges for outpatient setting,53.46,416.38,
SCREW 3.0X34MM BUNION CANN / IH3034,2089400,CDM,278,RC,C1713,HCPCS,Outpatient,,,1496,1496,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.6,60,,718.08,percent of total billed charges,60% of total Billed charges for outpatient setting,1269.8,84.88,,1015.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122,75,,897.6,percent of total billed charges,75% of total billed charges for outpatient setting,748,50,,598.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.09,12.84,,153.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.8,80,,957.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.09,12.84,,153.67,percent of total billed charges,12.84% of total billed charges,192.09,12.84,,153.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1496,65,,1196.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.6,35,,418.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,897.6,60,,718.08,percent of total billed charges,60% of total billed charges for outpatient setting,192.09,1496,
SCREW 3.0X36MM BUNION CANN / IH3036,2308694,CDM,278,RC,C1713,HCPCS,Outpatient,,,1496,1496,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.6,60,,718.08,percent of total billed charges,60% of total Billed charges for outpatient setting,1269.8,84.88,,1015.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122,75,,897.6,percent of total billed charges,75% of total billed charges for outpatient setting,748,50,,598.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.09,12.84,,153.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.8,80,,957.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.09,12.84,,153.67,percent of total billed charges,12.84% of total billed charges,192.09,12.84,,153.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1496,65,,1196.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.6,35,,418.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,897.6,60,,718.08,percent of total billed charges,60% of total billed charges for outpatient setting,192.09,1496,
SCREW 3.0X36MM PART THRD / AR8730-36PT,69162352,CDM,278,RC,C1713,HCPCS,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.34,60,,311.47,percent of total billed charges,60% of total Billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.9,65,,519.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,60,,311.47,percent of total billed charges,60% of total billed charges for outpatient setting,83.32,648.9,
SCREW 3.0X38MM CANN T9 / IC3038,2312671,CDM,278,RC,C1713,HCPCS,Outpatient,,,860,860,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,60,,412.8,percent of total billed charges,60% of total Billed charges for outpatient setting,729.97,84.88,,583.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645,75,,516,percent of total billed charges,75% of total billed charges for outpatient setting,430,50,,344,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688,80,,550.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,860,65,,688,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301,35,,240.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,516,60,,412.8,percent of total billed charges,60% of total billed charges for outpatient setting,110.42,860,
SCREW 3.0X40MM CANN T9 / IC3040,2169769,CDM,278,RC,C1713,HCPCS,Outpatient,,,860,860,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,60,,412.8,percent of total billed charges,60% of total Billed charges for outpatient setting,729.97,84.88,,583.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645,75,,516,percent of total billed charges,75% of total billed charges for outpatient setting,430,50,,344,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688,80,,550.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,110.42,12.84,,88.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,860,65,,688,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301,35,,240.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,516,60,,412.8,percent of total billed charges,60% of total billed charges for outpatient setting,110.42,860,
SCREW 3.3X32MM TI LOCKING / 04.005.422,724266,CDM,278,RC,C1713,HCPCS,Outpatient,,,804.36,804.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.62,60,,386.1,percent of total billed charges,60% of total Billed charges for outpatient setting,682.74,84.88,,546.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.27,75,,482.62,percent of total billed charges,75% of total billed charges for outpatient setting,402.18,50,,321.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,12.84,,82.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,80,,514.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,12.84,,82.62,percent of total billed charges,12.84% of total billed charges,103.28,12.84,,82.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,804.36,65,,643.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.53,35,,225.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.62,60,,386.1,percent of total billed charges,60% of total billed charges for outpatient setting,103.28,804.36,
SCREW 3.3X34MM TI LOCKING / 04.005.424,123621,CDM,278,RC,C1713,HCPCS,Outpatient,,,804.36,804.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.62,60,,386.1,percent of total billed charges,60% of total Billed charges for outpatient setting,682.74,84.88,,546.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.27,75,,482.62,percent of total billed charges,75% of total billed charges for outpatient setting,402.18,50,,321.74,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,12.84,,82.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,80,,514.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,12.84,,82.62,percent of total billed charges,12.84% of total billed charges,103.28,12.84,,82.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,804.36,65,,643.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.53,35,,225.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,482.62,60,,386.1,percent of total billed charges,60% of total billed charges for outpatient setting,103.28,804.36,
SCREW 3.5 HEX 4.75X20MM FXD LOCKING,69161974,CDM,278,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 3.5 HEX 4.75X25MM LK / 180552,69161589,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 3.5 HEX 4.75X30MM LK / 180553,69169746,CDM,278,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 3.50X40MM VARIAX / 657440,1916496,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.50X65MM VARIAX / 657465,1967908,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.50X70MM VARIAX / 657470,1967909,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5MM TRANSVERSE / SK19,7037400,CDM,278,RC,C1713,HCPCS,Outpatient,,,1912,1912,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.2,60,,917.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1622.91,84.88,,1298.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434,75,,1147.2,percent of total billed charges,75% of total billed charges for outpatient setting,956,50,,764.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1529.6,80,,1223.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,245.5,12.84,,196.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1912,65,,1529.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.2,35,,535.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1147.2,60,,917.76,percent of total billed charges,60% of total billed charges for outpatient setting,245.5,1912,
SCREW 3.5X10MM  / 40-35010,69162805,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X10MM CORTEX / 204.810,6152809,CDM,278,RC,C1713,HCPCS,Outpatient,,,145.68,145.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.41,60,,69.93,percent of total billed charges,60% of total Billed charges for outpatient setting,123.65,84.88,,98.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.26,75,,87.41,percent of total billed charges,75% of total billed charges for outpatient setting,72.84,50,,58.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.71,12.84,,14.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.54,80,,93.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.71,12.84,,14.97,percent of total billed charges,12.84% of total billed charges,18.71,12.84,,14.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.68,65,,116.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.99,35,,40.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.41,60,,69.93,percent of total billed charges,60% of total billed charges for outpatient setting,18.71,145.68,
SCREW 3.5X10MM LOCK / 40-35610,70000126,CDM,278,RC,C1713,HCPCS,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
SCREW 3.5X10MM LOCKING / 657310,70000264,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.04,579.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.42,60,,277.94,percent of total billed charges,60% of total Billed charges for outpatient setting,491.49,84.88,,393.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.28,75,,347.42,percent of total billed charges,75% of total billed charges for outpatient setting,289.52,50,,231.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,80,,370.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.04,65,,463.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,35,,162.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.42,60,,277.94,percent of total billed charges,60% of total billed charges for outpatient setting,74.35,579.04,
SCREW 3.5X10MM LOCKING / AR-8835L-10,70000503,CDM,278,RC,C1713,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,60,,231.84,percent of total billed charges,60% of total Billed charges for outpatient setting,409.97,84.88,,327.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,75,,289.8,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,50,,193.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,80,,309.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483,65,,386.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,35,,135.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.8,60,,231.84,percent of total billed charges,60% of total billed charges for outpatient setting,62.02,483,
SCREW 3.5X10MM NON LK / 657410,69169259,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X10MM NONLOCKING / 654410,70000799,CDM,278,RC,,,Outpatient,,,356.2,356.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.72,60,,170.98,percent of total billed charges,60% of total Billed charges for outpatient setting,302.34,84.88,,241.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.1,50,,142.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.15,75,,213.72,percent of total billed charges,75% of total billed charges for outpatient setting,178.1,50,,142.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.74,12.84,,36.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.96,80,,227.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.74,12.84,,36.59,percent of total billed charges,12.84% of total billed charges,45.74,12.84,,36.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,356.2,65,,284.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.67,35,,99.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,213.72,60,,170.98,percent of total billed charges,60% of total billed charges for outpatient setting,45.74,356.2,
SCREW 3.5X11MM NON LK FL THRD/ 657411,71000280,CDM,278,RC,C1713,HCPCS,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 3.5X12MM CORTEX / 204.812,6152810,CDM,278,RC,C1713,HCPCS,Outpatient,,,127.08,127.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.25,60,,61,percent of total billed charges,60% of total Billed charges for outpatient setting,107.87,84.88,,86.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.31,75,,76.25,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,50,,50.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.66,80,,81.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.08,65,,101.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,35,,35.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.25,60,,61,percent of total billed charges,60% of total billed charges for outpatient setting,16.32,127.08,
SCREW 3.5X12MM CORTICAL / 58913512,71000566,CDM,278,RC,C1713,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,60,,168.96,percent of total billed charges,60% of total Billed charges for outpatient setting,298.78,84.88,,239.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,75,,211.2,percent of total billed charges,75% of total billed charges for outpatient setting,176,50,,140.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.6,80,,225.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,352,65,,281.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.2,35,,98.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.2,60,,168.96,percent of total billed charges,60% of total billed charges for outpatient setting,45.2,352,
SCREW 3.5X12MM CORTICAL / AR-8735-12,71000434,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 3.5X12MM CORTICAL / AR8835-12,69162690,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X12MM KREULOCK / AR-8935CL-12,71000436,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 3.5X12MM LCK LPRO TI / AR-8935L-12,70000542,CDM,278,RC,C1713,HCPCS,Outpatient,,,367.71,367.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.63,60,,176.5,percent of total billed charges,60% of total Billed charges for outpatient setting,312.11,84.88,,249.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.78,75,,220.62,percent of total billed charges,75% of total billed charges for outpatient setting,183.86,50,,147.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.17,80,,235.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,367.71,65,,294.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,35,,102.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,220.63,60,,176.5,percent of total billed charges,60% of total billed charges for outpatient setting,47.21,367.71,
SCREW 3.5X12MM LOCK / 40-35612,70000089,CDM,278,RC,C1713,HCPCS,Outpatient,,,956.05,956.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.63,60,,458.9,percent of total billed charges,60% of total Billed charges for outpatient setting,811.5,84.88,,649.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.04,75,,573.63,percent of total billed charges,75% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.84,80,,611.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.05,65,,764.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.62,35,,267.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,573.63,60,,458.9,percent of total billed charges,60% of total billed charges for outpatient setting,122.76,956.05,
SCREW 3.5X12MM LOCKING / 58803512,71000564,CDM,278,RC,C1713,HCPCS,Outpatient,,,692,692,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.2,60,,332.16,percent of total billed charges,60% of total Billed charges for outpatient setting,587.37,84.88,,469.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519,75,,415.2,percent of total billed charges,75% of total billed charges for outpatient setting,346,50,,276.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.6,80,,442.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,692,65,,553.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.2,35,,193.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.2,60,,332.16,percent of total billed charges,60% of total billed charges for outpatient setting,88.85,692,
SCREW 3.5X12MM LOCKING / 657312,69162593,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.04,579.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.42,60,,277.94,percent of total billed charges,60% of total Billed charges for outpatient setting,491.49,84.88,,393.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.28,75,,347.42,percent of total billed charges,75% of total billed charges for outpatient setting,289.52,50,,231.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,80,,370.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.04,65,,463.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,35,,162.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.42,60,,277.94,percent of total billed charges,60% of total billed charges for outpatient setting,74.35,579.04,
SCREW 3.5X12MM LOCKING / AR-8835L-12,70000504,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 3.5X12MM LOPRO TI / AR-835-12,70000540,CDM,278,RC,C1713,HCPCS,Outpatient,,,259.56,259.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.74,60,,124.59,percent of total billed charges,60% of total Billed charges for outpatient setting,220.31,84.88,,176.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,75,,155.74,percent of total billed charges,75% of total billed charges for outpatient setting,129.78,50,,103.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,80,,166.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,33.33,12.84,,26.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,259.56,65,,207.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,35,,72.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,60,,124.59,percent of total billed charges,60% of total billed charges for outpatient setting,33.33,259.56,
SCREW 3.5X12MM LOW PRO / 58813512,71000560,CDM,278,RC,C1713,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,60,,168.96,percent of total billed charges,60% of total Billed charges for outpatient setting,298.78,84.88,,239.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,75,,211.2,percent of total billed charges,75% of total billed charges for outpatient setting,176,50,,140.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.6,80,,225.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,352,65,,281.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.2,35,,98.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.2,60,,168.96,percent of total billed charges,60% of total billed charges for outpatient setting,45.2,352,
SCREW 3.5X12MM NON LK FL THRD / 657412,70000788,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X12MM QUARTEX / 1149.3512,69162646,CDM,278,RC,C1713,HCPCS,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,60,,1344,percent of total billed charges,60% of total Billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2940,105,,2352,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1680,60,,1344,percent of total billed charges,60% of total billed charges for outpatient setting,359.52,2940,
SCREW 3.5X12MM T10 / 40-35012,70000127,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X12MM T10 / 40-35012,70000553,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X12MM TITANIUM / 30-0257,951346,CDM,278,RC,C1713,HCPCS,Outpatient,,,284,284,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,60,,136.32,percent of total billed charges,60% of total Billed charges for outpatient setting,241.06,84.88,,192.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213,75,,170.4,percent of total billed charges,75% of total billed charges for outpatient setting,142,50,,113.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.2,80,,181.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,284,65,,227.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.4,35,,79.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.4,60,,136.32,percent of total billed charges,60% of total billed charges for outpatient setting,36.47,284,
SCREW 3.5X14MM CORTEX / 204.814,6152811,CDM,278,RC,C1713,HCPCS,Outpatient,,,137.35,137.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,60,,65.93,percent of total billed charges,60% of total Billed charges for outpatient setting,116.58,84.88,,93.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,75,,82.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.68,50,,54.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.88,80,,87.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.35,65,,109.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.07,35,,38.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.41,60,,65.93,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,137.35,
SCREW 3.5X14MM CORTICAL / AR-8735-14,71000416,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 3.5X14MM CORTICAL / AR8835-14,69162691,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X14MM KREULOCK / AR-8935CL-1,71000702,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 3.5X14MM LCK TI / AR-8935L-14,70000549,CDM,278,RC,C1713,HCPCS,Outpatient,,,367.71,367.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.63,60,,176.5,percent of total billed charges,60% of total Billed charges for outpatient setting,312.11,84.88,,249.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.78,75,,220.62,percent of total billed charges,75% of total billed charges for outpatient setting,183.86,50,,147.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.17,80,,235.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,47.21,12.84,,37.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,367.71,65,,294.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,35,,102.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,220.63,60,,176.5,percent of total billed charges,60% of total billed charges for outpatient setting,47.21,367.71,
SCREW 3.5X14MM LOCK / 40-35614,69162256,CDM,278,RC,,,Outpatient,,,836.55,836.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.93,60,,401.54,percent of total billed charges,60% of total Billed charges for outpatient setting,710.06,84.88,,568.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,418.28,50,,334.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,627.41,75,,501.93,percent of total billed charges,75% of total billed charges for outpatient setting,418.28,50,,334.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.41,12.84,,85.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.24,80,,535.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.41,12.84,,85.93,percent of total billed charges,12.84% of total billed charges,107.41,12.84,,85.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,836.55,65,,669.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.79,35,,234.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,501.93,60,,401.54,percent of total billed charges,60% of total billed charges for outpatient setting,107.41,836.55,
SCREW 3.5X14MM LOCKING / 212.103,69169819,CDM,278,RC,C1713,HCPCS,Outpatient,,,602.74,602.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.64,60,,289.31,percent of total billed charges,60% of total Billed charges for outpatient setting,511.61,84.88,,409.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.06,75,,361.65,percent of total billed charges,75% of total billed charges for outpatient setting,301.37,50,,241.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.19,80,,385.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.74,65,,482.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.96,35,,168.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.64,60,,289.31,percent of total billed charges,60% of total billed charges for outpatient setting,77.39,602.74,
SCREW 3.5X14MM LOCKING / 58803514,71000563,CDM,278,RC,C1713,HCPCS,Outpatient,,,692,692,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.2,60,,332.16,percent of total billed charges,60% of total Billed charges for outpatient setting,587.37,84.88,,469.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519,75,,415.2,percent of total billed charges,75% of total billed charges for outpatient setting,346,50,,276.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.6,80,,442.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,88.85,12.84,,71.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,692,65,,553.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.2,35,,193.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.2,60,,332.16,percent of total billed charges,60% of total billed charges for outpatient setting,88.85,692,
SCREW 3.5X14MM LOCKING / 657314,70000263,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.04,579.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.42,60,,277.94,percent of total billed charges,60% of total Billed charges for outpatient setting,491.49,84.88,,393.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.28,75,,347.42,percent of total billed charges,75% of total billed charges for outpatient setting,289.52,50,,231.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,80,,370.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.04,65,,463.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,35,,162.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.42,60,,277.94,percent of total billed charges,60% of total billed charges for outpatient setting,74.35,579.04,
SCREW 3.5X14MM LOCKING / 657316,70000262,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.04,579.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.42,60,,277.94,percent of total billed charges,60% of total Billed charges for outpatient setting,491.49,84.88,,393.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.28,75,,347.42,percent of total billed charges,75% of total billed charges for outpatient setting,289.52,50,,231.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,80,,370.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.04,65,,463.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,35,,162.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.42,60,,277.94,percent of total billed charges,60% of total billed charges for outpatient setting,74.35,579.04,
SCREW 3.5X14MM LOCKING / AR8835L-14,69162692,CDM,278,RC,C1713,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,60,,231.84,percent of total billed charges,60% of total Billed charges for outpatient setting,409.97,84.88,,327.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,75,,289.8,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,50,,193.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,80,,309.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483,65,,386.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,35,,135.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.8,60,,231.84,percent of total billed charges,60% of total billed charges for outpatient setting,62.02,483,
SCREW 3.5X14MM LOPRO TI / AR-8935-14,70000541,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 3.5X14MM LOW PRO / 58813514,71000561,CDM,278,RC,C1713,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,60,,168.96,percent of total billed charges,60% of total Billed charges for outpatient setting,298.78,84.88,,239.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,75,,211.2,percent of total billed charges,75% of total billed charges for outpatient setting,176,50,,140.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.6,80,,225.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,352,65,,281.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.2,35,,98.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.2,60,,168.96,percent of total billed charges,60% of total billed charges for outpatient setting,45.2,352,
SCREW 3.5X14MM NON LK FL TRD/ 657414,69162589,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X14MM QUARTEX / 1149.3514,69162617,CDM,278,RC,C1713,HCPCS,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,60,,1344,percent of total billed charges,60% of total Billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2940,105,,2352,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1680,60,,1344,percent of total billed charges,60% of total billed charges for outpatient setting,359.52,2940,
SCREW 3.5X14MM QUARTEX / 1149.3614,69169361,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 3.5X14MM STRYKER / 614814,69161692,CDM,278,RC,,,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW 3.5X14MM T10 / 40-35014,70000086,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X14MM TITANIUM / 30-0258,601051,CDM,278,RC,C1713,HCPCS,Outpatient,,,284,284,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,60,,136.32,percent of total billed charges,60% of total Billed charges for outpatient setting,241.06,84.88,,192.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213,75,,170.4,percent of total billed charges,75% of total billed charges for outpatient setting,142,50,,113.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.2,80,,181.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,284,65,,227.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.4,35,,79.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.4,60,,136.32,percent of total billed charges,60% of total billed charges for outpatient setting,36.47,284,
SCREW 3.5X16MM 204.216,6152797,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X16MM CORTEX / 204.816,6152812,CDM,278,RC,C1713,HCPCS,Outpatient,,,137.35,137.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,60,,65.93,percent of total billed charges,60% of total Billed charges for outpatient setting,116.58,84.88,,93.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,75,,82.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.68,50,,54.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.88,80,,87.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.35,65,,109.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.07,35,,38.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.41,60,,65.93,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,137.35,
SCREW 3.5X16MM CORTICAL / AR8835-16,69162324,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X16MM KREULOCK / AR-8935CL-16,71000703,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 3.5X16MM LCKING / 212.104,69160735,CDM,278,RC,C1713,HCPCS,Outpatient,,,602.74,602.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.64,60,,289.31,percent of total billed charges,60% of total Billed charges for outpatient setting,511.61,84.88,,409.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.06,75,,361.65,percent of total billed charges,75% of total billed charges for outpatient setting,301.37,50,,241.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.19,80,,385.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.74,65,,482.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.96,35,,168.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.64,60,,289.31,percent of total billed charges,60% of total billed charges for outpatient setting,77.39,602.74,
SCREW 3.5X16MM LOCK / 40-35616,69162257,CDM,278,RC,,,Outpatient,,,956.05,956.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.63,60,,458.9,percent of total billed charges,60% of total Billed charges for outpatient setting,811.5,84.88,,649.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717.04,75,,573.63,percent of total billed charges,75% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.84,80,,611.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.05,65,,764.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.62,35,,267.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,573.63,60,,458.9,percent of total billed charges,60% of total billed charges for outpatient setting,122.76,956.05,
SCREW 3.5X16MM LOCKING / AR-8835CL-16,71000833,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 3.5X16MM LOCKING / AR-8835L-16,71000511,CDM,278,RC,C1713,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,60,,231.84,percent of total billed charges,60% of total Billed charges for outpatient setting,409.97,84.88,,327.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,75,,289.8,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,50,,193.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,80,,309.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483,65,,386.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,35,,135.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.8,60,,231.84,percent of total billed charges,60% of total billed charges for outpatient setting,62.02,483,
SCREW 3.5X16MM LOPRO TI / AR-8935-16,71000701,CDM,278,RC,C1713,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,60,,120.96,percent of total billed charges,60% of total Billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,252,65,,201.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,60,,120.96,percent of total billed charges,60% of total billed charges for outpatient setting,32.36,252,
SCREW 3.5X16MM NON LK FK THRD / 657416,69162588,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X16MM NONLOCK / 40-35016,69162253,CDM,278,RC,,,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X16MM STRYKER / 614816,69161555,CDM,278,RC,,,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW 3.5X18MM 204.218,6152798,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X18MM COMPR / AR-8730-18H,69169755,CDM,278,RC,C1713,HCPCS,Outpatient,,,1470,1470,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,60,,705.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1247.74,84.88,,998.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,75,,882,percent of total billed charges,75% of total billed charges for outpatient setting,735,50,,588,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,80,,940.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,188.75,12.84,,151,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1470,65,,1176,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,35,,411.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,882,60,,705.6,percent of total billed charges,60% of total billed charges for outpatient setting,188.75,1470,
SCREW 3.5X18MM CORTEX / 204.818,6152813,CDM,278,RC,C1713,HCPCS,Outpatient,,,137.35,137.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,60,,65.93,percent of total billed charges,60% of total Billed charges for outpatient setting,116.58,84.88,,93.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,75,,82.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.68,50,,54.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.88,80,,87.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.35,65,,109.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.07,35,,38.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.41,60,,65.93,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,137.35,
SCREW 3.5X18MM CORTICAL / AR8835-18,69162325,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X18MM LOCK / 40-35618,69162258,CDM,278,RC,,,Outpatient,,,956.05,956.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.63,60,,458.9,percent of total billed charges,60% of total Billed charges for outpatient setting,811.5,84.88,,649.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717.04,75,,573.63,percent of total billed charges,75% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.84,80,,611.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.05,65,,764.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.62,35,,267.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,573.63,60,,458.9,percent of total billed charges,60% of total billed charges for outpatient setting,122.76,956.05,
SCREW 3.5X18MM LOCKING / 212.105,69161801,CDM,278,RC,C1769,HCPCS,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW 3.5X18MM LOCKING / 657318,70000327,CDM,278,RC,C1713,HCPCS,Outpatient,,,579.04,579.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.42,60,,277.94,percent of total billed charges,60% of total Billed charges for outpatient setting,491.49,84.88,,393.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.28,75,,347.42,percent of total billed charges,75% of total billed charges for outpatient setting,289.52,50,,231.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.23,80,,370.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,74.35,12.84,,59.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,579.04,65,,463.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,35,,162.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.42,60,,277.94,percent of total billed charges,60% of total billed charges for outpatient setting,74.35,579.04,
SCREW 3.5X18MM LOCKING /AR8835L-18,69162326,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.49,497.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,60,,238.79,percent of total billed charges,60% of total Billed charges for outpatient setting,422.27,84.88,,337.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.12,75,,298.5,percent of total billed charges,75% of total billed charges for outpatient setting,248.75,50,,199,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.99,80,,318.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,63.88,12.84,,51.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,497.49,65,,397.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.12,35,,139.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.49,60,,238.79,percent of total billed charges,60% of total billed charges for outpatient setting,63.88,497.49,
SCREW 3.5X18MM NON LK / 657418,70000265,CDM,278,RC,C1713,HCPCS,Outpatient,,,303.04,303.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.82,60,,145.46,percent of total billed charges,60% of total Billed charges for outpatient setting,257.22,84.88,,205.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.28,75,,181.82,percent of total billed charges,75% of total billed charges for outpatient setting,151.52,50,,121.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.91,12.84,,31.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.43,80,,193.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.91,12.84,,31.13,percent of total billed charges,12.84% of total billed charges,38.91,12.84,,31.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,303.04,65,,242.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.06,35,,84.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.82,60,,145.46,percent of total billed charges,60% of total billed charges for outpatient setting,38.91,303.04,
SCREW 3.5X18MM NON LOCK / 40-35018,69162254,CDM,278,RC,,,Outpatient,,,602.12,602.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.27,60,,289.02,percent of total billed charges,60% of total Billed charges for outpatient setting,511.08,84.88,,408.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,301.06,50,,240.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.59,75,,361.27,percent of total billed charges,75% of total billed charges for outpatient setting,301.06,50,,240.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.31,12.84,,61.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.7,80,,385.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.31,12.84,,61.85,percent of total billed charges,12.84% of total billed charges,77.31,12.84,,61.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.12,65,,481.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.74,35,,168.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.27,60,,289.02,percent of total billed charges,60% of total billed charges for outpatient setting,77.31,602.12,
SCREW 3.5X18MM STRYKER / 614818,69161554,CDM,278,RC,,,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW 3.5X18MM TITANIUM / 30-0260,407906,CDM,278,RC,C1713,HCPCS,Outpatient,,,284,284,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,60,,136.32,percent of total billed charges,60% of total Billed charges for outpatient setting,241.06,84.88,,192.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213,75,,170.4,percent of total billed charges,75% of total billed charges for outpatient setting,142,50,,113.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.2,80,,181.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,36.47,12.84,,29.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,284,65,,227.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.4,35,,79.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.4,60,,136.32,percent of total billed charges,60% of total billed charges for outpatient setting,36.47,284,
SCREW 3.5X20M NON LOCK / 657420,70000321,CDM,278,RC,C1713,HCPCS,Outpatient,,,360.86,360.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,60,,173.22,percent of total billed charges,60% of total Billed charges for outpatient setting,306.3,84.88,,245.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.65,75,,216.52,percent of total billed charges,75% of total billed charges for outpatient setting,180.43,50,,144.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,12.84,,37.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.69,80,,230.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,12.84,,37.06,percent of total billed charges,12.84% of total billed charges,46.33,12.84,,37.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,360.86,65,,288.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.3,35,,101.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216.52,60,,173.22,percent of total billed charges,60% of total billed charges for outpatient setting,46.33,360.86,
SCREW 3.5X20MM 204.220,6152799,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X20MM CORTEX / 204.820,6152814,CDM,278,RC,C1713,HCPCS,Outpatient,,,127.08,127.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.25,60,,61,percent of total billed charges,60% of total Billed charges for outpatient setting,107.87,84.88,,86.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.31,75,,76.25,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,50,,50.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.66,80,,81.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.08,65,,101.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,35,,35.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.25,60,,61,percent of total billed charges,60% of total billed charges for outpatient setting,16.32,127.08,
SCREW 3.5X20MM CORTICAL /AR-8835-20,69162482,CDM,278,RC,,,Outpatient,,,189.26,189.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,60,,90.85,percent of total billed charges,60% of total Billed charges for outpatient setting,160.64,84.88,,128.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.63,50,,75.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.95,75,,113.56,percent of total billed charges,75% of total billed charges for outpatient setting,94.63,50,,75.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,80,,121.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.26,65,,151.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,35,,52.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.56,60,,90.85,percent of total billed charges,60% of total billed charges for outpatient setting,24.3,189.26,
SCREW 3.5X20MM LOCKING / 657320,69169106,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.26,663.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.96,60,,318.37,percent of total billed charges,60% of total Billed charges for outpatient setting,562.98,84.88,,450.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.45,75,,397.96,percent of total billed charges,75% of total billed charges for outpatient setting,331.63,50,,265.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,80,,424.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.26,65,,530.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.14,35,,185.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.96,60,,318.37,percent of total billed charges,60% of total billed charges for outpatient setting,85.16,663.26,
SCREW 3.5X20MM LOW PRO / 58813520,71000562,CDM,278,RC,C1713,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,60,,168.96,percent of total billed charges,60% of total Billed charges for outpatient setting,298.78,84.88,,239.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,75,,211.2,percent of total billed charges,75% of total billed charges for outpatient setting,176,50,,140.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.6,80,,225.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,45.2,12.84,,36.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,352,65,,281.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.2,35,,98.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.2,60,,168.96,percent of total billed charges,60% of total billed charges for outpatient setting,45.2,352,
SCREW 3.5X20MM T10 FULL THREAD / 657320,70000323,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X22MM 204.222,6152800,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X22MM AXSOS NON LCK / 661422,69169781,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X22MM COMPR FT / AR-8730-22H,70000533,CDM,278,RC,C1713,HCPCS,Outpatient,,,1400,1400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,60,,672,percent of total billed charges,60% of total Billed charges for outpatient setting,1188.32,84.88,,950.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,75,,840,percent of total billed charges,75% of total billed charges for outpatient setting,700,50,,560,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,80,,896,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1400,65,,1120,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490,35,,392,percent of total billed charges,35% of total Billed charges for Outpatient Setting,840,60,,672,percent of total billed charges,60% of total billed charges for outpatient setting,179.76,1400,
SCREW 3.5X22MM CORTEX / 204.822,6152815,CDM,278,RC,C1713,HCPCS,Outpatient,,,137.35,137.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,60,,65.93,percent of total billed charges,60% of total Billed charges for outpatient setting,116.58,84.88,,93.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,75,,82.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.68,50,,54.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.88,80,,87.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.35,65,,109.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.07,35,,38.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.41,60,,65.93,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,137.35,
SCREW 3.5X22MM CORTICAL / AR8835-22,69162693,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X22MM LOCKING / 657322,70000325,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X22MM NON LK / 657422,69162590,CDM,278,RC,,,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 3.5X22MM STRYKER / 614822,69161958,CDM,278,RC,,,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW 3.5X24MM 204.224,6152801,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X24MM CORTEX / 204.824,6152816,CDM,278,RC,C1713,HCPCS,Outpatient,,,137.35,137.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,60,,65.93,percent of total billed charges,60% of total Billed charges for outpatient setting,116.58,84.88,,93.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,75,,82.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.68,50,,54.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.88,80,,87.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,17.64,12.84,,14.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.35,65,,109.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.07,35,,38.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.41,60,,65.93,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,137.35,
SCREW 3.5X24MM CORTICAL / 661424,69169236,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
"SCREW 3.5X24MM CORTICAL,  LOCKING",69161660,CDM,278,RC,,,Outpatient,,,757.48,757.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.49,60,,363.59,percent of total billed charges,60% of total Billed charges for outpatient setting,642.95,84.88,,514.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.11,75,,454.49,percent of total billed charges,75% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.98,80,,484.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,757.48,65,,605.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.12,35,,212.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,454.49,60,,363.59,percent of total billed charges,60% of total billed charges for outpatient setting,97.26,757.48,
SCREW 3.5X24MM FULL THRD / 657424,70000348,CDM,278,RC,C1713,HCPCS,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 3.5X24MM LOCK / 40-35624,70000384,CDM,278,RC,C1713,HCPCS,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
SCREW 3.5X24MM LOCKING /657324,69169109,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.26,663.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.96,60,,318.37,percent of total billed charges,60% of total Billed charges for outpatient setting,562.98,84.88,,450.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.45,75,,397.96,percent of total billed charges,75% of total billed charges for outpatient setting,331.63,50,,265.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,80,,424.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.26,65,,530.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.14,35,,185.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.96,60,,318.37,percent of total billed charges,60% of total billed charges for outpatient setting,85.16,663.26,
SCREW 3.5X24MM QUARTEX / 1149.3524,2059164,CDM,278,RC,C1713,HCPCS,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,60,,1344,percent of total billed charges,60% of total Billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2940,105,,2352,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1680,60,,1344,percent of total billed charges,60% of total billed charges for outpatient setting,359.52,2940,
SCREW 3.5X24MM STRYKER / 614824,69161959,CDM,278,RC,,,Outpatient,,,463.4,463.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.04,60,,222.43,percent of total billed charges,60% of total Billed charges for outpatient setting,393.33,84.88,,314.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.55,75,,278.04,percent of total billed charges,75% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.72,80,,296.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,463.4,65,,370.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,35,,129.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,278.04,60,,222.43,percent of total billed charges,60% of total billed charges for outpatient setting,59.5,463.4,
SCREW 3.5X26MM 204.226,6152802,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 3.5X26MM CORTEX 204.826,6152817,CDM,278,RC,,,Outpatient,,,152.96,152.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.78,60,,73.42,percent of total billed charges,60% of total Billed charges for outpatient setting,129.83,84.88,,103.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.48,50,,61.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.72,75,,91.78,percent of total billed charges,75% of total billed charges for outpatient setting,76.48,50,,61.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.64,12.84,,15.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.37,80,,97.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.64,12.84,,15.71,percent of total billed charges,12.84% of total billed charges,19.64,12.84,,15.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.96,65,,122.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,35,,42.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.78,60,,73.42,percent of total billed charges,60% of total billed charges for outpatient setting,19.64,152.96,
SCREW 3.5X26MM CORTICAL / 661426,70000627,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
"SCREW 3.5X26MM CORTICAL,  LOCKING",69161655,CDM,278,RC,,,Outpatient,,,757.48,757.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.49,60,,363.59,percent of total billed charges,60% of total Billed charges for outpatient setting,642.95,84.88,,514.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.11,75,,454.49,percent of total billed charges,75% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.98,80,,484.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,757.48,65,,605.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.12,35,,212.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,454.49,60,,363.59,percent of total billed charges,60% of total billed charges for outpatient setting,97.26,757.48,
SCREW 3.5X26MM FULL THRD / 657426,70000322,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X26MM LOCKING / 657326,69169108,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X26MM QUARTEX / 1149.3526,2059165,CDM,278,RC,C1713,HCPCS,Outpatient,,,2800,2800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,60,,1344,percent of total billed charges,60% of total Billed charges for outpatient setting,2376.64,84.88,,1901.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,75,,1680,percent of total billed charges,75% of total billed charges for outpatient setting,1400,50,,1120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,80,,1792,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,359.52,12.84,,287.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2940,105,,2352,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,35,,784,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1680,60,,1344,percent of total billed charges,60% of total billed charges for outpatient setting,359.52,2940,
SCREW 3.5X28MM 204.228,6152803,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X28MM CORTEX / 204.828,6152818,CDM,278,RC,C1713,HCPCS,Outpatient,,,127.08,127.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.25,60,,61,percent of total billed charges,60% of total Billed charges for outpatient setting,107.87,84.88,,86.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.31,75,,76.25,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,50,,50.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.66,80,,81.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.08,65,,101.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,35,,35.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.25,60,,61,percent of total billed charges,60% of total billed charges for outpatient setting,16.32,127.08,
SCREW 3.5X28MM CORTICAL / 661428,69169237,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X28MM LOCKING / 657328,69169107,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X28MM T10 FULL THRD / 657428,70000320,CDM,278,RC,C1713,HCPCS,Outpatient,,,345.83,345.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.5,60,,166,percent of total billed charges,60% of total Billed charges for outpatient setting,293.54,84.88,,234.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.37,75,,207.5,percent of total billed charges,75% of total billed charges for outpatient setting,172.92,50,,138.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.66,80,,221.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,345.83,65,,276.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.04,35,,96.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.5,60,,166,percent of total billed charges,60% of total billed charges for outpatient setting,44.4,345.83,
SCREW 3.5X30MM 204.230,6152804,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5X30MM CORTEX 204.830,6152819,CDM,278,RC,,,Outpatient,,,161.03,161.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.62,60,,77.3,percent of total billed charges,60% of total Billed charges for outpatient setting,136.68,84.88,,109.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.52,50,,64.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.77,75,,96.62,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,50,,64.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,12.84,,16.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.82,80,,103.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,12.84,,16.54,percent of total billed charges,12.84% of total billed charges,20.68,12.84,,16.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.03,65,,128.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.36,35,,45.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.62,60,,77.3,percent of total billed charges,60% of total billed charges for outpatient setting,20.68,161.03,
SCREW 3.5X30MM LOCKING / 657330,70000349,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X30MM NON LCK / 661430,70000671,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X30MM T10 FULL THRD / 657430,70000318,CDM,278,RC,C1713,HCPCS,Outpatient,,,360.86,360.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,60,,173.22,percent of total billed charges,60% of total Billed charges for outpatient setting,306.3,84.88,,245.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.65,75,,216.52,percent of total billed charges,75% of total billed charges for outpatient setting,180.43,50,,144.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,12.84,,37.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.69,80,,230.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,12.84,,37.06,percent of total billed charges,12.84% of total billed charges,46.33,12.84,,37.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,360.86,65,,288.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.3,35,,101.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216.52,60,,173.22,percent of total billed charges,60% of total billed charges for outpatient setting,46.33,360.86,
SCREW 3.5X32MM / 40-35032,70000382,CDM,278,RC,C1713,HCPCS,Outpatient,,,311.69,311.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.01,60,,149.61,percent of total billed charges,60% of total Billed charges for outpatient setting,264.56,84.88,,211.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.77,75,,187.02,percent of total billed charges,75% of total billed charges for outpatient setting,155.85,50,,124.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.35,80,,199.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,311.69,65,,249.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.09,35,,87.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,187.01,60,,149.61,percent of total billed charges,60% of total billed charges for outpatient setting,40.02,311.69,
SCREW 3.5X32MM 204.232,6152805,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
SCREW 3.5x32MM CORTEX 204.832,6152820,CDM,278,RC,,,Outpatient,,,164.24,164.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.54,60,,78.83,percent of total billed charges,60% of total Billed charges for outpatient setting,139.41,84.88,,111.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.12,50,,65.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.18,75,,98.54,percent of total billed charges,75% of total billed charges for outpatient setting,82.12,50,,65.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.09,12.84,,16.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,80,,105.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.09,12.84,,16.87,percent of total billed charges,12.84% of total billed charges,21.09,12.84,,16.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,164.24,65,,131.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.48,35,,45.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.54,60,,78.83,percent of total billed charges,60% of total billed charges for outpatient setting,21.09,164.24,
SCREW 3.5X32MM LOCKING / 657332,70000644,CDM,278,RC,C1713,HCPCS,Outpatient,,,635.63,635.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.38,60,,305.1,percent of total billed charges,60% of total Billed charges for outpatient setting,539.52,84.88,,431.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.72,75,,381.38,percent of total billed charges,75% of total billed charges for outpatient setting,317.82,50,,254.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.5,80,,406.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.63,65,,508.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.47,35,,177.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.38,60,,305.1,percent of total billed charges,60% of total billed charges for outpatient setting,81.61,635.63,
SCREW 3.5X32MM NON LCK / 661432,69169238,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X32MM T10 FULL THRD  / 657432,70000319,CDM,278,RC,C1713,HCPCS,Outpatient,,,366.41,366.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.85,60,,175.88,percent of total billed charges,60% of total Billed charges for outpatient setting,311.01,84.88,,248.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.81,75,,219.85,percent of total billed charges,75% of total billed charges for outpatient setting,183.21,50,,146.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.05,12.84,,37.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.13,80,,234.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.05,12.84,,37.64,percent of total billed charges,12.84% of total billed charges,47.05,12.84,,37.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,366.41,65,,293.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.24,35,,102.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,219.85,60,,175.88,percent of total billed charges,60% of total billed charges for outpatient setting,47.05,366.41,
SCREW 3.5X33MM HEX HEAD / 00-5901-035-33,69169757,CDM,272,RC,C1713,HCPCS,Outpatient,,,861,861,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.7,70,,482.16,percent of total billed charges,70% of total billed charges for outpatient setting,730.82,84.88,,584.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.75,75,,516.6,percent of total billed charges,75% of total billed charges for outpatient setting,602.7,70,,482.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.8,80,,551.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,110.55,12.84,,88.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,559.65,65,,447.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.35,35,,241.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,774.9,90,,619.92,percent of total billed charges,90% of total billed charges for outpatient setting,110.55,774.9,
SCREW 3.5X34MM / 40-35034,70000380,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X34MM 204.234,6152806,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
"SCREW 3.5X34MM CANCEL,  LOCKING",69161653,CDM,278,RC,,,Outpatient,,,757.48,757.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.49,60,,363.59,percent of total billed charges,60% of total Billed charges for outpatient setting,642.95,84.88,,514.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.11,75,,454.49,percent of total billed charges,75% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.98,80,,484.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,757.48,65,,605.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.12,35,,212.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,454.49,60,,363.59,percent of total billed charges,60% of total billed charges for outpatient setting,97.26,757.48,
SCREW 3.5X34MM CORTEX 204.834,6152821,CDM,278,RC,,,Outpatient,,,85.39,85.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.23,60,,40.98,percent of total billed charges,60% of total Billed charges for outpatient setting,72.48,84.88,,57.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.7,50,,34.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.04,75,,51.23,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,50,,34.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,80,,54.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.39,65,,68.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,35,,23.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.23,60,,40.98,percent of total billed charges,60% of total billed charges for outpatient setting,10.96,85.39,
SCREW 3.5X34MM CORTEX 204.834,69169314,CDM,278,RC,C1713,HCPCS,Outpatient,,,153.56,153.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,60,,73.71,percent of total billed charges,60% of total Billed charges for outpatient setting,130.34,84.88,,104.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.17,75,,92.14,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,80,,98.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.75,35,,43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.14,60,,73.71,percent of total billed charges,60% of total billed charges for outpatient setting,19.72,153.56,
SCREW 3.5X34MM CORTICAL / 661434,70000628,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
"SCREW 3.5X34MM CORTICAL, NON LOCK",69161652,CDM,278,RC,,,Outpatient,,,285.17,285.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.1,60,,136.88,percent of total billed charges,60% of total Billed charges for outpatient setting,242.05,84.88,,193.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,142.59,50,,114.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.88,75,,171.1,percent of total billed charges,75% of total billed charges for outpatient setting,142.59,50,,114.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,12.84,,29.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.14,80,,182.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,12.84,,29.3,percent of total billed charges,12.84% of total billed charges,36.62,12.84,,29.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,285.17,65,,228.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.81,35,,79.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171.1,60,,136.88,percent of total billed charges,60% of total billed charges for outpatient setting,36.62,285.17,
SCREW 3.5X34MM NON LK / 657434,70000347,CDM,272,RC,,,Outpatient,,,360.36,360.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.25,70,,201.8,percent of total billed charges,70% of total billed charges for outpatient setting,305.87,84.88,,244.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,180.18,50,,144.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.27,75,,216.22,percent of total billed charges,75% of total billed charges for outpatient setting,252.25,70,,201.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.29,80,,230.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,234.23,65,,187.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.13,35,,100.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,324.32,90,,259.46,percent of total billed charges,90% of total billed charges for outpatient setting,46.27,324.32,
SCREW 3.5X35MM CORTICAL / AR-8835-35,71000519,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X36MM 204.236,6152807,CDM,278,RC,,,Outpatient,,,113.62,113.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.17,60,,54.54,percent of total billed charges,60% of total Billed charges for outpatient setting,96.44,84.88,,77.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.81,50,,45.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.22,75,,68.18,percent of total billed charges,75% of total billed charges for outpatient setting,56.81,50,,45.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.59,12.84,,11.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.9,80,,72.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.59,12.84,,11.67,percent of total billed charges,12.84% of total billed charges,14.59,12.84,,11.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,113.62,65,,90.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.77,35,,31.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.17,60,,54.54,percent of total billed charges,60% of total billed charges for outpatient setting,14.59,113.62,
SCREW 3.5X36MM AXSOS CORT / 661436,1519479,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
"SCREW 3.5X36MM CANCEL,  LOCKING",69161654,CDM,278,RC,,,Outpatient,,,757.48,757.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.49,60,,363.59,percent of total billed charges,60% of total Billed charges for outpatient setting,642.95,84.88,,514.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.11,75,,454.49,percent of total billed charges,75% of total billed charges for outpatient setting,378.74,50,,302.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.98,80,,484.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,97.26,12.84,,77.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,757.48,65,,605.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.12,35,,212.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,454.49,60,,363.59,percent of total billed charges,60% of total billed charges for outpatient setting,97.26,757.48,
SCREW 3.5X36MM CORTEX 204.836,6152822,CDM,278,RC,,,Outpatient,,,153.56,153.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,60,,73.71,percent of total billed charges,60% of total Billed charges for outpatient setting,130.34,84.88,,104.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.17,75,,92.14,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,80,,98.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.75,35,,43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.14,60,,73.71,percent of total billed charges,60% of total billed charges for outpatient setting,19.72,153.56,
SCREW 3.5X36MM LOCKING / 657336,70000643,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.26,663.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.96,60,,318.37,percent of total billed charges,60% of total Billed charges for outpatient setting,562.98,84.88,,450.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.45,75,,397.96,percent of total billed charges,75% of total billed charges for outpatient setting,331.63,50,,265.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,80,,424.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.26,65,,530.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.14,35,,185.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.96,60,,318.37,percent of total billed charges,60% of total billed charges for outpatient setting,85.16,663.26,
SCREW 3.5X36MM LOCKING VA / 02.127.136,1178734,CDM,278,RC,C1713,HCPCS,Outpatient,,,603,603,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.8,60,,289.44,percent of total billed charges,60% of total Billed charges for outpatient setting,511.83,84.88,,409.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.25,75,,361.8,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,50,,241.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,80,,385.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,603,65,,482.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.05,35,,168.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.8,60,,289.44,percent of total billed charges,60% of total billed charges for outpatient setting,77.43,603,
SCREW 3.5X36MM T10 FULL THREAD / 657436,70000618,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X38MM  CORTEX 204.838,6152823,CDM,278,RC,,,Outpatient,,,85.39,85.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.23,60,,40.98,percent of total billed charges,60% of total Billed charges for outpatient setting,72.48,84.88,,57.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.7,50,,34.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.04,75,,51.23,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,50,,34.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,80,,54.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.39,65,,68.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,35,,23.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.23,60,,40.98,percent of total billed charges,60% of total billed charges for outpatient setting,10.96,85.39,
SCREW 3.5X38MM / 40-35038,70000379,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X38MM // 204.238,6152808,CDM,278,RC,,,Outpatient,,,65.74,65.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.44,60,,31.55,percent of total billed charges,60% of total Billed charges for outpatient setting,55.8,84.88,,44.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.31,75,,39.45,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,50,,26.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,80,,42.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,8.44,12.84,,6.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,65,,52.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,35,,18.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,60,,31.55,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,65.74,
"SCREW 3.5X38MM CORTICAL, NON LOCK",69161659,CDM,278,RC,,,Outpatient,,,285.17,285.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.1,60,,136.88,percent of total billed charges,60% of total Billed charges for outpatient setting,242.05,84.88,,193.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,142.59,50,,114.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.88,75,,171.1,percent of total billed charges,75% of total billed charges for outpatient setting,142.59,50,,114.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,12.84,,29.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.14,80,,182.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,12.84,,29.3,percent of total billed charges,12.84% of total billed charges,36.62,12.84,,29.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,285.17,65,,228.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.81,35,,79.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171.1,60,,136.88,percent of total billed charges,60% of total billed charges for outpatient setting,36.62,285.17,
SCREW 3.5X38MM LOCKING / 657338,70000329,CDM,278,RC,C1713,HCPCS,Outpatient,,,1047.97,1047.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.78,60,,503.02,percent of total billed charges,60% of total Billed charges for outpatient setting,889.52,84.88,,711.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.98,75,,628.78,percent of total billed charges,75% of total billed charges for outpatient setting,523.99,50,,419.19,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.56,12.84,,107.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.38,80,,670.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.56,12.84,,107.65,percent of total billed charges,12.84% of total billed charges,134.56,12.84,,107.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.97,65,,838.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.79,35,,293.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.78,60,,503.02,percent of total billed charges,60% of total billed charges for outpatient setting,134.56,1047.97,
SCREW 3.5X38MM NON LCK / 661438,69169779,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X38MM T10 FULL THREAD / 657438,70000619,CDM,278,RC,C1713,HCPCS,Outpatient,,,360.36,360.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.22,60,,172.98,percent of total billed charges,60% of total Billed charges for outpatient setting,305.87,84.88,,244.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.27,75,,216.22,percent of total billed charges,75% of total billed charges for outpatient setting,180.18,50,,144.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.29,80,,230.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,360.36,65,,288.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.13,35,,100.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216.22,60,,172.98,percent of total billed charges,60% of total billed charges for outpatient setting,46.27,360.36,
SCREW 3.5X40MM / 40-35040,70000602,CDM,278,RC,C1713,HCPCS,Outpatient,,,311.69,311.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.01,60,,149.61,percent of total billed charges,60% of total Billed charges for outpatient setting,264.56,84.88,,211.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.77,75,,187.02,percent of total billed charges,75% of total billed charges for outpatient setting,155.85,50,,124.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.35,80,,199.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,311.69,65,,249.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.09,35,,87.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,187.01,60,,149.61,percent of total billed charges,60% of total billed charges for outpatient setting,40.02,311.69,
SCREW 3.5X40MM AXSOS CORT / 661440,1477059,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X40MM CORTICAL / AR-8835-40,71000540,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X40MMCORTEX / 204.840,6152824,CDM,278,RC,,,Outpatient,,,153.56,153.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,60,,73.71,percent of total billed charges,60% of total Billed charges for outpatient setting,130.34,84.88,,104.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.17,75,,92.14,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,80,,98.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.75,35,,43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.14,60,,73.71,percent of total billed charges,60% of total billed charges for outpatient setting,19.72,153.56,
SCREW 3.5X42MM NON LK / 657442,69169287,CDM,278,RC,C1713,HCPCS,Outpatient,,,345.83,345.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.5,60,,166,percent of total billed charges,60% of total Billed charges for outpatient setting,293.54,84.88,,234.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.37,75,,207.5,percent of total billed charges,75% of total billed charges for outpatient setting,172.92,50,,138.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.66,80,,221.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,44.4,12.84,,35.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,345.83,65,,276.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.04,35,,96.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.5,60,,166,percent of total billed charges,60% of total billed charges for outpatient setting,44.4,345.83,
SCREW 3.5X44MM / 40-35028,70000381,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X44MM / 40-35044,70000087,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X44MM LOCK / 40-35644,70000088,CDM,278,RC,C1713,HCPCS,Outpatient,,,956.05,956.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.63,60,,458.9,percent of total billed charges,60% of total Billed charges for outpatient setting,811.5,84.88,,649.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.04,75,,573.63,percent of total billed charges,75% of total billed charges for outpatient setting,478.03,50,,382.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.84,80,,611.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,122.76,12.84,,98.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,956.05,65,,764.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.62,35,,267.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,573.63,60,,458.9,percent of total billed charges,60% of total billed charges for outpatient setting,122.76,956.05,
SCREW 3.5X44MM NON LK / 657444,70000683,CDM,278,RC,C1713,HCPCS,Outpatient,,,360.36,360.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.22,60,,172.98,percent of total billed charges,60% of total Billed charges for outpatient setting,305.87,84.88,,244.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.27,75,,216.22,percent of total billed charges,75% of total billed charges for outpatient setting,180.18,50,,144.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.29,80,,230.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,46.27,12.84,,37.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,360.36,65,,288.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.13,35,,100.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,216.22,60,,172.98,percent of total billed charges,60% of total billed charges for outpatient setting,46.27,360.36,
SCREW 3.5X45MM CORTEX / 204.845,6152825,CDM,278,RC,C1713,HCPCS,Outpatient,,,127.08,127.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.25,60,,61,percent of total billed charges,60% of total Billed charges for outpatient setting,107.87,84.88,,86.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.31,75,,76.25,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,50,,50.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.66,80,,81.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,127.08,65,,101.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,35,,35.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.25,60,,61,percent of total billed charges,60% of total billed charges for outpatient setting,16.32,127.08,
SCREW 3.5X45MM LOCKING / 657345,71000114,CDM,278,RC,C1713,HCPCS,Outpatient,,,631.68,631.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.01,60,,303.21,percent of total billed charges,60% of total Billed charges for outpatient setting,536.17,84.88,,428.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.76,75,,379.01,percent of total billed charges,75% of total billed charges for outpatient setting,315.84,50,,252.67,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.34,80,,404.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,81.11,12.84,,64.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,631.68,65,,505.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.09,35,,176.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,379.01,60,,303.21,percent of total billed charges,60% of total billed charges for outpatient setting,81.11,631.68,
SCREW 3.5X46MM NON LK / 657446,69169606,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X48MM / 40-35042,70000601,CDM,278,RC,C1713,HCPCS,Outpatient,,,311.69,311.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.01,60,,149.61,percent of total billed charges,60% of total Billed charges for outpatient setting,264.56,84.88,,211.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.77,75,,187.02,percent of total billed charges,75% of total billed charges for outpatient setting,155.85,50,,124.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.35,80,,199.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,311.69,65,,249.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.09,35,,87.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,187.01,60,,149.61,percent of total billed charges,60% of total billed charges for outpatient setting,40.02,311.69,
SCREW 3.5X48MM NON LK / 657448,69162592,CDM,278,RC,,,Outpatient,,,566.28,566.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.77,60,,271.82,percent of total billed charges,60% of total Billed charges for outpatient setting,480.66,84.88,,384.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,283.14,50,,226.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.71,75,,339.77,percent of total billed charges,75% of total billed charges for outpatient setting,283.14,50,,226.51,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.71,12.84,,58.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.02,80,,362.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.71,12.84,,58.17,percent of total billed charges,12.84% of total billed charges,72.71,12.84,,58.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,566.28,65,,453.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.2,35,,158.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,339.77,60,,271.82,percent of total billed charges,60% of total billed charges for outpatient setting,72.71,566.28,
SCREW 3.5X48MM NON LOCK / 40-35050,70000600,CDM,278,RC,C1713,HCPCS,Outpatient,,,311.69,311.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.01,60,,149.61,percent of total billed charges,60% of total Billed charges for outpatient setting,264.56,84.88,,211.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.77,75,,187.02,percent of total billed charges,75% of total billed charges for outpatient setting,155.85,50,,124.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.35,80,,199.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,40.02,12.84,,32.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,311.69,65,,249.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.09,35,,87.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,187.01,60,,149.61,percent of total billed charges,60% of total billed charges for outpatient setting,40.02,311.69,
SCREW 3.5X50MM AXSOS CORT / 661450,1477040,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X50MM CORTEX 204.850,6152826,CDM,278,RC,,,Outpatient,,,117.1,117.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.26,60,,56.21,percent of total billed charges,60% of total Billed charges for outpatient setting,99.39,84.88,,79.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.55,50,,46.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.83,75,,70.26,percent of total billed charges,75% of total billed charges for outpatient setting,58.55,50,,46.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,12.84,,12.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.68,80,,74.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,12.84,,12.03,percent of total billed charges,12.84% of total billed charges,15.04,12.84,,12.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.1,65,,93.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,35,,32.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.26,60,,56.21,percent of total billed charges,60% of total billed charges for outpatient setting,15.04,117.1,
SCREW 3.5X50MM NON LK / 657450,69162591,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X50MM NON LOCK / 40-35050,70000359,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X54MM CORTICAL / AR-8835-54,71000510,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 3.5X55MM CRTX / 204.855,70000398,CDM,278,RC,,,Outpatient,,,144.06,144.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.44,60,,69.15,percent of total billed charges,60% of total Billed charges for outpatient setting,122.28,84.88,,97.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.03,50,,57.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.05,75,,86.44,percent of total billed charges,75% of total billed charges for outpatient setting,72.03,50,,57.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.25,80,,92.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,18.5,12.84,,14.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,144.06,65,,115.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.42,35,,40.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86.44,60,,69.15,percent of total billed charges,60% of total billed charges for outpatient setting,18.5,144.06,
SCREW 3.5X55MM LOCKING / 657355,70000324,CDM,278,RC,C1713,HCPCS,Outpatient,,,1047.97,1047.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.78,60,,503.02,percent of total billed charges,60% of total Billed charges for outpatient setting,889.52,84.88,,711.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.98,75,,628.78,percent of total billed charges,75% of total billed charges for outpatient setting,523.99,50,,419.19,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.56,12.84,,107.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.38,80,,670.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.56,12.84,,107.65,percent of total billed charges,12.84% of total billed charges,134.56,12.84,,107.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.97,65,,838.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.79,35,,293.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.78,60,,503.02,percent of total billed charges,60% of total billed charges for outpatient setting,134.56,1047.97,
SCREW 3.5X55MM LOCKING /657355,69169105,CDM,278,RC,C1713,HCPCS,Outpatient,,,635.63,635.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.38,60,,305.1,percent of total billed charges,60% of total Billed charges for outpatient setting,539.52,84.88,,431.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.72,75,,381.38,percent of total billed charges,75% of total billed charges for outpatient setting,317.82,50,,254.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.5,80,,406.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,81.61,12.84,,65.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,635.63,65,,508.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.47,35,,177.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.38,60,,305.1,percent of total billed charges,60% of total billed charges for outpatient setting,81.61,635.63,
SCREW 3.5X55MM NON LCK / 661455,69169337,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X55MM NON LK / 657455,69169493,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X55MM T10 / 40-35055,70000375,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW 3.5X56MM LOCKING VA / 02.127.156,1178743,CDM,278,RC,C1713,HCPCS,Outpatient,,,603,603,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.8,60,,289.44,percent of total billed charges,60% of total Billed charges for outpatient setting,511.83,84.88,,409.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.25,75,,361.8,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,50,,241.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,80,,385.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,603,65,,482.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.05,35,,168.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.8,60,,289.44,percent of total billed charges,60% of total billed charges for outpatient setting,77.43,603,
SCREW 3.5X60MM AXSOS CORT / 661460,1624182,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X60MM LOCKING VA / 02.127.160,1178744,CDM,278,RC,C1713,HCPCS,Outpatient,,,603,603,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.8,60,,289.44,percent of total billed charges,60% of total Billed charges for outpatient setting,511.83,84.88,,409.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.25,75,,361.8,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,50,,241.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,80,,385.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,77.43,12.84,,61.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,603,65,,482.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.05,35,,168.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.8,60,,289.44,percent of total billed charges,60% of total billed charges for outpatient setting,77.43,603,
SCREW 3.5X60MM NON LK / 657460,69169494,CDM,278,RC,C1713,HCPCS,Outpatient,,,315.04,315.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.02,60,,151.22,percent of total billed charges,60% of total Billed charges for outpatient setting,267.41,84.88,,213.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.28,75,,189.02,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,50,,126.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.03,80,,201.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,40.45,12.84,,32.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,315.04,65,,252.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.26,35,,88.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.02,60,,151.22,percent of total billed charges,60% of total billed charges for outpatient setting,40.45,315.04,
SCREW 3.5X65MM CORTEX / 661465,69169409,CDM,278,RC,C1713,HCPCS,Outpatient,,,195.3,195.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.18,60,,93.74,percent of total billed charges,60% of total Billed charges for outpatient setting,165.77,84.88,,132.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.48,75,,117.18,percent of total billed charges,75% of total billed charges for outpatient setting,97.65,50,,78.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.08,12.84,,20.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.24,80,,124.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.08,12.84,,20.06,percent of total billed charges,12.84% of total billed charges,25.08,12.84,,20.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,195.3,65,,156.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.36,35,,54.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,117.18,60,,93.74,percent of total billed charges,60% of total billed charges for outpatient setting,25.08,195.3,
SCREW 3.5X65MM LOCKING / 212.125,174279,CDM,278,RC,C1713,HCPCS,Outpatient,,,501,501,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.6,60,,240.48,percent of total billed charges,60% of total Billed charges for outpatient setting,425.25,84.88,,340.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.75,75,,300.6,percent of total billed charges,75% of total billed charges for outpatient setting,250.5,50,,200.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,12.84,,51.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.8,80,,320.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,12.84,,51.46,percent of total billed charges,12.84% of total billed charges,64.33,12.84,,51.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,501,65,,400.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.35,35,,140.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.6,60,,240.48,percent of total billed charges,60% of total billed charges for outpatient setting,64.33,501,
SCREW 3.5X6MM NON LOCK / 657406,71000281,CDM,278,RC,C1713,HCPCS,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 3.5X70MM AXSOS CORT / 661470,1530074,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X70MM CRTX / 204.870,69169308,CDM,278,RC,C1713,HCPCS,Outpatient,,,153.56,153.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,60,,73.71,percent of total billed charges,60% of total Billed charges for outpatient setting,130.34,84.88,,104.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.17,75,,92.14,percent of total billed charges,75% of total billed charges for outpatient setting,76.78,50,,61.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,80,,98.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,19.72,12.84,,15.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.75,35,,43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.14,60,,73.71,percent of total billed charges,60% of total billed charges for outpatient setting,19.72,153.56,
SCREW 3.5X70MM LOCKING / 212.126,69169309,CDM,278,RC,C1713,HCPCS,Outpatient,,,674.1,674.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,60,,323.57,percent of total billed charges,60% of total Billed charges for outpatient setting,572.18,84.88,,457.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.58,75,,404.46,percent of total billed charges,75% of total billed charges for outpatient setting,337.05,50,,269.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,80,,431.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,674.1,65,,539.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.94,35,,188.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,404.46,60,,323.57,percent of total billed charges,60% of total billed charges for outpatient setting,86.55,674.1,
SCREW 3.5X75MM AXSOS CORT / 661475,1457890,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X75MM LOCKING / 212.127,69169311,CDM,278,RC,C1713,HCPCS,Outpatient,,,501,501,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.6,60,,240.48,percent of total billed charges,60% of total Billed charges for outpatient setting,425.25,84.88,,340.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.75,75,,300.6,percent of total billed charges,75% of total billed charges for outpatient setting,250.5,50,,200.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,12.84,,51.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.8,80,,320.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,12.84,,51.46,percent of total billed charges,12.84% of total billed charges,64.33,12.84,,51.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,501,65,,400.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.35,35,,140.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.6,60,,240.48,percent of total billed charges,60% of total billed charges for outpatient setting,64.33,501,
SCREW 3.5X80MM AXSOS CORT / 661480,1477042,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X80MM LOCKING / 212.128,69169312,CDM,278,RC,C1713,HCPCS,Outpatient,,,674.1,674.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,60,,323.57,percent of total billed charges,60% of total Billed charges for outpatient setting,572.18,84.88,,457.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.58,75,,404.46,percent of total billed charges,75% of total billed charges for outpatient setting,337.05,50,,269.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,80,,431.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,674.1,65,,539.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.94,35,,188.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,404.46,60,,323.57,percent of total billed charges,60% of total billed charges for outpatient setting,86.55,674.1,
SCREW 3.5X85MM AXSOS CORT / 661485,1477043,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.5X85MM LOCKING / 212.129,69169310,CDM,278,RC,C1713,HCPCS,Outpatient,,,674.1,674.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,60,,323.57,percent of total billed charges,60% of total Billed charges for outpatient setting,572.18,84.88,,457.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.58,75,,404.46,percent of total billed charges,75% of total billed charges for outpatient setting,337.05,50,,269.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,80,,431.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,86.55,12.84,,69.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,674.1,65,,539.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.94,35,,188.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,404.46,60,,323.57,percent of total billed charges,60% of total billed charges for outpatient setting,86.55,674.1,
SCREW 3.5X8MM LOCKING / 657308,70000328,CDM,278,RC,C1713,HCPCS,Outpatient,,,697.14,697.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.28,60,,334.62,percent of total billed charges,60% of total Billed charges for outpatient setting,591.73,84.88,,473.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.86,75,,418.29,percent of total billed charges,75% of total billed charges for outpatient setting,348.57,50,,278.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.71,80,,446.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,697.14,65,,557.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244,35,,195.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,418.28,60,,334.62,percent of total billed charges,60% of total billed charges for outpatient setting,89.51,697.14,
SCREW 3.5X8MM NON LOCK / 657408,1627168,CDM,278,RC,C1713,HCPCS,Outpatient,,,343.68,343.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.21,60,,164.97,percent of total billed charges,60% of total Billed charges for outpatient setting,291.72,84.88,,233.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,75,,206.21,percent of total billed charges,75% of total billed charges for outpatient setting,171.84,50,,137.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.94,80,,219.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,44.13,12.84,,35.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,343.68,65,,274.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,35,,96.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.21,60,,164.97,percent of total billed charges,60% of total billed charges for outpatient setting,44.13,343.68,
SCREW 3.5X90MM AXSOS CORT / 661490,1602929,CDM,278,RC,C1713,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,60,,83.52,percent of total billed charges,60% of total Billed charges for outpatient setting,147.69,84.88,,118.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,75,,104.4,percent of total billed charges,75% of total billed charges for outpatient setting,87,50,,69.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,80,,111.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,22.34,12.84,,17.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174,65,,139.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,35,,48.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.4,60,,83.52,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,174,
SCREW 3.6 x 16MM  184.112,69169113,CDM,278,RC,C1713,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
SCREW 3.6 x 16MM  184.116,69169112,CDM,278,RC,C1713,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
SCREW 3.6X14MM / 184.114,69162528,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 3.6X14MM VARIABLE / 184.154,69162066,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 3.6X16MM VARIABLE / 184.156,69162187,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 3.70X40MM LISFRANC / 48503740,577931,CDM,278,RC,C1713,HCPCS,Outpatient,,,2088,2088,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.8,60,,1002.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1772.29,84.88,,1417.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1566,75,,1252.8,percent of total billed charges,75% of total billed charges for outpatient setting,1044,50,,835.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.1,12.84,,214.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1670.4,80,,1336.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.1,12.84,,214.48,percent of total billed charges,12.84% of total billed charges,268.1,12.84,,214.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2088,65,,1670.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.8,35,,584.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1252.8,60,,1002.24,percent of total billed charges,60% of total billed charges for outpatient setting,268.1,2088,
SCREW 33MM MIS HEADED / 00-5983-040-33,71000293,CDM,278,RC,C1713,HCPCS,Outpatient,,,340,340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204,60,,163.2,percent of total billed charges,60% of total Billed charges for outpatient setting,288.59,84.88,,230.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255,75,,204,percent of total billed charges,75% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272,80,,217.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,340,65,,272,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,35,,95.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204,60,,163.2,percent of total billed charges,60% of total billed charges for outpatient setting,43.66,340,
SCREW 4.0X 45MM CAN THRD 206.045,6152840,CDM,278,RC,,,Outpatient,,,117.1,117.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.26,60,,56.21,percent of total billed charges,60% of total Billed charges for outpatient setting,99.39,84.88,,79.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.55,50,,46.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.83,75,,70.26,percent of total billed charges,75% of total billed charges for outpatient setting,58.55,50,,46.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,12.84,,12.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.68,80,,74.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,12.84,,12.03,percent of total billed charges,12.84% of total billed charges,15.04,12.84,,12.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.1,65,,93.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,35,,32.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.26,60,,56.21,percent of total billed charges,60% of total billed charges for outpatient setting,15.04,117.1,
SCREW 4.0X10MM CAN 207.010,6152844,CDM,278,RC,,,Outpatient,,,89.23,89.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,60,,42.83,percent of total billed charges,60% of total Billed charges for outpatient setting,75.74,84.88,,60.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.92,75,,53.54,percent of total billed charges,75% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.38,80,,57.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.23,65,,71.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,35,,24.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.54,60,,42.83,percent of total billed charges,60% of total billed charges for outpatient setting,11.46,89.23,
SCREW 4.0X10MM CAN THRD 206.010,6152827,CDM,278,RC,,,Outpatient,,,143.17,143.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,60,,68.72,percent of total billed charges,60% of total Billed charges for outpatient setting,121.52,84.88,,97.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,75,,85.9,percent of total billed charges,75% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,80,,91.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.11,35,,40.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.9,60,,68.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.38,143.17,
SCREW 4.0X10MM NONLOCK / AR-8840-10,71000512,CDM,278,RC,C1713,HCPCS,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,60,,88.2,percent of total billed charges,60% of total Billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.75,65,,147,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.25,60,,88.2,percent of total billed charges,60% of total billed charges for outpatient setting,23.59,183.75,
SCREW 4.0X12MM CAN 207.012,6152845,CDM,278,RC,,,Outpatient,,,89.23,89.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,60,,42.83,percent of total billed charges,60% of total Billed charges for outpatient setting,75.74,84.88,,60.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.92,75,,53.54,percent of total billed charges,75% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.38,80,,57.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.23,65,,71.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,35,,24.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.54,60,,42.83,percent of total billed charges,60% of total billed charges for outpatient setting,11.46,89.23,
SCREW 4.0X12MM CAN THRD 206.012,6152828,CDM,278,RC,,,Outpatient,,,143.17,143.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,60,,68.72,percent of total billed charges,60% of total Billed charges for outpatient setting,121.52,84.88,,97.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,75,,85.9,percent of total billed charges,75% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,80,,91.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.11,35,,40.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.9,60,,68.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.38,143.17,
SCREW 4.0X14MM CAN 207.014,6152846,CDM,278,RC,,,Outpatient,,,89.23,89.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,60,,42.83,percent of total billed charges,60% of total Billed charges for outpatient setting,75.74,84.88,,60.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.92,75,,53.54,percent of total billed charges,75% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.38,80,,57.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.23,65,,71.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,35,,24.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.54,60,,42.83,percent of total billed charges,60% of total billed charges for outpatient setting,11.46,89.23,
SCREW 4.0X14MM CAN THRD // 206.014,6152829,CDM,278,RC,,,Outpatient,,,151.2,151.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,60,,72.58,percent of total billed charges,60% of total Billed charges for outpatient setting,128.34,84.88,,102.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.6,50,,60.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,75,,90.72,percent of total billed charges,75% of total billed charges for outpatient setting,75.6,50,,60.48,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,12.84,,15.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,80,,96.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,12.84,,15.53,percent of total billed charges,12.84% of total billed charges,19.41,12.84,,15.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,151.2,65,,120.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,35,,42.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,90.72,60,,72.58,percent of total billed charges,60% of total billed charges for outpatient setting,19.41,151.2,
SCREW 4.0X14MM CANNULATED  207.614,69161420,CDM,278,RC,,,Outpatient,,,1109.04,1109.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.42,60,,532.34,percent of total billed charges,60% of total Billed charges for outpatient setting,941.35,84.88,,753.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,554.52,50,,443.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,831.78,75,,665.42,percent of total billed charges,75% of total billed charges for outpatient setting,554.52,50,,443.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.4,12.84,,113.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.23,80,,709.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.4,12.84,,113.92,percent of total billed charges,12.84% of total billed charges,142.4,12.84,,113.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1109.04,65,,887.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.16,35,,310.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,665.42,60,,532.34,percent of total billed charges,60% of total billed charges for outpatient setting,142.4,1109.04,
SCREW 4.0X14MM TI CAN STRYKER / 604614S,70000158,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X16MM CAN 207.016,6152847,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 4.0X16MM CAN THRD / 206.016,6152830,CDM,278,RC,C1713,HCPCS,Outpatient,,,104.58,104.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.75,60,,50.2,percent of total billed charges,60% of total Billed charges for outpatient setting,88.77,84.88,,71.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.44,75,,62.75,percent of total billed charges,75% of total billed charges for outpatient setting,52.29,50,,41.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.66,80,,66.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.58,65,,83.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.6,35,,29.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.75,60,,50.2,percent of total billed charges,60% of total billed charges for outpatient setting,13.43,104.58,
SCREW 4.0X18MM CAN 207.018,6152848,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 4.0X18MM CAN THRD / 206.018,6152831,CDM,278,RC,C1713,HCPCS,Outpatient,,,119.82,119.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.89,60,,57.51,percent of total billed charges,60% of total Billed charges for outpatient setting,101.7,84.88,,81.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.87,75,,71.9,percent of total billed charges,75% of total billed charges for outpatient setting,59.91,50,,47.93,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,12.84,,12.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.86,80,,76.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,12.84,,12.3,percent of total billed charges,12.84% of total billed charges,15.38,12.84,,12.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.82,65,,95.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.94,35,,33.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.89,60,,57.51,percent of total billed charges,60% of total billed charges for outpatient setting,15.38,119.82,
SCREW 4.0X20MM CAN 207.020,6152849,CDM,278,RC,,,Outpatient,,,89.23,89.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.54,60,,42.83,percent of total billed charges,60% of total Billed charges for outpatient setting,75.74,84.88,,60.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.92,75,,53.54,percent of total billed charges,75% of total billed charges for outpatient setting,44.62,50,,35.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.38,80,,57.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,11.46,12.84,,9.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.23,65,,71.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,35,,24.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.54,60,,42.83,percent of total billed charges,60% of total billed charges for outpatient setting,11.46,89.23,
SCREW 4.0X20MM CAN THRD / 206.020,6152832,CDM,278,RC,C1713,HCPCS,Outpatient,,,104.58,104.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.75,60,,50.2,percent of total billed charges,60% of total Billed charges for outpatient setting,88.77,84.88,,71.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.44,75,,62.75,percent of total billed charges,75% of total billed charges for outpatient setting,52.29,50,,41.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.66,80,,66.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.58,65,,83.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.6,35,,29.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.75,60,,50.2,percent of total billed charges,60% of total billed charges for outpatient setting,13.43,104.58,
SCREW 4.0X20MM CANNULATED /  207.620,69169328,CDM,278,RC,,,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X20MM TI CAN STRYKER / 604620S,70000159,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X22MM CAN 207.022,6152850,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 4.0X22MM CAN THRD 206.022,6152833,CDM,278,RC,,,Outpatient,,,157.01,157.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.21,60,,75.37,percent of total billed charges,60% of total Billed charges for outpatient setting,133.27,84.88,,106.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.76,75,,94.21,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.61,80,,100.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.01,65,,125.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,35,,43.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.21,60,,75.37,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,157.01,
SCREW 4.0X24MM CAN 207.024,6152851,CDM,278,RC,,,Outpatient,,,143.17,143.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,60,,68.72,percent of total billed charges,60% of total Billed charges for outpatient setting,121.52,84.88,,97.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,75,,85.9,percent of total billed charges,75% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,80,,91.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.11,35,,40.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.9,60,,68.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.38,143.17,
SCREW 4.0X24MM CAN THRD  206.024,6152834,CDM,278,RC,,,Outpatient,,,157.01,157.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.21,60,,75.37,percent of total billed charges,60% of total Billed charges for outpatient setting,133.27,84.88,,106.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.76,75,,94.21,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.61,80,,100.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.01,65,,125.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,35,,43.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.21,60,,75.37,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,157.01,
SCREW 4.0X24MM TI CAN STRYKER / 604624S,69162886,CDM,278,RC,C1713,HCPCS,Outpatient,,,647.17,647.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,60,,310.64,percent of total billed charges,60% of total Billed charges for outpatient setting,549.32,84.88,,439.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.38,75,,388.3,percent of total billed charges,75% of total billed charges for outpatient setting,323.59,50,,258.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.74,80,,414.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,647.17,65,,517.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.51,35,,181.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.3,60,,310.64,percent of total billed charges,60% of total billed charges for outpatient setting,83.1,647.17,
SCREW 4.0X24MM TI LOCKING / 04.005.414,70000416,CDM,278,RC,C1713,HCPCS,Outpatient,,,749.09,749.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.45,60,,359.56,percent of total billed charges,60% of total Billed charges for outpatient setting,635.83,84.88,,508.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.82,75,,449.46,percent of total billed charges,75% of total billed charges for outpatient setting,374.55,50,,299.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.27,80,,479.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,749.09,65,,599.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.18,35,,209.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.45,60,,359.56,percent of total billed charges,60% of total billed charges for outpatient setting,96.18,749.09,
SCREW 4.0X26MM CAN  207.026,6152852,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 4.0X26MM CAN THRD 206.026,6152835,CDM,278,RC,,,Outpatient,,,93.06,93.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,60,,44.67,percent of total billed charges,60% of total Billed charges for outpatient setting,78.99,84.88,,63.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.8,75,,55.84,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,80,,59.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.06,65,,74.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,35,,26.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.84,60,,44.67,percent of total billed charges,60% of total billed charges for outpatient setting,11.95,93.06,
SCREW 4.0X26MM CANNULATED  207.626,69169329,CDM,278,RC,,,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X26MM TI CAN STRYKER / 604626S,69162887,CDM,278,RC,C1713,HCPCS,Outpatient,,,647.17,647.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,60,,310.64,percent of total billed charges,60% of total Billed charges for outpatient setting,549.32,84.88,,439.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.38,75,,388.3,percent of total billed charges,75% of total billed charges for outpatient setting,323.59,50,,258.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.74,80,,414.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,647.17,65,,517.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.51,35,,181.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.3,60,,310.64,percent of total billed charges,60% of total billed charges for outpatient setting,83.1,647.17,
SCREW 4.0X28MM CAN 207.028,6152853,CDM,278,RC,,,Outpatient,,,143.17,143.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,60,,68.72,percent of total billed charges,60% of total Billed charges for outpatient setting,121.52,84.88,,97.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,75,,85.9,percent of total billed charges,75% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,80,,91.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.11,35,,40.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.9,60,,68.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.38,143.17,
SCREW 4.0X28MM CAN THRD 206.028,6152836,CDM,278,RC,,,Outpatient,,,157.01,157.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.21,60,,75.37,percent of total billed charges,60% of total Billed charges for outpatient setting,133.27,84.88,,106.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.76,75,,94.21,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.61,80,,100.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.01,65,,125.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,35,,43.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.21,60,,75.37,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,157.01,
SCREW 4.0X28MM QUARTEX / 1149.4028,69162783,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 4.0X28MM TI LOCKING / 04.005.418,70000415,CDM,278,RC,C1713,HCPCS,Outpatient,,,749.09,749.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.45,60,,359.56,percent of total billed charges,60% of total Billed charges for outpatient setting,635.83,84.88,,508.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.82,75,,449.46,percent of total billed charges,75% of total billed charges for outpatient setting,374.55,50,,299.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.27,80,,479.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,749.09,65,,599.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.18,35,,209.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.45,60,,359.56,percent of total billed charges,60% of total billed charges for outpatient setting,96.18,749.09,
SCREW 4.0X30MM CAN 207.030,6152854,CDM,278,RC,,,Outpatient,,,157.01,157.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.21,60,,75.37,percent of total billed charges,60% of total Billed charges for outpatient setting,133.27,84.88,,106.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.76,75,,94.21,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.61,80,,100.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.01,65,,125.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,35,,43.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.21,60,,75.37,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,157.01,
SCREW 4.0X30MM CAN THRD  206.030,6152837,CDM,278,RC,,,Outpatient,,,93.06,93.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,60,,44.67,percent of total billed charges,60% of total Billed charges for outpatient setting,78.99,84.88,,63.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.8,75,,55.84,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,80,,59.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.06,65,,74.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,35,,26.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.84,60,,44.67,percent of total billed charges,60% of total billed charges for outpatient setting,11.95,93.06,
SCREW 4.0X30MM CANN SHT / AR-8840C-30,70000505,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
SCREW 4.0X30MM TI CAN STRYKER / 604630S,70000157,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X32MM LOCKING / 661032,69169412,CDM,278,RC,C1713,HCPCS,Outpatient,,,768.77,768.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.26,60,,369.01,percent of total billed charges,60% of total Billed charges for outpatient setting,652.53,84.88,,522.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.58,75,,461.26,percent of total billed charges,75% of total billed charges for outpatient setting,384.39,50,,307.51,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.71,12.84,,78.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.02,80,,492.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.71,12.84,,78.97,percent of total billed charges,12.84% of total billed charges,98.71,12.84,,78.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,768.77,65,,615.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.07,35,,215.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,461.26,60,,369.01,percent of total billed charges,60% of total billed charges for outpatient setting,98.71,768.77,
SCREW 4.0X32MM TI CAN STRYKER / 604650S,70000156,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X34MM CANNLTED / 6047345,70000129,CDM,278,RC,C1713,HCPCS,Outpatient,,,1002.33,1002.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.4,60,,481.12,percent of total billed charges,60% of total Billed charges for outpatient setting,850.78,84.88,,680.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,751.75,75,,601.4,percent of total billed charges,75% of total billed charges for outpatient setting,501.17,50,,400.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,12.84,,102.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.86,80,,641.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,12.84,,102.96,percent of total billed charges,12.84% of total billed charges,128.7,12.84,,102.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1002.33,65,,801.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.82,35,,280.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,601.4,60,,481.12,percent of total billed charges,60% of total billed charges for outpatient setting,128.7,1002.33,
SCREW 4.0X34MM CANNULATED / 1437634,69161593,CDM,278,RC,C1713,HCPCS,Outpatient,,,984.73,984.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.84,60,,472.67,percent of total billed charges,60% of total Billed charges for outpatient setting,835.84,84.88,,668.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.55,75,,590.84,percent of total billed charges,75% of total billed charges for outpatient setting,492.37,50,,393.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.78,80,,630.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,984.73,65,,787.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.66,35,,275.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,590.84,60,,472.67,percent of total billed charges,60% of total billed charges for outpatient setting,126.44,984.73,
SCREW 4.0X34MM TI CAN STRYKER / 604634S,70000171,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X35MM CAN 207.035,6152855,CDM,278,RC,,,Outpatient,,,157.01,157.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.21,60,,75.37,percent of total billed charges,60% of total Billed charges for outpatient setting,133.27,84.88,,106.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.76,75,,94.21,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,50,,62.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.61,80,,100.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.01,65,,125.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,35,,43.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.21,60,,75.37,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,157.01,
SCREW 4.0X35MM CAN THRD 206.035,6152838,CDM,278,RC,,,Outpatient,,,93.06,93.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,60,,44.67,percent of total billed charges,60% of total Billed charges for outpatient setting,78.99,84.88,,63.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.8,75,,55.84,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,80,,59.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.06,65,,74.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,35,,26.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.84,60,,44.67,percent of total billed charges,60% of total billed charges for outpatient setting,11.95,93.06,
SCREW 4.0X35MM CANN SHT / AR-8840C-35,69162765,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
SCREW 4.0X36MM ASNIS CANN / 663036,2227695,CDM,278,RC,C1713,HCPCS,Outpatient,,,2298.96,2298.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.38,60,,1103.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1951.36,84.88,,1561.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1724.22,75,,1379.38,percent of total billed charges,75% of total billed charges for outpatient setting,1149.48,50,,919.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.19,12.84,,236.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.17,80,,1471.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.19,12.84,,236.15,percent of total billed charges,12.84% of total billed charges,295.19,12.84,,236.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2413.91,105,,1931.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.64,35,,643.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1379.38,60,,1103.5,percent of total billed charges,60% of total billed charges for outpatient setting,295.19,2413.91,
SCREW 4.0X36MM TI CAN STRYKER / 604636S,70000170,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X38MM CANNULATED / 207.638,416970,CDM,278,RC,C1713,HCPCS,Outpatient,,,900.6,900.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.36,60,,432.29,percent of total billed charges,60% of total Billed charges for outpatient setting,764.43,84.88,,611.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.45,75,,540.36,percent of total billed charges,75% of total billed charges for outpatient setting,450.3,50,,360.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.48,80,,576.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900.6,65,,720.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.21,35,,252.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540.36,60,,432.29,percent of total billed charges,60% of total billed charges for outpatient setting,115.64,900.6,
SCREW 4.0X38MM TI CAN STRYKER / 604638S,588033,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X40MM AXSOS LOCK / 661040,70000629,CDM,278,RC,C1713,HCPCS,Outpatient,,,732.16,732.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.3,60,,351.44,percent of total billed charges,60% of total Billed charges for outpatient setting,621.46,84.88,,497.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.12,75,,439.3,percent of total billed charges,75% of total billed charges for outpatient setting,366.08,50,,292.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.73,80,,468.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,732.16,65,,585.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.26,35,,205.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,439.3,60,,351.44,percent of total billed charges,60% of total billed charges for outpatient setting,94.01,732.16,
SCREW 4.0X40MM CAN 207.040,6152856,CDM,278,RC,,,Outpatient,,,143.17,143.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.9,60,,68.72,percent of total billed charges,60% of total Billed charges for outpatient setting,121.52,84.88,,97.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,75,,85.9,percent of total billed charges,75% of total billed charges for outpatient setting,71.59,50,,57.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,80,,91.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,18.38,12.84,,14.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,143.17,65,,114.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.11,35,,40.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.9,60,,68.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.38,143.17,
SCREW 4.0X40MM CAN THRD 206.040,6152839,CDM,278,RC,,,Outpatient,,,93.06,93.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,60,,44.67,percent of total billed charges,60% of total Billed charges for outpatient setting,78.99,84.88,,63.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.8,75,,55.84,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,80,,59.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.06,65,,74.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,35,,26.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.84,60,,44.67,percent of total billed charges,60% of total billed charges for outpatient setting,11.95,93.06,
SCREW 4.0X40MM CANN / 325040S,70000470,CDM,278,RC,C1713,HCPCS,Outpatient,,,1000.17,1000.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.1,60,,480.08,percent of total billed charges,60% of total Billed charges for outpatient setting,848.94,84.88,,679.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.13,75,,600.1,percent of total billed charges,75% of total billed charges for outpatient setting,500.09,50,,400.07,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.14,80,,640.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,128.42,12.84,,102.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1000.17,65,,800.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.06,35,,280.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,600.1,60,,480.08,percent of total billed charges,60% of total billed charges for outpatient setting,128.42,1000.17,
SCREW 4.0X40MM CANN LGTHR / AR-8840CL-40,71000585,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4.0X40MM CANNULATED / 207.640,69169164,CDM,278,RC,C1713,HCPCS,Outpatient,,,900.6,900.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.36,60,,432.29,percent of total billed charges,60% of total Billed charges for outpatient setting,764.43,84.88,,611.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.45,75,,540.36,percent of total billed charges,75% of total billed charges for outpatient setting,450.3,50,,360.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.48,80,,576.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900.6,65,,720.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.21,35,,252.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540.36,60,,432.29,percent of total billed charges,60% of total billed charges for outpatient setting,115.64,900.6,
SCREW 4.0X40MM TI CAN STRYKER / 604640S,70000169,CDM,278,RC,C1713,HCPCS,Outpatient,,,542.64,542.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.58,60,,260.46,percent of total billed charges,60% of total Billed charges for outpatient setting,460.59,84.88,,368.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.98,75,,325.58,percent of total billed charges,75% of total billed charges for outpatient setting,271.32,50,,217.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.11,80,,347.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,542.64,65,,434.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.92,35,,151.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.58,60,,260.46,percent of total billed charges,60% of total billed charges for outpatient setting,69.67,542.64,
SCREW 4.0X42MM CNNLTED / 604642S,70000484,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X44MM AXSOS LOCK / 661044,1611473,CDM,278,RC,C1713,HCPCS,Outpatient,,,732.16,732.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.3,60,,351.44,percent of total billed charges,60% of total Billed charges for outpatient setting,621.46,84.88,,497.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.12,75,,439.3,percent of total billed charges,75% of total billed charges for outpatient setting,366.08,50,,292.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.73,80,,468.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,732.16,65,,585.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.26,35,,205.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,439.3,60,,351.44,percent of total billed charges,60% of total billed charges for outpatient setting,94.01,732.16,
SCREW 4.0X44MM CANNLATED / 604644S,69162651,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X44MM CANNULATED  207.644,69159590,CDM,278,RC,,,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X44MM LNG THR CANLTED  207.744,69169235,CDM,278,RC,C1713,HCPCS,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X44MM TI LOCKING / 04.005.434,70000409,CDM,278,RC,,,Outpatient,,,749.09,749.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.45,60,,359.56,percent of total billed charges,60% of total Billed charges for outpatient setting,635.83,84.88,,508.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,374.55,50,,299.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,561.82,75,,449.46,percent of total billed charges,75% of total billed charges for outpatient setting,374.55,50,,299.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.27,80,,479.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,749.09,65,,599.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.18,35,,209.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.45,60,,359.56,percent of total billed charges,60% of total billed charges for outpatient setting,96.18,749.09,
SCREW 4.0X45MM CAN 207.045,6152857,CDM,278,RC,,,Outpatient,,,131.23,131.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,60,,62.99,percent of total billed charges,60% of total Billed charges for outpatient setting,111.39,84.88,,89.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,75,,78.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.62,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,80,,83.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,65,,104.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.93,35,,36.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.74,60,,62.99,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.23,
SCREW 4.0X45MM CANN LNG / AR-8840CL-45,71000835,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4.0X45MM CANN SHT / AR-8840C-45,71000584,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4.0X46MM AXSOS LOCK / 661046,1457886,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X46MM CANN SHRT / 207.646,69169820,CDM,278,RC,C1713,HCPCS,Outpatient,,,900.6,900.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.36,60,,432.29,percent of total billed charges,60% of total Billed charges for outpatient setting,764.43,84.88,,611.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.45,75,,540.36,percent of total billed charges,75% of total billed charges for outpatient setting,450.3,50,,360.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.48,80,,576.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900.6,65,,720.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.21,35,,252.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540.36,60,,432.29,percent of total billed charges,60% of total billed charges for outpatient setting,115.64,900.6,
SCREW 4.0X46MM TI CAN STRYKER / 604646S,70000485,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X48MM AXSOS LOCK / 661048,69169341,CDM,278,RC,C1713,HCPCS,Outpatient,,,744.74,744.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.84,60,,357.47,percent of total billed charges,60% of total Billed charges for outpatient setting,632.14,84.88,,505.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.56,75,,446.85,percent of total billed charges,75% of total billed charges for outpatient setting,372.37,50,,297.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.79,80,,476.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,744.74,65,,595.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.66,35,,208.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.84,60,,357.47,percent of total billed charges,60% of total billed charges for outpatient setting,95.62,744.74,
SCREW 4.0X48MM CANN / 207.650,69161431,CDM,278,RC,C1713,HCPCS,Outpatient,,,786,786,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.6,60,,377.28,percent of total billed charges,60% of total Billed charges for outpatient setting,667.16,84.88,,533.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.5,75,,471.6,percent of total billed charges,75% of total billed charges for outpatient setting,393,50,,314.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.92,12.84,,80.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.8,80,,503.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.92,12.84,,80.74,percent of total billed charges,12.84% of total billed charges,100.92,12.84,,80.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,786,65,,628.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.1,35,,220.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,471.6,60,,377.28,percent of total billed charges,60% of total billed charges for outpatient setting,100.92,786,
SCREW 4.0x48MM CANNULATED 207.648,69160844,CDM,278,RC,C1769,HCPCS,Outpatient,,,1087.3,1087.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.38,60,,521.9,percent of total billed charges,60% of total Billed charges for outpatient setting,922.9,84.88,,738.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.48,75,,652.38,percent of total billed charges,75% of total billed charges for outpatient setting,543.65,50,,434.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.61,12.84,,111.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.84,80,,695.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.61,12.84,,111.69,percent of total billed charges,12.84% of total billed charges,139.61,12.84,,111.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1087.3,65,,869.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.56,35,,304.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,652.38,60,,521.9,percent of total billed charges,60% of total billed charges for outpatient setting,139.61,1087.3,
SCREW 4.0X48MM TI LOCKING / 04.005.438,70000408,CDM,278,RC,C1713,HCPCS,Outpatient,,,749.09,749.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.45,60,,359.56,percent of total billed charges,60% of total Billed charges for outpatient setting,635.83,84.88,,508.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.82,75,,449.46,percent of total billed charges,75% of total billed charges for outpatient setting,374.55,50,,299.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.27,80,,479.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,96.18,12.84,,76.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,749.09,65,,599.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.18,35,,209.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.45,60,,359.56,percent of total billed charges,60% of total billed charges for outpatient setting,96.18,749.09,
SCREW 4.0X50 CANNULATED 1437650,69162865,CDM,278,RC,C1713,HCPCS,Outpatient,,,748.4,748.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.04,60,,359.23,percent of total billed charges,60% of total Billed charges for outpatient setting,635.24,84.88,,508.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.3,75,,449.04,percent of total billed charges,75% of total billed charges for outpatient setting,374.2,50,,299.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.09,12.84,,76.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.72,80,,478.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.09,12.84,,76.87,percent of total billed charges,12.84% of total billed charges,96.09,12.84,,76.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,748.4,65,,598.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.94,35,,209.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,449.04,60,,359.23,percent of total billed charges,60% of total billed charges for outpatient setting,96.09,748.4,
SCREW 4.0X50MM AXSOS LOCK / 661050,69169340,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X50MM CAN 207.050,6152858,CDM,278,RC,,,Outpatient,,,156.98,156.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.19,60,,75.35,percent of total billed charges,60% of total Billed charges for outpatient setting,133.24,84.88,,106.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.49,50,,62.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.74,75,,94.19,percent of total billed charges,75% of total billed charges for outpatient setting,78.49,50,,62.79,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.58,80,,100.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,20.16,12.84,,16.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156.98,65,,125.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.94,35,,43.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.19,60,,75.35,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,156.98,
SCREW 4.0X50MM CAN THRD 206.050,6152841,CDM,278,RC,,,Outpatient,,,121.01,121.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.61,60,,58.09,percent of total billed charges,60% of total Billed charges for outpatient setting,102.71,84.88,,82.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,60.51,50,,48.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.76,75,,72.61,percent of total billed charges,75% of total billed charges for outpatient setting,60.51,50,,48.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.54,12.84,,12.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.81,80,,77.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.54,12.84,,12.43,percent of total billed charges,12.84% of total billed charges,15.54,12.84,,12.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,121.01,65,,96.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.35,35,,33.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.61,60,,58.09,percent of total billed charges,60% of total billed charges for outpatient setting,15.54,121.01,
SCREW 4.0X50MM TI CAN STRYKER / 604650S,69161565,CDM,278,RC,C1713,HCPCS,Outpatient,,,542.64,542.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.58,60,,260.46,percent of total billed charges,60% of total Billed charges for outpatient setting,460.59,84.88,,368.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.98,75,,325.58,percent of total billed charges,75% of total billed charges for outpatient setting,271.32,50,,217.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.11,80,,347.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,542.64,65,,434.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.92,35,,151.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.58,60,,260.46,percent of total billed charges,60% of total billed charges for outpatient setting,69.67,542.64,
SCREW 4.0X54MM CANLTD SHRT THD / 207.654,771985,CDM,278,RC,C1713,HCPCS,Outpatient,,,900.6,900.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.36,60,,432.29,percent of total billed charges,60% of total Billed charges for outpatient setting,764.43,84.88,,611.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.45,75,,540.36,percent of total billed charges,75% of total billed charges for outpatient setting,450.3,50,,360.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.48,80,,576.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,115.64,12.84,,92.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,900.6,65,,720.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.21,35,,252.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540.36,60,,432.29,percent of total billed charges,60% of total billed charges for outpatient setting,115.64,900.6,
SCREW 4.0X55MM AXSOS LOCK / 661055,1574963,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X55MM CAN THRD / 206.055,6152842,CDM,278,RC,C1713,HCPCS,Outpatient,,,104.58,104.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.75,60,,50.2,percent of total billed charges,60% of total Billed charges for outpatient setting,88.77,84.88,,71.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.44,75,,62.75,percent of total billed charges,75% of total billed charges for outpatient setting,52.29,50,,41.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.66,80,,66.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,13.43,12.84,,10.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.58,65,,83.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.6,35,,29.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.75,60,,50.2,percent of total billed charges,60% of total billed charges for outpatient setting,13.43,104.58,
SCREW 4.0X55MM CANNULATED / 604655S,70000331,CDM,278,RC,C1713,HCPCS,Outpatient,,,542.64,542.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.58,60,,260.46,percent of total billed charges,60% of total Billed charges for outpatient setting,460.59,84.88,,368.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.98,75,,325.58,percent of total billed charges,75% of total billed charges for outpatient setting,271.32,50,,217.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.11,80,,347.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,69.67,12.84,,55.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,542.64,65,,434.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.92,35,,151.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,325.58,60,,260.46,percent of total billed charges,60% of total billed charges for outpatient setting,69.67,542.64,
SCREW 4.0X60 CANNULATED  1437660,69161868,CDM,278,RC,C1713,HCPCS,Outpatient,,,984.73,984.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.84,60,,472.67,percent of total billed charges,60% of total Billed charges for outpatient setting,835.84,84.88,,668.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.55,75,,590.84,percent of total billed charges,75% of total billed charges for outpatient setting,492.37,50,,393.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.78,80,,630.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,984.73,65,,787.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.66,35,,275.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,590.84,60,,472.67,percent of total billed charges,60% of total billed charges for outpatient setting,126.44,984.73,
SCREW 4.0X60MM AXSOS LOCK / 661060,69169413,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X60MM CAN THRD 206.060,6152843,CDM,278,RC,,,Outpatient,,,93.06,93.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.84,60,,44.67,percent of total billed charges,60% of total Billed charges for outpatient setting,78.99,84.88,,63.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.8,75,,55.84,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,50,,37.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,80,,59.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,11.95,12.84,,9.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.06,65,,74.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,35,,26.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.84,60,,44.67,percent of total billed charges,60% of total billed charges for outpatient setting,11.95,93.06,
SCREW 4.0X60MM CANLTD SHRT THD / 207.660,69169439,CDM,278,RC,C1713,HCPCS,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X60MM CANN LGTHRD /AR-8840CL-60,69162829,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
SCREW 4.0X60MM CANN TI / 604660S,69169444,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X64MM LNG THR CANLTED  207.764,69169364,CDM,278,RC,C1713,HCPCS,Outpatient,,,1052.1,1052.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.26,60,,505.01,percent of total billed charges,60% of total Billed charges for outpatient setting,893.02,84.88,,714.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.08,75,,631.26,percent of total billed charges,75% of total billed charges for outpatient setting,526.05,50,,420.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.68,80,,673.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,135.09,12.84,,108.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1052.1,65,,841.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.24,35,,294.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,631.26,60,,505.01,percent of total billed charges,60% of total billed charges for outpatient setting,135.09,1052.1,
SCREW 4.0X65MM AXSOS LOCK / 661065,1519782,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X65MM CANN TI / 604665S,588042,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X70MM AXSOS LOCK / 661070,69169410,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X70MM CANNLTED / 604670S,588043,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4.0X70MM CANNULATED / 1437670,69161864,CDM,278,RC,,,Outpatient,,,984.73,984.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.84,60,,472.67,percent of total billed charges,60% of total Billed charges for outpatient setting,835.84,84.88,,668.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,492.37,50,,393.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,738.55,75,,590.84,percent of total billed charges,75% of total billed charges for outpatient setting,492.37,50,,393.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.78,80,,630.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,126.44,12.84,,101.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,984.73,65,,787.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.66,35,,275.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,590.84,60,,472.67,percent of total billed charges,60% of total billed charges for outpatient setting,126.44,984.73,
SCREW 4.0X75MM AXSOS LOCK / 661075,69169411,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X80MM AXSOS LOCK / 661080,1457897,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.0X85MM AXSOS LOCK / 661085,1457887,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4.2 X 12MM   184.012,69162474,CDM,278,RC,C1713,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
SCREW 4.2 X 16MM   184.016,69162671,CDM,278,RC,C1713,HCPCS,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
SCREW 4.2MM X14MM VARIABLE   184.014,69162135,CDM,278,RC,,,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.9,60,,519.12,percent of total billed charges,60% of total Billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1081.5,65,,865.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,648.9,60,,519.12,percent of total billed charges,60% of total billed charges for outpatient setting,138.86,1081.5,
SCREW 4.2X12MM VARIABLE / 184.052,69162332,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 4.2X14MM VAR / 184.054,69162171,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 4.2X14MM XTEND / 161.014,69161702,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 4.2X16MM VARIABLE / 184.056,69162190,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 4.50X30MM TIT AXSOS / 661730,1597798,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X32MM TIT AXSOS / 661732,1482356,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X34MM TIT AXSOS / 661734,1570459,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X36MM TIT AXSOS / 661736,1482357,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X38MM TIT AXSOS / 661738,1459627,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X40MM TIT AXSOS / 661740,1479471,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X44MM TIT AXSOS / 661744,1582065,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X60MM TIT AXSOS / 661760,1482359,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X65MM TIT AXSOS / 661765,1482360,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.50X70MM TIT AXSOS / 661770,1577448,CDM,278,RC,C1713,HCPCS,Outpatient,,,217.6,217.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,60,,104.45,percent of total billed charges,60% of total Billed charges for outpatient setting,184.7,84.88,,147.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,75,,130.56,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,50,,87.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.08,80,,139.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,27.94,12.84,,22.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,65,,174.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.16,35,,60.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.56,60,,104.45,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,217.6,
SCREW 4.5X18MM METAGLENE / 1307-70-018,813862,CDM,278,RC,C1713,HCPCS,Outpatient,,,580,580,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348,60,,278.4,percent of total billed charges,60% of total Billed charges for outpatient setting,492.3,84.88,,393.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435,75,,348,percent of total billed charges,75% of total billed charges for outpatient setting,290,50,,232,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464,80,,371.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580,65,,464,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,35,,162.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348,60,,278.4,percent of total billed charges,60% of total billed charges for outpatient setting,74.47,580,
SCREW 4.5X22MM QUARTEX / 1149.4522,69162656,CDM,278,RC,,,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 4.5X24MM METAGLENE / 1307-70-024,217058,CDM,278,RC,C1713,HCPCS,Outpatient,,,580,580,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348,60,,278.4,percent of total billed charges,60% of total Billed charges for outpatient setting,492.3,84.88,,393.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435,75,,348,percent of total billed charges,75% of total billed charges for outpatient setting,290,50,,232,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464,80,,371.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580,65,,464,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,35,,162.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348,60,,278.4,percent of total billed charges,60% of total billed charges for outpatient setting,74.47,580,
SCREW 4.5X24MM QUARTEX / 1149.4024,69162737,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 4.5X26MM QUARTEX / 1149.4026,69162786,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 4.5X30MM METAGLENE / 1307-70-030,165164,CDM,278,RC,C1713,HCPCS,Outpatient,,,580,580,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348,60,,278.4,percent of total billed charges,60% of total Billed charges for outpatient setting,492.3,84.88,,393.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435,75,,348,percent of total billed charges,75% of total billed charges for outpatient setting,290,50,,232,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464,80,,371.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580,65,,464,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,35,,162.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348,60,,278.4,percent of total billed charges,60% of total billed charges for outpatient setting,74.47,580,
SCREW 4.5X36MM CANNULATED / 214.736,69162364,CDM,278,RC,,,Outpatient,,,1091.93,1091.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.16,60,,524.13,percent of total billed charges,60% of total Billed charges for outpatient setting,926.83,84.88,,741.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,545.97,50,,436.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,818.95,75,,655.16,percent of total billed charges,75% of total billed charges for outpatient setting,545.97,50,,436.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.54,80,,698.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1091.93,65,,873.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.18,35,,305.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,655.16,60,,524.13,percent of total billed charges,60% of total billed charges for outpatient setting,140.2,1091.93,
SCREW 4.5X36MM METAGLENE / 1307-70-036,165165,CDM,278,RC,C1713,HCPCS,Outpatient,,,580,580,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348,60,,278.4,percent of total billed charges,60% of total Billed charges for outpatient setting,492.3,84.88,,393.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435,75,,348,percent of total billed charges,75% of total billed charges for outpatient setting,290,50,,232,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464,80,,371.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,74.47,12.84,,59.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,580,65,,464,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,35,,162.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,348,60,,278.4,percent of total billed charges,60% of total billed charges for outpatient setting,74.47,580,
SCREW 4.5X42MM CANNULATED / 214.742,69162365,CDM,278,RC,,,Outpatient,,,1091.93,1091.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.16,60,,524.13,percent of total billed charges,60% of total Billed charges for outpatient setting,926.83,84.88,,741.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,545.97,50,,436.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,818.95,75,,655.16,percent of total billed charges,75% of total billed charges for outpatient setting,545.97,50,,436.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.54,80,,698.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,140.2,12.84,,112.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1091.93,65,,873.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.18,35,,305.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,655.16,60,,524.13,percent of total billed charges,60% of total billed charges for outpatient setting,140.2,1091.93,
SCREW 4.5X54MM CAN. PART/THRD  214.554,69162039,CDM,272,RC,,,Outpatient,,,1070.52,1070.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.36,70,,599.49,percent of total billed charges,70% of total billed charges for outpatient setting,908.66,84.88,,726.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,535.26,50,,428.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802.89,75,,642.31,percent of total billed charges,75% of total billed charges for outpatient setting,749.36,70,,599.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.45,12.84,,109.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,856.42,80,,685.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.45,12.84,,109.96,percent of total billed charges,12.84% of total billed charges,137.45,12.84,,109.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,695.84,65,,556.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.68,35,,299.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,963.47,90,,770.78,percent of total billed charges,90% of total billed charges for outpatient setting,137.45,963.47,
SCREW 4.5x60MM HEADLESS  /02.226.660,69169423,CDM,278,RC,C1713,HCPCS,Outpatient,,,1839.6,1839.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.76,60,,883.01,percent of total billed charges,60% of total Billed charges for outpatient setting,1561.45,84.88,,1249.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.7,75,,1103.76,percent of total billed charges,75% of total billed charges for outpatient setting,919.8,50,,735.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1471.68,80,,1177.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1839.6,65,,1471.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.86,35,,515.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.76,60,,883.01,percent of total billed charges,60% of total billed charges for outpatient setting,236.2,1839.6,
SCREW 4.5x65MM HEADLESS  /02.226.665,69169425,CDM,278,RC,C1713,HCPCS,Outpatient,,,1839.6,1839.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.76,60,,883.01,percent of total billed charges,60% of total Billed charges for outpatient setting,1561.45,84.88,,1249.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.7,75,,1103.76,percent of total billed charges,75% of total billed charges for outpatient setting,919.8,50,,735.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1471.68,80,,1177.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1839.6,65,,1471.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.86,35,,515.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.76,60,,883.01,percent of total billed charges,60% of total billed charges for outpatient setting,236.2,1839.6,
SCREW 4.5x85MM HEADLESS  /02.226.685,69169426,CDM,278,RC,C1713,HCPCS,Outpatient,,,1839.6,1839.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.76,60,,883.01,percent of total billed charges,60% of total Billed charges for outpatient setting,1561.45,84.88,,1249.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.7,75,,1103.76,percent of total billed charges,75% of total billed charges for outpatient setting,919.8,50,,735.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1471.68,80,,1177.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,236.2,12.84,,188.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1839.6,65,,1471.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.86,35,,515.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.76,60,,883.01,percent of total billed charges,60% of total billed charges for outpatient setting,236.2,1839.6,
SCREW 4.6MM VIP / 171.318,882614,CDM,278,RC,C1713,HCPCS,Outpatient,,,440,440,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,60,,211.2,percent of total billed charges,60% of total Billed charges for outpatient setting,373.47,84.88,,298.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330,75,,264,percent of total billed charges,75% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,80,,281.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,440,65,,352,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,35,,123.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,264,60,,211.2,percent of total billed charges,60% of total billed charges for outpatient setting,56.5,440,
SCREW 4.6X12MM XTEND / 171.012,69162159,CDM,278,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,60,,211.2,percent of total billed charges,60% of total Billed charges for outpatient setting,373.47,84.88,,298.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330,75,,264,percent of total billed charges,75% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,80,,281.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,440,65,,352,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,35,,123.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,264,60,,211.2,percent of total billed charges,60% of total billed charges for outpatient setting,56.5,440,
SCREW 4.6X14MM RESCUE / 171.014,69161759,CDM,278,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,60,,211.2,percent of total billed charges,60% of total Billed charges for outpatient setting,373.47,84.88,,298.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330,75,,264,percent of total billed charges,75% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,80,,281.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,440,65,,352,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,35,,123.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,264,60,,211.2,percent of total billed charges,60% of total billed charges for outpatient setting,56.5,440,
"SCREW 4.75 X 15MM, FIXED/LOCKING",69161576,CDM,278,RC,,,Outpatient,,,904.52,904.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.71,60,,434.17,percent of total billed charges,60% of total Billed charges for outpatient setting,767.76,84.88,,614.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,452.26,50,,361.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,678.39,75,,542.71,percent of total billed charges,75% of total billed charges for outpatient setting,452.26,50,,361.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.14,12.84,,92.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.62,80,,578.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.14,12.84,,92.91,percent of total billed charges,12.84% of total billed charges,116.14,12.84,,92.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,904.52,65,,723.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.58,35,,253.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,542.71,60,,434.17,percent of total billed charges,60% of total billed charges for outpatient setting,116.14,904.52,
"SCREW 4.75 X 25MM, FIXED/LOCKING",69161577,CDM,278,RC,,,Outpatient,,,904.52,904.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.71,60,,434.17,percent of total billed charges,60% of total Billed charges for outpatient setting,767.76,84.88,,614.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,452.26,50,,361.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,678.39,75,,542.71,percent of total billed charges,75% of total billed charges for outpatient setting,452.26,50,,361.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.14,12.84,,92.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.62,80,,578.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.14,12.84,,92.91,percent of total billed charges,12.84% of total billed charges,116.14,12.84,,92.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,904.52,65,,723.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.58,35,,253.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,542.71,60,,434.17,percent of total billed charges,60% of total billed charges for outpatient setting,116.14,904.52,
SCREW 4.75X15MM LOCKING /180550,69161646,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 4.75X15MM NON LOCK COMPR / 180557,70000256,CDM,278,RC,C1713,HCPCS,Outpatient,,,324.45,324.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,60,,155.74,percent of total billed charges,60% of total Billed charges for outpatient setting,275.39,84.88,,220.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.34,75,,194.67,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,50,,129.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,12.84,,33.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.56,80,,207.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,12.84,,33.33,percent of total billed charges,12.84% of total billed charges,41.66,12.84,,33.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,324.45,65,,259.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,35,,90.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,60,,155.74,percent of total billed charges,60% of total billed charges for outpatient setting,41.66,324.45,
SCREW 4.75X20MM NON LOCK COMPR / 180558,70000258,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 4.75X25MM NON LOCK COMPR / 180559,70000578,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 4.75X30MM NON LOCK COMPR / 180560,70000257,CDM,278,RC,,,Outpatient,,,324.45,324.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,60,,155.74,percent of total billed charges,60% of total Billed charges for outpatient setting,275.39,84.88,,220.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,162.23,50,,129.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.34,75,,194.67,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,50,,129.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,12.84,,33.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.56,80,,207.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,12.84,,33.33,percent of total billed charges,12.84% of total billed charges,41.66,12.84,,33.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,324.45,65,,259.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,35,,90.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.67,60,,155.74,percent of total billed charges,60% of total billed charges for outpatient setting,41.66,324.45,
SCREW 4.75X40MM NON LOCK COMPR / 180555,1430186,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 4.75X45 NON LOCK COMPR / 180556,69169789,CDM,278,RC,C1713,HCPCS,Outpatient,,,242.55,242.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,60,,116.42,percent of total billed charges,60% of total Billed charges for outpatient setting,205.88,84.88,,164.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.91,75,,145.53,percent of total billed charges,75% of total billed charges for outpatient setting,121.28,50,,97.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,80,,155.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,242.55,65,,194.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.89,35,,67.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.53,60,,116.42,percent of total billed charges,60% of total billed charges for outpatient setting,31.14,242.55,
SCREW 4/3X20MM SCHANZ / 294.771,69162092,CDM,278,RC,C1713,HCPCS,Outpatient,,,784.65,784.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.79,60,,376.63,percent of total billed charges,60% of total Billed charges for outpatient setting,666.01,84.88,,532.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.49,75,,470.79,percent of total billed charges,75% of total billed charges for outpatient setting,392.33,50,,313.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.75,12.84,,80.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.72,80,,502.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.75,12.84,,80.6,percent of total billed charges,12.84% of total billed charges,100.75,12.84,,80.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,784.65,65,,627.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.63,35,,219.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,470.79,60,,376.63,percent of total billed charges,60% of total billed charges for outpatient setting,100.75,784.65,
SCREW 48MM MIS HEADED / 00-5983-040-48,71000294,CDM,278,RC,C1713,HCPCS,Outpatient,,,340,340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204,60,,163.2,percent of total billed charges,60% of total Billed charges for outpatient setting,288.59,84.88,,230.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255,75,,204,percent of total billed charges,75% of total billed charges for outpatient setting,170,50,,136,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272,80,,217.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,43.66,12.84,,34.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,340,65,,272,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,35,,95.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204,60,,163.2,percent of total billed charges,60% of total billed charges for outpatient setting,43.66,340,
SCREW 4X12MM VARIABLE / UM154-40-12,69169457,CDM,278,RC,C1713,HCPCS,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,60,,302.4,percent of total billed charges,60% of total Billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,630,65,,504,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378,60,,302.4,percent of total billed charges,60% of total billed charges for outpatient setting,80.89,630,
SCREW 4X14MM CANCELLOUS / 607314,70000635,CDM,278,RC,C1713,HCPCS,Outpatient,,,231.17,231.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.7,60,,110.96,percent of total billed charges,60% of total Billed charges for outpatient setting,196.22,84.88,,156.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.38,75,,138.7,percent of total billed charges,75% of total billed charges for outpatient setting,115.59,50,,92.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.68,12.84,,23.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.94,80,,147.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.68,12.84,,23.74,percent of total billed charges,12.84% of total billed charges,29.68,12.84,,23.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,231.17,65,,184.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.91,35,,64.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,138.7,60,,110.96,percent of total billed charges,60% of total billed charges for outpatient setting,29.68,231.17,
SCREW 4X14MM LOCKING / 661014,70000634,CDM,278,RC,C1713,HCPCS,Outpatient,,,814.37,814.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.62,60,,390.9,percent of total billed charges,60% of total Billed charges for outpatient setting,691.24,84.88,,552.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.78,75,,488.62,percent of total billed charges,75% of total billed charges for outpatient setting,407.19,50,,325.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.57,12.84,,83.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.5,80,,521.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.57,12.84,,83.66,percent of total billed charges,12.84% of total billed charges,104.57,12.84,,83.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,814.37,65,,651.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.03,35,,228.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,488.62,60,,390.9,percent of total billed charges,60% of total billed charges for outpatient setting,104.57,814.37,
SCREW 4X14MM VARIABLE / UM154-40-14,69169380,CDM,278,RC,C1713,HCPCS,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,60,,302.4,percent of total billed charges,60% of total Billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,630,65,,504,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378,60,,302.4,percent of total billed charges,60% of total billed charges for outpatient setting,80.89,630,
SCREW 4X24MM LOCKING / 661024,69169239,CDM,278,RC,C1713,HCPCS,Outpatient,,,744.74,744.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.84,60,,357.47,percent of total billed charges,60% of total Billed charges for outpatient setting,632.14,84.88,,505.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.56,75,,446.85,percent of total billed charges,75% of total billed charges for outpatient setting,372.37,50,,297.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.79,80,,476.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,744.74,65,,595.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.66,35,,208.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.84,60,,357.47,percent of total billed charges,60% of total billed charges for outpatient setting,95.62,744.74,
SCREW 4X26MM LOCKING / 661026,70000633,CDM,278,RC,C1713,HCPCS,Outpatient,,,732.16,732.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.3,60,,351.44,percent of total billed charges,60% of total Billed charges for outpatient setting,621.46,84.88,,497.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.12,75,,439.3,percent of total billed charges,75% of total billed charges for outpatient setting,366.08,50,,292.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.73,80,,468.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,732.16,65,,585.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.26,35,,205.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,439.3,60,,351.44,percent of total billed charges,60% of total billed charges for outpatient setting,94.01,732.16,
SCREW 4X28MM LOCKING / 661028,69169338,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4X28MM LO-PRO / AR-5051-28,71000852,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X30MM LOCKING / 1896-4030S,359661,CDM,278,RC,C1713,HCPCS,Outpatient,,,596.4,596.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.84,60,,286.27,percent of total billed charges,60% of total Billed charges for outpatient setting,506.22,84.88,,404.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.3,75,,357.84,percent of total billed charges,75% of total billed charges for outpatient setting,298.2,50,,238.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.58,12.84,,61.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.12,80,,381.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.58,12.84,,61.26,percent of total billed charges,12.84% of total billed charges,76.58,12.84,,61.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,596.4,65,,477.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.74,35,,166.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,357.84,60,,286.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.58,596.4,
SCREW 4X30MM LOCKING / 661030,69169240,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4X34MM LOCKING / 661034,70000632,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.52,663.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.11,60,,318.49,percent of total billed charges,60% of total Billed charges for outpatient setting,563.2,84.88,,450.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.64,75,,398.11,percent of total billed charges,75% of total billed charges for outpatient setting,331.76,50,,265.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.82,80,,424.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,85.2,12.84,,68.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.52,65,,530.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.23,35,,185.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,398.11,60,,318.49,percent of total billed charges,60% of total billed charges for outpatient setting,85.2,663.52,
SCREW 4X34MM LO-PRO / AR-5051-34,71000819,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X36MM LOCKING / 661036,70000631,CDM,278,RC,C1713,HCPCS,Outpatient,,,744.74,744.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.84,60,,357.47,percent of total billed charges,60% of total Billed charges for outpatient setting,632.14,84.88,,505.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.56,75,,446.85,percent of total billed charges,75% of total billed charges for outpatient setting,372.37,50,,297.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.79,80,,476.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,744.74,65,,595.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.66,35,,208.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.84,60,,357.47,percent of total billed charges,60% of total billed charges for outpatient setting,95.62,744.74,
SCREW 4X36MM LO-PRO / AR-5051-36,69169487,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X38MM AXSOS TITNM / 607338,1626838,CDM,278,RC,C1713,HCPCS,Outpatient,,,208,208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.8,60,,99.84,percent of total billed charges,60% of total Billed charges for outpatient setting,176.55,84.88,,141.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,75,,124.8,percent of total billed charges,75% of total billed charges for outpatient setting,104,50,,83.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.4,80,,133.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208,65,,166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,35,,58.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.8,60,,99.84,percent of total billed charges,60% of total billed charges for outpatient setting,26.71,208,
SCREW 4X38MM LOCKING / 661038,69169241,CDM,278,RC,C1713,HCPCS,Outpatient,,,744.74,744.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.84,60,,357.47,percent of total billed charges,60% of total Billed charges for outpatient setting,632.14,84.88,,505.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.56,75,,446.85,percent of total billed charges,75% of total billed charges for outpatient setting,372.37,50,,297.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.79,80,,476.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,95.62,12.84,,76.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,744.74,65,,595.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.66,35,,208.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,446.84,60,,357.47,percent of total billed charges,60% of total billed charges for outpatient setting,95.62,744.74,
SCREW 4X38MM LO-PRO / AR-5051-38,70000517,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X40MM CANN TI / 604740S,70000604,CDM,278,RC,C1713,HCPCS,Outpatient,,,647.17,647.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,60,,310.64,percent of total billed charges,60% of total Billed charges for outpatient setting,549.32,84.88,,439.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.38,75,,388.3,percent of total billed charges,75% of total billed charges for outpatient setting,323.59,50,,258.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.74,80,,414.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,647.17,65,,517.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.51,35,,181.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.3,60,,310.64,percent of total billed charges,60% of total billed charges for outpatient setting,83.1,647.17,
SCREW 4X40MM CANNULATED / 663040,69169889,CDM,278,RC,C1713,HCPCS,Outpatient,,,2298.96,2298.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.38,60,,1103.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1951.36,84.88,,1561.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1724.22,75,,1379.38,percent of total billed charges,75% of total billed charges for outpatient setting,1149.48,50,,919.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.19,12.84,,236.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.17,80,,1471.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.19,12.84,,236.15,percent of total billed charges,12.84% of total billed charges,295.19,12.84,,236.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2413.91,105,,1931.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.64,35,,643.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1379.38,60,,1103.5,percent of total billed charges,60% of total billed charges for outpatient setting,295.19,2413.91,
SCREW 4X40MM LO-PRO / AR-5051-40,71000853,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X42MM LOCKING / 661042,69169339,CDM,278,RC,C1713,HCPCS,Outpatient,,,732.16,732.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.3,60,,351.44,percent of total billed charges,60% of total Billed charges for outpatient setting,621.46,84.88,,497.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.12,75,,439.3,percent of total billed charges,75% of total billed charges for outpatient setting,366.08,50,,292.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.73,80,,468.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,94.01,12.84,,75.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,732.16,65,,585.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.26,35,,205.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,439.3,60,,351.44,percent of total billed charges,60% of total billed charges for outpatient setting,94.01,732.16,
SCREW 4X44MM LO-PRO / AR-5051-44,71000854,CDM,278,RC,C1713,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.8,60,,332.64,percent of total billed charges,60% of total Billed charges for outpatient setting,588.22,84.88,,470.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.75,75,,415.8,percent of total billed charges,75% of total billed charges for outpatient setting,346.5,50,,277.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.4,80,,443.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,88.98,12.84,,71.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,693,65,,554.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,35,,194.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,415.8,60,,332.64,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,693,
SCREW 4X48MM CANN ASNIS / 604648S,588038,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.32,594.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.59,60,,285.27,percent of total billed charges,60% of total Billed charges for outpatient setting,504.46,84.88,,403.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.74,75,,356.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.16,50,,237.73,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.46,80,,380.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,76.31,12.84,,61.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,594.32,65,,475.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.01,35,,166.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,356.59,60,,285.27,percent of total billed charges,60% of total billed charges for outpatient setting,76.31,594.32,
SCREW 4X48MM CANN TI / 604748S,70000603,CDM,278,RC,C1713,HCPCS,Outpatient,,,647.17,647.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,60,,310.64,percent of total billed charges,60% of total Billed charges for outpatient setting,549.32,84.88,,439.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.38,75,,388.3,percent of total billed charges,75% of total billed charges for outpatient setting,323.59,50,,258.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.74,80,,414.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,83.1,12.84,,66.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,647.17,65,,517.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.51,35,,181.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,388.3,60,,310.64,percent of total billed charges,60% of total billed charges for outpatient setting,83.1,647.17,
SCREW 4X50MM CANNULATED / 663050,70000676,CDM,278,RC,C1713,HCPCS,Outpatient,,,2861.65,2861.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1716.99,60,,1373.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2428.97,84.88,,1943.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2146.24,75,,1716.99,percent of total billed charges,75% of total billed charges for outpatient setting,1430.83,50,,1144.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.44,12.84,,293.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2289.32,80,,1831.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.44,12.84,,293.95,percent of total billed charges,12.84% of total billed charges,367.44,12.84,,293.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3004.73,105,,2403.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.58,35,,801.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1716.99,60,,1373.59,percent of total billed charges,60% of total billed charges for outpatient setting,367.44,3004.73,
SCREW 4X60MM AXSOS TITNM / 607360,1609621,CDM,278,RC,C1713,HCPCS,Outpatient,,,208,208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.8,60,,99.84,percent of total billed charges,60% of total Billed charges for outpatient setting,176.55,84.88,,141.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,75,,124.8,percent of total billed charges,75% of total billed charges for outpatient setting,104,50,,83.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.4,80,,133.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208,65,,166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,35,,58.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.8,60,,99.84,percent of total billed charges,60% of total billed charges for outpatient setting,26.71,208,
SCREW 4X65MM AXSOS TITNM / 607365,1603815,CDM,278,RC,C1713,HCPCS,Outpatient,,,208,208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.8,60,,99.84,percent of total billed charges,60% of total Billed charges for outpatient setting,176.55,84.88,,141.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,75,,124.8,percent of total billed charges,75% of total billed charges for outpatient setting,104,50,,83.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.4,80,,133.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,26.71,12.84,,21.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,208,65,,166.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,35,,58.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.8,60,,99.84,percent of total billed charges,60% of total billed charges for outpatient setting,26.71,208,
"SCREW 5.0 X 40MM, CANNLTED  /325440S",69162538,CDM,278,RC,,,Outpatient,,,1095.78,1095.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.47,60,,525.98,percent of total billed charges,60% of total Billed charges for outpatient setting,930.1,84.88,,744.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,547.89,50,,438.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,821.84,75,,657.47,percent of total billed charges,75% of total billed charges for outpatient setting,547.89,50,,438.31,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.62,80,,701.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1095.78,65,,876.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.52,35,,306.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,657.47,60,,525.98,percent of total billed charges,60% of total billed charges for outpatient setting,140.7,1095.78,
"SCREW 5.0 X 48MM, CANNLTED  /325448",69162175,CDM,278,RC,,,Outpatient,,,1289.15,1289.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.49,60,,618.79,percent of total billed charges,60% of total Billed charges for outpatient setting,1094.23,84.88,,875.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,644.58,50,,515.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,966.86,75,,773.49,percent of total billed charges,75% of total billed charges for outpatient setting,644.58,50,,515.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.53,12.84,,132.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1031.32,80,,825.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.53,12.84,,132.42,percent of total billed charges,12.84% of total billed charges,165.53,12.84,,132.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1289.15,65,,1031.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.2,35,,360.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,773.49,60,,618.79,percent of total billed charges,60% of total billed charges for outpatient setting,165.53,1289.15,
SCREW 5.0X25MM PHERIPHERAL1257-25-000,69169776,CDM,278,RC,,,Outpatient,,,684.6,684.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.76,60,,328.61,percent of total billed charges,60% of total Billed charges for outpatient setting,581.09,84.88,,464.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,342.3,50,,273.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,513.45,75,,410.76,percent of total billed charges,75% of total billed charges for outpatient setting,342.3,50,,273.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.9,12.84,,70.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,547.68,80,,438.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.9,12.84,,70.32,percent of total billed charges,12.84% of total billed charges,87.9,12.84,,70.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,684.6,65,,547.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.61,35,,191.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,410.76,60,,328.61,percent of total billed charges,60% of total billed charges for outpatient setting,87.9,684.6,
SCREW 5.0X36MM CANN / 325436S,69162539,CDM,278,RC,,,Outpatient,,,1095.78,1095.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.47,60,,525.98,percent of total billed charges,60% of total Billed charges for outpatient setting,930.1,84.88,,744.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,547.89,50,,438.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,821.84,75,,657.47,percent of total billed charges,75% of total billed charges for outpatient setting,547.89,50,,438.31,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.62,80,,701.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,140.7,12.84,,112.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1095.78,65,,876.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.52,35,,306.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,657.47,60,,525.98,percent of total billed charges,60% of total billed charges for outpatient setting,140.7,1095.78,
SCREW 5.0X55MM BONE ASNIS / 663155,1167060,CDM,278,RC,C1713,HCPCS,Outpatient,,,2262,2262,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1357.2,60,,1085.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1919.99,84.88,,1535.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1696.5,75,,1357.2,percent of total billed charges,75% of total billed charges for outpatient setting,1131,50,,904.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.44,12.84,,232.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1809.6,80,,1447.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.44,12.84,,232.35,percent of total billed charges,12.84% of total billed charges,290.44,12.84,,232.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2375.1,105,,1900.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,791.7,35,,633.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1357.2,60,,1085.76,percent of total billed charges,60% of total billed charges for outpatient setting,290.44,2375.1,
SCREW 5.1x 14MM RESCUE  171.414,69162125,CDM,278,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,60,,363.38,percent of total billed charges,60% of total Billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,757.05,65,,605.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,454.23,60,,363.38,percent of total billed charges,60% of total billed charges for outpatient setting,97.21,757.05,
SCREW 5.1x 16MM RESCUE  171.416,69162357,CDM,278,RC,,,Outpatient,,,1514.1,1514.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,60,,726.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.17,84.88,,1028.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1135.58,75,,908.46,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,80,,969.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.1,65,,1211.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,35,,423.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.46,60,,726.77,percent of total billed charges,60% of total billed charges for outpatient setting,194.41,1514.1,
SCREW 5.1X12MM VIP / 171.412,69162787,CDM,278,RC,C1713,HCPCS,Outpatient,,,1514.1,1514.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,60,,726.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.17,84.88,,1028.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,75,,908.46,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,80,,969.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.1,65,,1211.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,35,,423.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.46,60,,726.77,percent of total billed charges,60% of total billed charges for outpatient setting,194.41,1514.1,
SCREW 5.5X25MM VAR ANGLE / 176.725,69162820,CDM,278,RC,C1713,HCPCS,Outpatient,,,1050,1050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,60,,504,percent of total billed charges,60% of total Billed charges for outpatient setting,891.24,84.88,,712.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.5,75,,630,percent of total billed charges,75% of total billed charges for outpatient setting,525,50,,420,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,80,,672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1050,65,,840,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,35,,294,percent of total billed charges,35% of total Billed charges for Outpatient Setting,630,60,,504,percent of total billed charges,60% of total billed charges for outpatient setting,134.82,1050,
SCREW 5.5X30MM VAR ANGLE / 176.730,69169509,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 5.5x35MM LONG / E3S5535,69169350,CDM,278,RC,C1713,HCPCS,Outpatient,,,3215.63,3215.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,60,,1543.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2729.43,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,1607.82,50,,1286.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3376.41,105,,2701.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.38,60,,1543.5,percent of total billed charges,60% of total billed charges for outpatient setting,412.89,3376.41,
SCREW 5.5X35MM VAR ANGLE / 176.735,1662282,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 5.5X40MM CREO / 5119.1540,69161980,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
SCREW 5.5x40MM LONG / E3S5540,69169351,CDM,278,RC,C1713,HCPCS,Outpatient,,,3215.63,3215.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,60,,1543.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2729.43,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,1607.82,50,,1286.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3376.41,105,,2701.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.38,60,,1543.5,percent of total billed charges,60% of total billed charges for outpatient setting,412.89,3376.41,
SCREW 5.5X40MM VAR ANGLE / 176.740,69169387,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,60,,230.4,percent of total billed charges,60% of total Billed charges for outpatient setting,407.42,84.88,,325.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,288,percent of total billed charges,75% of total billed charges for outpatient setting,240,50,,192,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,80,,307.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,61.63,12.84,,49.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,480,65,,384,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,35,,134.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,288,60,,230.4,percent of total billed charges,60% of total billed charges for outpatient setting,61.63,480,
SCREW 5.5X45MM REVOLVE / 185.455,69162302,CDM,278,RC,,,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW 5.5X55MM CREO / 5119.1555,69162840,CDM,278,RC,C1713,HCPCS,Outpatient,,,3595.99,3595.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.59,60,,1726.07,percent of total billed charges,60% of total Billed charges for outpatient setting,3052.28,84.88,,2441.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2696.99,75,,2157.59,percent of total billed charges,75% of total billed charges for outpatient setting,1798,50,,1438.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2876.79,80,,2301.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,461.73,12.84,,369.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3775.79,105,,3020.63,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.6,35,,1006.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2157.59,60,,1726.07,percent of total billed charges,60% of total billed charges for outpatient setting,461.73,3775.79,
SCREW 5X30MM LOCKING / 458.930S,45950,CDM,278,RC,C1713,HCPCS,Outpatient,,,1048.36,1048.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,60,,503.22,percent of total billed charges,60% of total Billed charges for outpatient setting,889.85,84.88,,711.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.27,75,,629.02,percent of total billed charges,75% of total billed charges for outpatient setting,524.18,50,,419.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.69,80,,670.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1048.36,65,,838.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.93,35,,293.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.02,60,,503.22,percent of total billed charges,60% of total billed charges for outpatient setting,134.61,1048.36,
SCREW 5X34MM LOCKING / 458.934S,45951,CDM,278,RC,C1713,HCPCS,Outpatient,,,1048.36,1048.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,60,,503.22,percent of total billed charges,60% of total Billed charges for outpatient setting,889.85,84.88,,711.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.27,75,,629.02,percent of total billed charges,75% of total billed charges for outpatient setting,524.18,50,,419.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.69,80,,670.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1048.36,65,,838.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.93,35,,293.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.02,60,,503.22,percent of total billed charges,60% of total billed charges for outpatient setting,134.61,1048.36,
SCREW 5X35MM LOCKING / 1896-5035S,482313,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 5X36MM LOCKING / 458.936S,45952,CDM,278,RC,C1713,HCPCS,Outpatient,,,1048.36,1048.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,60,,503.22,percent of total billed charges,60% of total Billed charges for outpatient setting,889.85,84.88,,711.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.27,75,,629.02,percent of total billed charges,75% of total billed charges for outpatient setting,524.18,50,,419.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.69,80,,670.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1048.36,65,,838.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.93,35,,293.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.02,60,,503.22,percent of total billed charges,60% of total billed charges for outpatient setting,134.61,1048.36,
SCREW 5X40MM LOCKING / 458.940S,45954,CDM,278,RC,C1713,HCPCS,Outpatient,,,1048.36,1048.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,60,,503.22,percent of total billed charges,60% of total Billed charges for outpatient setting,889.85,84.88,,711.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.27,75,,629.02,percent of total billed charges,75% of total billed charges for outpatient setting,524.18,50,,419.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.69,80,,670.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1048.36,65,,838.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.93,35,,293.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.02,60,,503.22,percent of total billed charges,60% of total billed charges for outpatient setting,134.61,1048.36,
SCREW 5X42MM LOCKING / 458.942S,45955,CDM,278,RC,C1713,HCPCS,Outpatient,,,1048.36,1048.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,60,,503.22,percent of total billed charges,60% of total Billed charges for outpatient setting,889.85,84.88,,711.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.27,75,,629.02,percent of total billed charges,75% of total billed charges for outpatient setting,524.18,50,,419.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.69,80,,670.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,134.61,12.84,,107.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1048.36,65,,838.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.93,35,,293.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,629.02,60,,503.22,percent of total billed charges,60% of total billed charges for outpatient setting,134.61,1048.36,
SCREW 5X45MM LOCKING / 1896-5045S,482315,CDM,278,RC,C1713,HCPCS,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,60,,282.24,percent of total billed charges,60% of total Billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,588,65,,470.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,352.8,60,,282.24,percent of total billed charges,60% of total billed charges for outpatient setting,75.5,588,
SCREW 5X55MM CONDYLE T2 / 1895-5055S,70000688,CDM,278,RC,,,Outpatient,,,719.97,719.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.98,60,,345.58,percent of total billed charges,60% of total Billed charges for outpatient setting,611.11,84.88,,488.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,539.98,75,,431.98,percent of total billed charges,75% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.98,80,,460.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,719.97,65,,575.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.99,35,,201.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,431.98,60,,345.58,percent of total billed charges,60% of total billed charges for outpatient setting,92.44,719.97,
SCREW 5X60MM CONDYLE T2 / 1895-5060S,70000689,CDM,278,RC,,,Outpatient,,,719.97,719.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.98,60,,345.58,percent of total billed charges,60% of total Billed charges for outpatient setting,611.11,84.88,,488.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,539.98,75,,431.98,percent of total billed charges,75% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.98,80,,460.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,719.97,65,,575.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.99,35,,201.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,431.98,60,,345.58,percent of total billed charges,60% of total billed charges for outpatient setting,92.44,719.97,
SCREW 5X65MM CONDYLE T2 / 1895-5065S,70000690,CDM,278,RC,,,Outpatient,,,719.97,719.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.98,60,,345.58,percent of total billed charges,60% of total Billed charges for outpatient setting,611.11,84.88,,488.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,539.98,75,,431.98,percent of total billed charges,75% of total billed charges for outpatient setting,359.99,50,,287.99,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.98,80,,460.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,92.44,12.84,,73.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,719.97,65,,575.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.99,35,,201.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,431.98,60,,345.58,percent of total billed charges,60% of total billed charges for outpatient setting,92.44,719.97,
SCREW 6.5 x 30mm CENTRAL,69161812,CDM,278,RC,,,Outpatient,,,891.16,891.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.7,60,,427.76,percent of total billed charges,60% of total Billed charges for outpatient setting,756.42,84.88,,605.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,445.58,50,,356.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,668.37,75,,534.7,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,50,,356.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.42,12.84,,91.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.93,80,,570.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.42,12.84,,91.54,percent of total billed charges,12.84% of total billed charges,114.42,12.84,,91.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,891.16,65,,712.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.91,35,,249.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,534.7,60,,427.76,percent of total billed charges,60% of total billed charges for outpatient setting,114.42,891.16,
"SCREW 6.5,35MM/216.035",6152157,CDM,270,RC,,,Outpatient,,,224.4,224.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.08,70,,125.66,percent of total billed charges,70% of total billed charges for outpatient setting,190.47,84.88,,152.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,112.2,50,,89.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,75,,134.64,percent of total billed charges,75% of total billed charges for outpatient setting,157.08,70,,125.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.52,80,,143.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,28.81,12.84,,23.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,145.86,65,,116.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.54,35,,62.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,201.96,90,,161.57,percent of total billed charges,90% of total billed charges for outpatient setting,28.81,201.96,
SCREW 6.50X20 CANCL / 1217-20-500,69169753,CDM,278,RC,C1713,HCPCS,Outpatient,,,420,420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,60,,201.6,percent of total billed charges,60% of total Billed charges for outpatient setting,356.5,84.88,,285.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,75,,252,percent of total billed charges,75% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,80,,268.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,420,65,,336,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,35,,117.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,252,60,,201.6,percent of total billed charges,60% of total billed charges for outpatient setting,53.93,420,
SCREW 6.50X30MM CREO / 5119.1632,1567828,CDM,278,RC,C1713,HCPCS,Outpatient,,,3180,3180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1908,60,,1526.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2699.18,84.88,,2159.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2385,75,,1908,percent of total billed charges,75% of total billed charges for outpatient setting,1590,50,,1272,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.31,12.84,,326.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2544,80,,2035.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.31,12.84,,326.65,percent of total billed charges,12.84% of total billed charges,408.31,12.84,,326.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3339,105,,2671.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113,35,,890.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1908,60,,1526.4,percent of total billed charges,60% of total billed charges for outpatient setting,408.31,3339,
SCREW 6.5MM 16MM THREAD 30MM/216.030,6152590,CDM,278,RC,,,Outpatient,,,93.92,93.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.35,60,,45.08,percent of total billed charges,60% of total Billed charges for outpatient setting,79.72,84.88,,63.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.96,50,,37.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.44,75,,56.35,percent of total billed charges,75% of total billed charges for outpatient setting,46.96,50,,37.57,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.06,12.84,,9.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.14,80,,60.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.06,12.84,,9.65,percent of total billed charges,12.84% of total billed charges,12.06,12.84,,9.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.92,65,,75.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,35,,26.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.35,60,,45.08,percent of total billed charges,60% of total billed charges for outpatient setting,12.06,93.92,
SCREW 6.5x10MM TENODESIS  / AR-1655PS-10,69169791,CDM,278,RC,C1713,HCPCS,Outpatient,,,1197,1197,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.2,60,,574.56,percent of total billed charges,60% of total Billed charges for outpatient setting,1016.01,84.88,,812.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.75,75,,718.2,percent of total billed charges,75% of total billed charges for outpatient setting,598.5,50,,478.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.69,12.84,,122.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.6,80,,766.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.69,12.84,,122.95,percent of total billed charges,12.84% of total billed charges,153.69,12.84,,122.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1197,65,,957.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.95,35,,335.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,718.2,60,,574.56,percent of total billed charges,60% of total billed charges for outpatient setting,153.69,1197,
SCREW 6.5X15MM CANCL / 1217-15-500,71000472,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SCREW 6.5X15MM POROCOAT TRAY,69161984,CDM,278,RC,,,Outpatient,,,738.19,738.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.91,60,,354.33,percent of total billed charges,60% of total Billed charges for outpatient setting,626.58,84.88,,501.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.64,75,,442.91,percent of total billed charges,75% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.55,80,,472.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,738.19,65,,590.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.37,35,,206.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,442.91,60,,354.33,percent of total billed charges,60% of total billed charges for outpatient setting,94.78,738.19,
SCREW 6.5X20MM CENTRAL / 115394,69162020,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X20MM POROCOAT TRAY,69161983,CDM,278,RC,,,Outpatient,,,738.19,738.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.91,60,,354.33,percent of total billed charges,60% of total Billed charges for outpatient setting,626.58,84.88,,501.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.64,75,,442.91,percent of total billed charges,75% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.55,80,,472.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,738.19,65,,590.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.37,35,,206.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,442.91,60,,354.33,percent of total billed charges,60% of total billed charges for outpatient setting,94.78,738.19,
SCREW 6.5X20MM SELF TAP / 00-6250-065-20,71000205,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
"SCREW 6.5X20MM, CENTRAL",69161588,CDM,278,RC,,,Outpatient,,,891.16,891.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.7,60,,427.76,percent of total billed charges,60% of total Billed charges for outpatient setting,756.42,84.88,,605.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,445.58,50,,356.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,668.37,75,,534.7,percent of total billed charges,75% of total billed charges for outpatient setting,445.58,50,,356.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.42,12.84,,91.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.93,80,,570.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.42,12.84,,91.54,percent of total billed charges,12.84% of total billed charges,114.42,12.84,,91.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,891.16,65,,712.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.91,35,,249.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,534.7,60,,427.76,percent of total billed charges,60% of total billed charges for outpatient setting,114.42,891.16,
SCREW 6.5X25MM  CANCELLOUS / 71332525,69162340,CDM,278,RC,,,Outpatient,,,482.35,482.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.41,60,,231.53,percent of total billed charges,60% of total Billed charges for outpatient setting,409.42,84.88,,327.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,241.18,50,,192.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.76,75,,289.41,percent of total billed charges,75% of total billed charges for outpatient setting,241.18,50,,192.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.93,12.84,,49.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.88,80,,308.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.93,12.84,,49.54,percent of total billed charges,12.84% of total billed charges,61.93,12.84,,49.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,482.35,65,,385.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.82,35,,135.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.41,60,,231.53,percent of total billed charges,60% of total billed charges for outpatient setting,61.93,482.35,
SCREW 6.5x25MM /6250-65-25,69169414,CDM,272,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,70,,235.2,percent of total billed charges,70% of total billed charges for outpatient setting,356.5,84.88,,285.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315,75,,252,percent of total billed charges,75% of total billed charges for outpatient setting,294,70,,235.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,80,,268.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,273,65,,218.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,35,,117.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,378,90,,302.4,percent of total billed charges,90% of total billed charges for outpatient setting,53.93,378,
SCREW 6.5X25MM CANCL / 1217-25-500,69169754,CDM,278,RC,C1713,HCPCS,Outpatient,,,420,420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,60,,201.6,percent of total billed charges,60% of total Billed charges for outpatient setting,356.5,84.88,,285.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,75,,252,percent of total billed charges,75% of total billed charges for outpatient setting,210,50,,168,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,80,,268.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,53.93,12.84,,43.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,420,65,,336,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,35,,117.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,252,60,,201.6,percent of total billed charges,60% of total billed charges for outpatient setting,53.93,420,
SCREW 6.5X25MM CENTRAL / 115381,69161575,CDM,278,RC,,,Outpatient,,,242.55,242.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,60,,116.42,percent of total billed charges,60% of total Billed charges for outpatient setting,205.88,84.88,,164.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.28,50,,97.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.91,75,,145.53,percent of total billed charges,75% of total billed charges for outpatient setting,121.28,50,,97.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,80,,155.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,242.55,65,,194.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.89,35,,67.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.53,60,,116.42,percent of total billed charges,60% of total billed charges for outpatient setting,31.14,242.55,
SCREW 6.5X25MM CENTRAL / 115395,69161973,CDM,278,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X25MM POROCOAT TRAY,69161985,CDM,278,RC,,,Outpatient,,,738.19,738.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.91,60,,354.33,percent of total billed charges,60% of total Billed charges for outpatient setting,626.58,84.88,,501.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.64,75,,442.91,percent of total billed charges,75% of total billed charges for outpatient setting,369.1,50,,295.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.55,80,,472.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,94.78,12.84,,75.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,738.19,65,,590.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.37,35,,206.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,442.91,60,,354.33,percent of total billed charges,60% of total billed charges for outpatient setting,94.78,738.19,
SCREW 6.5X25MM SELF TAP / 00-6250-065-25,71000036,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SCREW 6.5X30MM  CANCELLOUS / 71332530,69162341,CDM,278,RC,,,Outpatient,,,482.35,482.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.41,60,,231.53,percent of total billed charges,60% of total Billed charges for outpatient setting,409.42,84.88,,327.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,241.18,50,,192.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.76,75,,289.41,percent of total billed charges,75% of total billed charges for outpatient setting,241.18,50,,192.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.93,12.84,,49.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.88,80,,308.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.93,12.84,,49.54,percent of total billed charges,12.84% of total billed charges,61.93,12.84,,49.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,482.35,65,,385.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.82,35,,135.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.41,60,,231.53,percent of total billed charges,60% of total billed charges for outpatient setting,61.93,482.35,
SCREW 6.5X30MM CANCL 1217-30-500,69169775,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SCREW 6.5X30MM CNTRL COMPR / 115396,69162644,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X30MM SELF TAP / 00-6250-065-30,71000085,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SCREW 6.5x35MM / E3S6535,69169333,CDM,278,RC,C1713,HCPCS,Outpatient,,,3215.63,3215.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,60,,1543.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2729.43,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,1607.82,50,,1286.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3376.41,105,,2701.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.38,60,,1543.5,percent of total billed charges,60% of total billed charges for outpatient setting,412.89,3376.41,
SCREW 6.5X35MM CENTRAL/115383,69169285,CDM,278,RC,C1713,HCPCS,Outpatient,,,242.55,242.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.53,60,,116.42,percent of total billed charges,60% of total Billed charges for outpatient setting,205.88,84.88,,164.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.91,75,,145.53,percent of total billed charges,75% of total billed charges for outpatient setting,121.28,50,,97.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.04,80,,155.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,31.14,12.84,,24.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,242.55,65,,194.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.89,35,,67.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,145.53,60,,116.42,percent of total billed charges,60% of total billed charges for outpatient setting,31.14,242.55,
SCREW 6.5X35MM CNTRL COMPR / 115397,70000069,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X35MM POLYAXIAL /2911-06535,69169145,CDM,278,RC,C1713,HCPCS,Outpatient,,,3312.1,3312.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.26,60,,1589.81,percent of total billed charges,60% of total Billed charges for outpatient setting,2811.31,84.88,,2249.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484.08,75,,1987.26,percent of total billed charges,75% of total billed charges for outpatient setting,1656.05,50,,1324.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2649.68,80,,2119.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3477.71,105,,2782.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.24,35,,927.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1987.26,60,,1589.81,percent of total billed charges,60% of total billed charges for outpatient setting,425.27,3477.71,
SCREW 6.5X35MM SELF TAP / 00-6250-065-35,71000172,CDM,278,RC,C1713,HCPCS,Outpatient,,,350,350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,168,percent of total billed charges,60% of total Billed charges for outpatient setting,297.08,84.88,,237.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.5,75,,210,percent of total billed charges,75% of total billed charges for outpatient setting,175,50,,140,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,12.84,,35.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,80,,224,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,12.84,,35.95,percent of total billed charges,12.84% of total billed charges,44.94,12.84,,35.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,350,65,,280,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,35,,98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,210,60,,168,percent of total billed charges,60% of total billed charges for outpatient setting,44.94,350,
SCREW 6.5x40MM / E3S6540,69169278,CDM,278,RC,C1713,HCPCS,Outpatient,,,3215.63,3215.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,60,,1543.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2729.43,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,1607.82,50,,1286.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3376.41,105,,2701.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.38,60,,1543.5,percent of total billed charges,60% of total billed charges for outpatient setting,412.89,3376.41,
SCREW 6.5X40MM CNTRL COMPR / 115398,69169611,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X40MM CREO / 5119.1640,69161732,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
SCREW 6.5X40MM POLYAXIAL /2911-06540,69169144,CDM,278,RC,C1713,HCPCS,Outpatient,,,3312.1,3312.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.26,60,,1589.81,percent of total billed charges,60% of total Billed charges for outpatient setting,2811.31,84.88,,2249.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484.08,75,,1987.26,percent of total billed charges,75% of total billed charges for outpatient setting,1656.05,50,,1324.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2649.68,80,,2119.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3477.71,105,,2782.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.24,35,,927.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1987.26,60,,1589.81,percent of total billed charges,60% of total billed charges for outpatient setting,425.27,3477.71,
SCREW 6.5X40MM REVOLVE / 185.464,69162384,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW 6.5X40MM SELF TAP / 00-6250-065-40,71000037,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SCREW 6.5x45MM / E3S6545,69169279,CDM,278,RC,C1713,HCPCS,Outpatient,,,3215.63,3215.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,60,,1543.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2729.43,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,1607.82,50,,1286.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3376.41,105,,2701.13,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.38,60,,1543.5,percent of total billed charges,60% of total billed charges for outpatient setting,412.89,3376.41,
SCREW 6.5X45MM CREO / 5119.1645,69161788,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
SCREW 6.5X45MM CREO / 5119.1647,69162803,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
SCREW 6.5X45MM HEX / 115399,1603700,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5x45MM POLYAXIAL /2911-06545,69169158,CDM,278,RC,C1713,HCPCS,Outpatient,,,3312.1,3312.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.26,60,,1589.81,percent of total billed charges,60% of total Billed charges for outpatient setting,2811.31,84.88,,2249.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484.08,75,,1987.26,percent of total billed charges,75% of total billed charges for outpatient setting,1656.05,50,,1324.84,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2649.68,80,,2119.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,425.27,12.84,,340.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3477.71,105,,2782.17,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.24,35,,927.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1987.26,60,,1589.81,percent of total billed charges,60% of total billed charges for outpatient setting,425.27,3477.71,
SCREW 6.5X45MM REVOLVE  / 185.465,69162432,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW 6.5X50MM RVS CNTRL / 115400,1707445,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW 6.5X70MM TI CAN STRYKER / 602670S,70000437,CDM,278,RC,C1713,HCPCS,Outpatient,,,1559.09,1559.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.45,60,,748.36,percent of total billed charges,60% of total Billed charges for outpatient setting,1323.36,84.88,,1058.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1169.32,75,,935.46,percent of total billed charges,75% of total billed charges for outpatient setting,779.55,50,,623.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.19,12.84,,160.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.27,80,,997.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.19,12.84,,160.15,percent of total billed charges,12.84% of total billed charges,200.19,12.84,,160.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1559.09,65,,1247.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.68,35,,436.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,935.45,60,,748.36,percent of total billed charges,60% of total billed charges for outpatient setting,200.19,1559.09,
SCREW 6X35MM CORTICAL / 1867-31-635,69162947,CDM,278,RC,C1713,HCPCS,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
SCREW 6X40MM CORTICAL / 1867-31-640,70000196,CDM,278,RC,C1713,HCPCS,Outpatient,,,3300,3300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1980,60,,1584,percent of total billed charges,60% of total Billed charges for outpatient setting,2801.04,84.88,,2240.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2475,75,,1980,percent of total billed charges,75% of total billed charges for outpatient setting,1650,50,,1320,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2640,80,,2112,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,423.72,12.84,,338.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3465,105,,2772,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,35,,924,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,60,,1584,percent of total billed charges,60% of total billed charges for outpatient setting,423.72,3465,
SCREW 7.0X20MM BC VENTED / AR-4020C-07,71000627,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 7.3X80MM CANNULATED / 208.880,69160174,CDM,278,RC,C1769,HCPCS,Outpatient,,,1515.23,1515.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,909.14,60,,727.31,percent of total billed charges,60% of total Billed charges for outpatient setting,1286.13,84.88,,1028.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.42,75,,909.14,percent of total billed charges,75% of total billed charges for outpatient setting,757.62,50,,606.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.56,12.84,,155.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.18,80,,969.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.56,12.84,,155.65,percent of total billed charges,12.84% of total billed charges,194.56,12.84,,155.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1515.23,65,,1212.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.33,35,,424.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,909.14,60,,727.31,percent of total billed charges,60% of total billed charges for outpatient setting,194.56,1515.23,
SCREW 7.5X50MM CREO / 5119.1752,1567844,CDM,278,RC,C1713,HCPCS,Outpatient,,,2782.5,2782.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.5,60,,1335.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2361.79,84.88,,1889.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2086.88,75,,1669.5,percent of total billed charges,75% of total billed charges for outpatient setting,1391.25,50,,1113,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2226,80,,1780.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,357.27,12.84,,285.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2921.63,105,,2337.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.88,35,,779.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1669.5,60,,1335.6,percent of total billed charges,60% of total billed charges for outpatient setting,357.27,2921.63,
SCREW 7.5X50MM REVOLVE / 185.476,312462,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW 8.0X20MM BC VENTED / AR-4020C-08,71000159,CDM,278,RC,C1713,HCPCS,Outpatient,,,1180,1180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708,60,,566.4,percent of total billed charges,60% of total Billed charges for outpatient setting,1001.58,84.88,,801.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885,75,,708,percent of total billed charges,75% of total billed charges for outpatient setting,590,50,,472,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944,80,,755.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,151.51,12.84,,121.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1180,65,,944,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,35,,330.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,708,60,,566.4,percent of total billed charges,60% of total billed charges for outpatient setting,151.51,1180,
SCREW 8X23MM INTERFERENCE AR-1380C,69162027,CDM,278,RC,,,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 8X28MM INTERFERENCE / AR-5028C-08,69162674,CDM,278,RC,C1713,HCPCS,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 9.0X20MM BC VENTED / AR-4020C-09,71000160,CDM,278,RC,C1713,HCPCS,Outpatient,,,1239,1239,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.4,60,,594.72,percent of total billed charges,60% of total Billed charges for outpatient setting,1051.66,84.88,,841.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,75,,743.4,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,50,,495.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.2,80,,792.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,159.09,12.84,,127.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1239,65,,991.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.65,35,,346.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,743.4,60,,594.72,percent of total billed charges,60% of total billed charges for outpatient setting,159.09,1239,
SCREW 9X20MM CANN / 7207007,69162932,CDM,278,RC,C1713,HCPCS,Outpatient,,,558.05,558.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.83,60,,267.86,percent of total billed charges,60% of total Billed charges for outpatient setting,473.67,84.88,,378.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.54,75,,334.83,percent of total billed charges,75% of total billed charges for outpatient setting,279.03,50,,223.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.44,80,,357.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,558.05,65,,446.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.32,35,,156.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,334.83,60,,267.86,percent of total billed charges,60% of total billed charges for outpatient setting,71.65,558.05,
SCREW 9X20MM INTERFERENCE / AR-1390C,71000668,CDM,278,RC,C1713,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,60,,231.84,percent of total billed charges,60% of total Billed charges for outpatient setting,409.97,84.88,,327.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,75,,289.8,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,50,,193.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,80,,309.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483,65,,386.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,35,,135.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.8,60,,231.84,percent of total billed charges,60% of total billed charges for outpatient setting,62.02,483,
SCREW 9X23MM INTERFERENCE AR-1390C,69162144,CDM,278,RC,,,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 9X25MM INTERFERENCE / AR-1391E,71000669,CDM,278,RC,C1713,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,60,,231.84,percent of total billed charges,60% of total Billed charges for outpatient setting,409.97,84.88,,327.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,75,,289.8,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,50,,193.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,80,,309.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,62.02,12.84,,49.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,483,65,,386.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,35,,135.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.8,60,,231.84,percent of total billed charges,60% of total billed charges for outpatient setting,62.02,483,
SCREW 9X28MM INTERFERENCE / AR-5028C-09,69162029,CDM,278,RC,,,Outpatient,,,1047.11,1047.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.27,60,,502.62,percent of total billed charges,60% of total Billed charges for outpatient setting,888.79,84.88,,711.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.33,75,,628.26,percent of total billed charges,75% of total billed charges for outpatient setting,523.56,50,,418.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.69,80,,670.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,134.45,12.84,,107.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1047.11,65,,837.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.49,35,,293.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.27,60,,502.62,percent of total billed charges,60% of total billed charges for outpatient setting,134.45,1047.11,
SCREW 9X30MM CORK / 7207009,69162931,CDM,278,RC,C1713,HCPCS,Outpatient,,,558.05,558.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.83,60,,267.86,percent of total billed charges,60% of total Billed charges for outpatient setting,473.67,84.88,,378.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.54,75,,334.83,percent of total billed charges,75% of total billed charges for outpatient setting,279.03,50,,223.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.44,80,,357.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,71.65,12.84,,57.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,558.05,65,,446.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.32,35,,156.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,334.83,60,,267.86,percent of total billed charges,60% of total billed charges for outpatient setting,71.65,558.05,
SCREW ATR SET /2901-10001,69169147,CDM,278,RC,C1713,HCPCS,Outpatient,,,216.3,216.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.78,60,,103.82,percent of total billed charges,60% of total Billed charges for outpatient setting,183.6,84.88,,146.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,75,,129.78,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,50,,86.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.04,80,,138.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,27.77,12.84,,22.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,216.3,65,,173.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,35,,60.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.78,60,,103.82,percent of total billed charges,60% of total billed charges for outpatient setting,27.77,216.3,
SCREW BONE 1.7X11MM STRYKER / 58-17011E,69161971,CDM,278,RC,,,Outpatient,,,463.4,463.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.04,60,,222.43,percent of total billed charges,60% of total Billed charges for outpatient setting,393.33,84.88,,314.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.55,75,,278.04,percent of total billed charges,75% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.72,80,,296.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,463.4,65,,370.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,35,,129.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,278.04,60,,222.43,percent of total billed charges,60% of total billed charges for outpatient setting,59.5,463.4,
SCREW BONE 150/50 CORTICAL / A60-15050,70000388,CDM,278,RC,C1713,HCPCS,Outpatient,,,670.53,670.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.32,60,,321.86,percent of total billed charges,60% of total Billed charges for outpatient setting,569.15,84.88,,455.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.9,75,,402.32,percent of total billed charges,75% of total billed charges for outpatient setting,335.27,50,,268.22,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.42,80,,429.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,86.1,12.84,,68.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,670.53,65,,536.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.69,35,,187.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,402.32,60,,321.86,percent of total billed charges,60% of total billed charges for outpatient setting,86.1,670.53,
SCREW BONE 2.3X10MM STRYKER / 58-23010E,70000107,CDM,278,RC,C1713,HCPCS,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW BONE 2.3X12MM STRYKER / 58-23012E,70000108,CDM,278,RC,C1718,HCPCS,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10867.23,100,,,Fee Schedule,100% of Custom Fee Schedule,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,10867.23,
SCREW BONE 2.3X8MM STRYKER / 58-23008E,70000106,CDM,278,RC,,,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW BONE T10 3.5X20MM  / 40-35020,69162255,CDM,278,RC,,,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW BONE T7 2.3X28MM / 53-23228E,70000199,CDM,278,RC,C1713,HCPCS,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW BONE T7 2.7X22MM / 53-27222E,70000267,CDM,278,RC,,,Outpatient,,,522.14,522.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.28,60,,250.62,percent of total billed charges,60% of total Billed charges for outpatient setting,443.19,84.88,,354.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.61,75,,313.29,percent of total billed charges,75% of total billed charges for outpatient setting,261.07,50,,208.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.71,80,,334.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,67.04,12.84,,53.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,522.14,65,,417.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.75,35,,146.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,313.28,60,,250.62,percent of total billed charges,60% of total billed charges for outpatient setting,67.04,522.14,
SCREW CANNULATED COMPR. 24MM,69161440,CDM,278,RC,C1769,HCPCS,Outpatient,,,1918.21,1918.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.93,60,,920.74,percent of total billed charges,60% of total Billed charges for outpatient setting,1628.18,84.88,,1302.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1438.66,75,,1150.93,percent of total billed charges,75% of total billed charges for outpatient setting,959.11,50,,767.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1534.57,80,,1227.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1918.21,65,,1534.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.37,35,,537.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1150.93,60,,920.74,percent of total billed charges,60% of total billed charges for outpatient setting,246.3,1918.21,
SCREW CORTICAL 3.5X22 / AR-14122NL,70000241,CDM,278,RC,C1713,HCPCS,Outpatient,,,243.34,243.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,60,,116.8,percent of total billed charges,60% of total Billed charges for outpatient setting,206.55,84.88,,165.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.51,75,,146.01,percent of total billed charges,75% of total billed charges for outpatient setting,121.67,50,,97.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,80,,155.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,243.34,65,,194.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.17,35,,68.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146,60,,116.8,percent of total billed charges,60% of total billed charges for outpatient setting,31.24,243.34,
SCREW CORTICAL 3.5X24 / AR-14124NL,70000242,CDM,278,RC,C1713,HCPCS,Outpatient,,,243.34,243.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,60,,116.8,percent of total billed charges,60% of total Billed charges for outpatient setting,206.55,84.88,,165.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.51,75,,146.01,percent of total billed charges,75% of total billed charges for outpatient setting,121.67,50,,97.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,80,,155.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,243.34,65,,194.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.17,35,,68.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146,60,,116.8,percent of total billed charges,60% of total billed charges for outpatient setting,31.24,243.34,
SCREW CORTICAL 3.5X26 / AR-14126NL,70000243,CDM,278,RC,C1713,HCPCS,Outpatient,,,243.34,243.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,60,,116.8,percent of total billed charges,60% of total Billed charges for outpatient setting,206.55,84.88,,165.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.51,75,,146.01,percent of total billed charges,75% of total billed charges for outpatient setting,121.67,50,,97.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,80,,155.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,243.34,65,,194.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.17,35,,68.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146,60,,116.8,percent of total billed charges,60% of total billed charges for outpatient setting,31.24,243.34,
SCREW CORTICAL 3.5X32 / AR-14132,70000244,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW CORTICAL 3.5X34 / AR-14134,70000245,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW CORTICAL 3.5X38 / AR-14138,70000246,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW CORTICAL 4X36 / AR-14236,70000247,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW CORTICAL 4X38 / AR-14238,70000248,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW CORTICAL 4X42 / AR-14242,70000249,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW COUNTERSINK / 45-80040,70000373,CDM,272,RC,,,Outpatient,,,639.17,639.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.42,70,,357.94,percent of total billed charges,70% of total billed charges for outpatient setting,542.53,84.88,,434.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,319.59,50,,255.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479.38,75,,383.5,percent of total billed charges,75% of total billed charges for outpatient setting,447.42,70,,357.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,12.84,,65.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.34,80,,409.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,12.84,,65.66,percent of total billed charges,12.84% of total billed charges,82.07,12.84,,65.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,415.46,65,,332.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.71,35,,178.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,575.25,90,,460.2,percent of total billed charges,90% of total billed charges for outpatient setting,82.07,575.25,
SCREW CRT 3.5X22 LOCK / AR-14122,70000240,CDM,278,RC,C1713,HCPCS,Outpatient,,,484.51,484.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.71,60,,232.57,percent of total billed charges,60% of total Billed charges for outpatient setting,411.25,84.88,,329,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,50,,193.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.61,80,,310.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,484.51,65,,387.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,290.71,60,,232.57,percent of total billed charges,60% of total billed charges for outpatient setting,62.21,484.51,
SCREW FIXATION TEMP  / UM180-00-25,69169382,CDM,278,RC,C1713,HCPCS,Outpatient,,,131.25,131.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,60,,63,percent of total billed charges,60% of total Billed charges for outpatient setting,111.41,84.88,,89.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.44,75,,78.75,percent of total billed charges,75% of total billed charges for outpatient setting,65.63,50,,52.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,80,,84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,16.85,12.84,,13.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.25,65,,105,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,35,,36.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.75,60,,63,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,131.25,
SCREW HA 5.5X40MM / 187.240S,69162374,CDM,278,RC,,,Outpatient,,,2725.38,2725.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1635.23,60,,1308.18,percent of total billed charges,60% of total Billed charges for outpatient setting,2313.3,84.88,,1850.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,1362.69,50,,1090.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2044.04,75,,1635.23,percent of total billed charges,75% of total billed charges for outpatient setting,1362.69,50,,1090.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.94,12.84,,279.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2180.3,80,,1744.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.94,12.84,,279.95,percent of total billed charges,12.84% of total billed charges,349.94,12.84,,279.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2861.65,105,,2289.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.88,35,,763.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1635.23,60,,1308.18,percent of total billed charges,60% of total billed charges for outpatient setting,349.94,2861.65,
SCREW HEADLESS 2.4X17MM / 02.226.217,69161495,CDM,278,RC,,,Outpatient,,,1965,1965,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179,60,,943.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1667.89,84.88,,1334.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,982.5,50,,786,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1473.75,75,,1179,percent of total billed charges,75% of total billed charges for outpatient setting,982.5,50,,786,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.31,12.84,,201.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572,80,,1257.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.31,12.84,,201.85,percent of total billed charges,12.84% of total billed charges,252.31,12.84,,201.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1965,65,,1572,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,687.75,35,,550.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1179,60,,943.2,percent of total billed charges,60% of total billed charges for outpatient setting,252.31,1965,
SCREW HEADLESS 2.4X20MM / 02.226.220,69160975,CDM,278,RC,,,Outpatient,,,1965,1965,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179,60,,943.2,percent of total billed charges,60% of total Billed charges for outpatient setting,1667.89,84.88,,1334.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,982.5,50,,786,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1473.75,75,,1179,percent of total billed charges,75% of total billed charges for outpatient setting,982.5,50,,786,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.31,12.84,,201.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572,80,,1257.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.31,12.84,,201.85,percent of total billed charges,12.84% of total billed charges,252.31,12.84,,201.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1965,65,,1572,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,687.75,35,,550.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1179,60,,943.2,percent of total billed charges,60% of total billed charges for outpatient setting,252.31,1965,
SCREW LOCKING 2.4MM X 20MM/212.820,69159701,CDM,278,RC,,,Outpatient,,,563.01,563.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.81,60,,270.25,percent of total billed charges,60% of total Billed charges for outpatient setting,477.88,84.88,,382.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422.26,75,,337.81,percent of total billed charges,75% of total billed charges for outpatient setting,281.51,50,,225.21,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.41,80,,360.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,72.29,12.84,,57.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,563.01,65,,450.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,35,,157.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.81,60,,270.25,percent of total billed charges,60% of total billed charges for outpatient setting,72.29,563.01,
SCREW LOCKING 2.4MMX11MM / 212.811,70000573,CDM,278,RC,C1713,HCPCS,Outpatient,,,499.39,499.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.63,60,,239.7,percent of total billed charges,60% of total Billed charges for outpatient setting,423.88,84.88,,339.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.54,75,,299.63,percent of total billed charges,75% of total billed charges for outpatient setting,249.7,50,,199.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.51,80,,319.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,64.12,12.84,,51.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,499.39,65,,399.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.79,35,,139.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,299.63,60,,239.7,percent of total billed charges,60% of total billed charges for outpatient setting,64.12,499.39,
SCREW LOCKING 2.7X16MM STRYKER / 614516,69162558,CDM,278,RC,,,Outpatient,,,967.08,967.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.25,60,,464.2,percent of total billed charges,60% of total Billed charges for outpatient setting,820.86,84.88,,656.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,483.54,50,,386.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,725.31,75,,580.25,percent of total billed charges,75% of total billed charges for outpatient setting,483.54,50,,386.83,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.17,12.84,,99.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.66,80,,618.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.17,12.84,,99.34,percent of total billed charges,12.84% of total billed charges,124.17,12.84,,99.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,967.08,65,,773.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.48,35,,270.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,580.25,60,,464.2,percent of total billed charges,60% of total billed charges for outpatient setting,124.17,967.08,
SCREW LOCKING 2.7X8MM / 656308,70000679,CDM,278,RC,C1713,HCPCS,Outpatient,,,569.94,569.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.96,60,,273.57,percent of total billed charges,60% of total Billed charges for outpatient setting,483.77,84.88,,387.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.46,75,,341.97,percent of total billed charges,75% of total billed charges for outpatient setting,284.97,50,,227.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.18,12.84,,58.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.95,80,,364.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.18,12.84,,58.54,percent of total billed charges,12.84% of total billed charges,73.18,12.84,,58.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,569.94,65,,455.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.48,35,,159.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,341.96,60,,273.57,percent of total billed charges,60% of total billed charges for outpatient setting,73.18,569.94,
SCREW LOCKING 3.5MMX28MM / 212.110,70000403,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5MMX34MM / 212.113,70000400,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5MMX40MM / 212.117,70000399,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5MMX45MM / 212.119,70000404,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5MMX50MM / 212.121,70000402,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5X 6MM STRYKER / 614616,69161556,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X 70mm Stryker  614670,69162557,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X10MM STRYKER / 614610,69162555,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X12MM STRYKER / 614612,69161693,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X14MM STRYKER / 614614,69161558,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X18MM STRYKER / 614618,69161557,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X20MM / 212.106,70000401,CDM,278,RC,,,Outpatient,,,602.74,602.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.64,60,,289.31,percent of total billed charges,60% of total Billed charges for outpatient setting,511.61,84.88,,409.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,301.37,50,,241.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,452.06,75,,361.65,percent of total billed charges,75% of total billed charges for outpatient setting,301.37,50,,241.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.19,80,,385.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.74,65,,482.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.96,35,,168.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.64,60,,289.31,percent of total billed charges,60% of total billed charges for outpatient setting,77.39,602.74,
SCREW LOCKING 3.5X20MM STRYKER / 614620,69162556,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LOCKING 3.5X22MM STRYKER / 614622,69161956,CDM,278,RC,,,Outpatient,,,930.37,930.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.22,60,,446.58,percent of total billed charges,60% of total Billed charges for outpatient setting,789.7,84.88,,631.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,465.19,50,,372.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,697.78,75,,558.22,percent of total billed charges,75% of total billed charges for outpatient setting,465.19,50,,372.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.46,12.84,,95.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.3,80,,595.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.46,12.84,,95.57,percent of total billed charges,12.84% of total billed charges,119.46,12.84,,95.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,930.37,65,,744.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.63,35,,260.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,558.22,60,,446.58,percent of total billed charges,60% of total billed charges for outpatient setting,119.46,930.37,
SCREW LOCKING 3.5X24MM / 212.108,39563,CDM,278,RC,C1713,HCPCS,Outpatient,,,574.04,574.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.42,60,,275.54,percent of total billed charges,60% of total Billed charges for outpatient setting,487.25,84.88,,389.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.53,75,,344.42,percent of total billed charges,75% of total billed charges for outpatient setting,287.02,50,,229.62,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.71,12.84,,58.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.23,80,,367.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.71,12.84,,58.97,percent of total billed charges,12.84% of total billed charges,73.71,12.84,,58.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,574.04,65,,459.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.91,35,,160.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,344.42,60,,275.54,percent of total billed charges,60% of total billed charges for outpatient setting,73.71,574.04,
SCREW LOCKING 3.5X26MM / 212.109,69169795,CDM,278,RC,C1713,HCPCS,Outpatient,,,602.74,602.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.64,60,,289.31,percent of total billed charges,60% of total Billed charges for outpatient setting,511.61,84.88,,409.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.06,75,,361.65,percent of total billed charges,75% of total billed charges for outpatient setting,301.37,50,,241.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.19,80,,385.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,77.39,12.84,,61.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,602.74,65,,482.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.96,35,,168.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.64,60,,289.31,percent of total billed charges,60% of total billed charges for outpatient setting,77.39,602.74,
SCREW LOCKING 3.5x30MM / 212.111,69161429,CDM,278,RC,,,Outpatient,,,534.61,534.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.77,60,,256.62,percent of total billed charges,60% of total Billed charges for outpatient setting,453.78,84.88,,363.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.96,75,,320.77,percent of total billed charges,75% of total billed charges for outpatient setting,267.31,50,,213.85,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.69,80,,342.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,68.64,12.84,,54.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,534.61,65,,427.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,35,,149.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.77,60,,256.62,percent of total billed charges,60% of total billed charges for outpatient setting,68.64,534.61,
SCREW LOCKING 3.5X36MM STRYKER / 614636,69161957,CDM,278,RC,,,Outpatient,,,930.37,930.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.22,60,,446.58,percent of total billed charges,60% of total Billed charges for outpatient setting,789.7,84.88,,631.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,465.19,50,,372.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,697.78,75,,558.22,percent of total billed charges,75% of total billed charges for outpatient setting,465.19,50,,372.15,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.46,12.84,,95.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.3,80,,595.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.46,12.84,,95.57,percent of total billed charges,12.84% of total billed charges,119.46,12.84,,95.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,930.37,65,,744.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.63,35,,260.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,558.22,60,,446.58,percent of total billed charges,60% of total billed charges for outpatient setting,119.46,930.37,
SCREW LOCKING 4X30MM  04.005.420S,69162061,CDM,278,RC,C1776,HCPCS,Outpatient,,,1177.06,1177.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.24,60,,564.99,percent of total billed charges,60% of total Billed charges for outpatient setting,999.09,84.88,,799.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.8,75,,706.24,percent of total billed charges,75% of total billed charges for outpatient setting,588.53,50,,470.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.13,12.84,,120.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,941.65,80,,753.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.13,12.84,,120.9,percent of total billed charges,12.84% of total billed charges,151.13,12.84,,120.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1177.06,65,,941.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.97,35,,329.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,706.24,60,,564.99,percent of total billed charges,60% of total billed charges for outpatient setting,151.13,1177.06,
SCREW LOCKING 6.5X50MM STRYKER / 614650,70000064,CDM,278,RC,,,Outpatient,,,1007.53,1007.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.52,60,,483.62,percent of total billed charges,60% of total Billed charges for outpatient setting,855.19,84.88,,684.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.65,75,,604.52,percent of total billed charges,75% of total billed charges for outpatient setting,503.77,50,,403.02,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.02,80,,644.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,129.37,12.84,,103.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007.53,65,,806.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.64,35,,282.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.52,60,,483.62,percent of total billed charges,60% of total billed charges for outpatient setting,129.37,1007.53,
SCREW LO-PRO 4.5MMX45MM / AR-9045-45PT,70000093,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
SCREW LO-PRO 4X42MM / AR-5051-42,70000518,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
SCREW LO-PRO 4X50MM / AR-5051-50,69169488,CDM,278,RC,C1713,HCPCS,Outpatient,,,713.79,713.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.27,60,,342.62,percent of total billed charges,60% of total Billed charges for outpatient setting,605.86,84.88,,484.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.34,75,,428.27,percent of total billed charges,75% of total billed charges for outpatient setting,356.9,50,,285.52,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.03,80,,456.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,91.65,12.84,,73.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,713.79,65,,571.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.83,35,,199.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,428.27,60,,342.62,percent of total billed charges,60% of total billed charges for outpatient setting,91.65,713.79,
SCREW MAXIDRIVE 1.5X5MM  25-875-05-91,69162227,CDM,278,RC,C1713,HCPCS,Outpatient,,,255.83,255.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.5,60,,122.8,percent of total billed charges,60% of total Billed charges for outpatient setting,217.15,84.88,,173.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.87,75,,153.5,percent of total billed charges,75% of total billed charges for outpatient setting,127.92,50,,102.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.85,12.84,,26.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.66,80,,163.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.85,12.84,,26.28,percent of total billed charges,12.84% of total billed charges,32.85,12.84,,26.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,255.83,65,,204.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.54,35,,71.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.5,60,,122.8,percent of total billed charges,60% of total billed charges for outpatient setting,32.85,255.83,
SCREW MAXIDRIVE 1.8X5MM  25-876-05-91,69162228,CDM,278,RC,C1713,HCPCS,Outpatient,,,233.38,233.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.03,60,,112.02,percent of total billed charges,60% of total Billed charges for outpatient setting,198.09,84.88,,158.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.04,75,,140.03,percent of total billed charges,75% of total billed charges for outpatient setting,116.69,50,,93.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,12.84,,23.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.7,80,,149.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,12.84,,23.98,percent of total billed charges,12.84% of total billed charges,29.97,12.84,,23.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,233.38,65,,186.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,35,,65.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.03,60,,112.02,percent of total billed charges,60% of total billed charges for outpatient setting,29.97,233.38,
SCREW NON LOCK COMPR 4.75X35 / 180554,69169554,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,60,,115.2,percent of total billed charges,60% of total Billed charges for outpatient setting,203.71,84.88,,162.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,75,,144,percent of total billed charges,75% of total billed charges for outpatient setting,120,50,,96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,80,,153.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,30.82,12.84,,24.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,240,65,,192,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,35,,67.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144,60,,115.2,percent of total billed charges,60% of total billed charges for outpatient setting,30.82,240,
SCREW REVOLVE 5.5X30MM 185.452,69162395,CDM,278,RC,,,Outpatient,,,3250,3250,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,60,,1560,percent of total billed charges,60% of total Billed charges for outpatient setting,2758.6,84.88,,2206.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,1625,50,,1300,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2437.5,75,,1950,percent of total billed charges,75% of total billed charges for outpatient setting,1625,50,,1300,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2600,80,,2080,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3412.5,105,,2730,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,35,,910,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1950,60,,1560,percent of total billed charges,60% of total billed charges for outpatient setting,417.3,3412.5,
SCREW REVOLVE 5.5X35MM 185.453,69162369,CDM,278,RC,,,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
SCREW REVOLVE 5.5X40MM 185.454,69162368,CDM,278,RC,,,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
SCREW REVOLVE 6.5X30MM / 185.462,69162612,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW REVOLVE 6.5X35MM / 185.463,69162422,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW REVOLVE 6.5x50MM / 185.466,69162718,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SCREW REVOLVE 7.5X35MM 185.473,69162707,CDM,278,RC,C1713,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
SCREW REVOLVE 7.5X40MM 185.474,69162404,CDM,278,RC,,,Outpatient,,,3250,3250,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,60,,1560,percent of total billed charges,60% of total Billed charges for outpatient setting,2758.6,84.88,,2206.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,1625,50,,1300,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2437.5,75,,1950,percent of total billed charges,75% of total billed charges for outpatient setting,1625,50,,1300,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2600,80,,2080,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,417.3,12.84,,333.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3412.5,105,,2730,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,35,,910,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1950,60,,1560,percent of total billed charges,60% of total billed charges for outpatient setting,417.3,3412.5,
SCREW REVOLVE 7.5X45MM 185.475,69169296,CDM,278,RC,,,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
SCREW SET ELLIPSE / 182.500,69162382,CDM,278,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.34,60,,311.47,percent of total billed charges,60% of total Billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,648.9,65,,519.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,60,,311.47,percent of total billed charges,60% of total billed charges for outpatient setting,83.32,648.9,
SCREW SINGLE INNER / 1797-02-000,70000198,CDM,278,RC,C1713,HCPCS,Outpatient,,,821.94,821.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.16,60,,394.53,percent of total billed charges,60% of total Billed charges for outpatient setting,697.66,84.88,,558.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.46,75,,493.17,percent of total billed charges,75% of total billed charges for outpatient setting,410.97,50,,328.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.54,12.84,,84.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.55,80,,526.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.54,12.84,,84.43,percent of total billed charges,12.84% of total billed charges,105.54,12.84,,84.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,821.94,65,,657.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.68,35,,230.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,493.16,60,,394.53,percent of total billed charges,60% of total billed charges for outpatient setting,105.54,821.94,
SCREW SKY VRBLE 12MM / 1868-50-012,70000480,CDM,278,RC,C1713,HCPCS,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.68,60,,622.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1297.8,65,,1038.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,60,,622.94,percent of total billed charges,60% of total billed charges for outpatient setting,166.64,1297.8,
SCREW SKY VRBLE 14MM / 1868-50-014,70000351,CDM,278,RC,C1713,HCPCS,Outpatient,,,1297.8,1297.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.68,60,,622.94,percent of total billed charges,60% of total Billed charges for outpatient setting,1101.57,84.88,,881.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.35,75,,778.68,percent of total billed charges,75% of total billed charges for outpatient setting,648.9,50,,519.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.24,80,,830.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,166.64,12.84,,133.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1297.8,65,,1038.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,35,,363.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,60,,622.94,percent of total billed charges,60% of total billed charges for outpatient setting,166.64,1297.8,
SCREW T10 3.5X22MM / 40-35022,70000285,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW T10 3.5X24MM / 40-35024,70000165,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW T10 3.5X26MM LOCKING / 657326,70000620,CDM,278,RC,C1713,HCPCS,Outpatient,,,697.14,697.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.28,60,,334.62,percent of total billed charges,60% of total Billed charges for outpatient setting,591.73,84.88,,473.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.86,75,,418.29,percent of total billed charges,75% of total billed charges for outpatient setting,348.57,50,,278.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.71,80,,446.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,697.14,65,,557.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244,35,,195.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,418.28,60,,334.62,percent of total billed charges,60% of total billed charges for outpatient setting,89.51,697.14,
SCREW T10 3.5X28MM LOCKING / 657328,70000622,CDM,278,RC,C1713,HCPCS,Outpatient,,,697.15,697.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.29,60,,334.63,percent of total billed charges,60% of total Billed charges for outpatient setting,591.74,84.88,,473.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.86,75,,418.29,percent of total billed charges,75% of total billed charges for outpatient setting,348.58,50,,278.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.72,80,,446.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,89.51,12.84,,71.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,697.15,65,,557.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244,35,,195.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,418.29,60,,334.63,percent of total billed charges,60% of total billed charges for outpatient setting,89.51,697.15,
SCREW T10 3.5X30MM / 40-35030,70000128,CDM,278,RC,C1713,HCPCS,Outpatient,,,481.7,481.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.02,60,,231.22,percent of total billed charges,60% of total Billed charges for outpatient setting,408.87,84.88,,327.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.28,75,,289.02,percent of total billed charges,75% of total billed charges for outpatient setting,240.85,50,,192.68,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.36,80,,308.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,61.85,12.84,,49.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,481.7,65,,385.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.6,35,,134.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.02,60,,231.22,percent of total billed charges,60% of total billed charges for outpatient setting,61.85,481.7,
SCREW T10 3.5X34MM LOCKING / 657334,70000623,CDM,278,RC,C1713,HCPCS,Outpatient,,,678.1,678.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.86,60,,325.49,percent of total billed charges,60% of total Billed charges for outpatient setting,575.57,84.88,,460.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.58,75,,406.86,percent of total billed charges,75% of total billed charges for outpatient setting,339.05,50,,271.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.07,12.84,,69.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.48,80,,433.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.07,12.84,,69.66,percent of total billed charges,12.84% of total billed charges,87.07,12.84,,69.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,678.1,65,,542.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.34,35,,189.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,406.86,60,,325.49,percent of total billed charges,60% of total billed charges for outpatient setting,87.07,678.1,
SCREW T10 3.5X40MM LOCKING / 657340,70000621,CDM,278,RC,C1713,HCPCS,Outpatient,,,663.26,663.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.96,60,,318.37,percent of total billed charges,60% of total Billed charges for outpatient setting,562.98,84.88,,450.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.45,75,,397.96,percent of total billed charges,75% of total billed charges for outpatient setting,331.63,50,,265.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.61,80,,424.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,85.16,12.84,,68.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,663.26,65,,530.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.14,35,,185.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,397.96,60,,318.37,percent of total billed charges,60% of total billed charges for outpatient setting,85.16,663.26,
SCREW T10 BONE 3.5X28MM / 614828,70000486,CDM,278,RC,C1713,HCPCS,Outpatient,,,503.76,503.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.26,60,,241.81,percent of total billed charges,60% of total Billed charges for outpatient setting,427.59,84.88,,342.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.82,75,,302.26,percent of total billed charges,75% of total billed charges for outpatient setting,251.88,50,,201.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.01,80,,322.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,64.68,12.84,,51.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,503.76,65,,403.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,35,,141.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,302.26,60,,241.81,percent of total billed charges,60% of total billed charges for outpatient setting,64.68,503.76,
SCREW T10 BONE 3.5X42MM / 614842,69161960,CDM,278,RC,,,Outpatient,,,463.4,463.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.04,60,,222.43,percent of total billed charges,60% of total Billed charges for outpatient setting,393.33,84.88,,314.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.55,75,,278.04,percent of total billed charges,75% of total billed charges for outpatient setting,231.7,50,,185.36,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.72,80,,296.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,59.5,12.84,,47.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,463.4,65,,370.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,35,,129.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,278.04,60,,222.43,percent of total billed charges,60% of total billed charges for outpatient setting,59.5,463.4,
"SCREW THREAD 6.5,40MM/216.040",6152158,CDM,270,RC,,,Outpatient,,,247.75,247.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.43,70,,138.74,percent of total billed charges,70% of total billed charges for outpatient setting,210.29,84.88,,168.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.88,50,,99.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.81,75,,148.65,percent of total billed charges,75% of total billed charges for outpatient setting,173.43,70,,138.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,12.84,,25.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.2,80,,158.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.81,12.84,,25.45,percent of total billed charges,12.84% of total billed charges,31.81,12.84,,25.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.04,65,,128.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.71,35,,69.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,222.98,90,,178.38,percent of total billed charges,90% of total billed charges for outpatient setting,31.81,222.98,
SCREW XTEND 4.2X16MM / 161.016,69162466,CDM,278,RC,C1713,HCPCS,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.56,60,,207.65,percent of total billed charges,60% of total Billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,432.6,65,,346.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.56,60,,207.65,percent of total billed charges,60% of total billed charges for outpatient setting,55.55,432.6,
"SCREW, 4.0X28MM CANNULATED 207.628",69161421,CDM,278,RC,,,Outpatient,,,1087.3,1087.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.38,60,,521.9,percent of total billed charges,60% of total Billed charges for outpatient setting,922.9,84.88,,738.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,543.65,50,,434.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,815.48,75,,652.38,percent of total billed charges,75% of total billed charges for outpatient setting,543.65,50,,434.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.61,12.84,,111.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.84,80,,695.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.61,12.84,,111.69,percent of total billed charges,12.84% of total billed charges,139.61,12.84,,111.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1087.3,65,,869.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.56,35,,304.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,652.38,60,,521.9,percent of total billed charges,60% of total billed charges for outpatient setting,139.61,1087.3,
"SCREW, 7.3 CANNULATED 75MM  208.875",69161438,CDM,278,RC,C1769,HCPCS,Outpatient,,,1515.23,1515.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,909.14,60,,727.31,percent of total billed charges,60% of total Billed charges for outpatient setting,1286.13,84.88,,1028.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.42,75,,909.14,percent of total billed charges,75% of total billed charges for outpatient setting,757.62,50,,606.1,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.56,12.84,,155.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.18,80,,969.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.56,12.84,,155.65,percent of total billed charges,12.84% of total billed charges,194.56,12.84,,155.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1515.23,65,,1212.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.33,35,,424.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,909.14,60,,727.31,percent of total billed charges,60% of total billed charges for outpatient setting,194.56,1515.23,
"SCREW, CANNULATED COMPR. 18MM",69161439,CDM,278,RC,C1769,HCPCS,Outpatient,,,1918.21,1918.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.93,60,,920.74,percent of total billed charges,60% of total Billed charges for outpatient setting,1628.18,84.88,,1302.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1438.66,75,,1150.93,percent of total billed charges,75% of total billed charges for outpatient setting,959.11,50,,767.29,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1534.57,80,,1227.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,246.3,12.84,,197.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1918.21,65,,1534.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.37,35,,537.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1150.93,60,,920.74,percent of total billed charges,60% of total billed charges for outpatient setting,246.3,1918.21,
SCREWDRIVER T10 AO / 703887,1627320,CDM,272,RC,,,Outpatient,,,1082.4,1082.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.68,70,,606.14,percent of total billed charges,70% of total billed charges for outpatient setting,918.74,84.88,,734.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,541.2,50,,432.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,811.8,75,,649.44,percent of total billed charges,75% of total billed charges for outpatient setting,757.68,70,,606.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.98,12.84,,111.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.92,80,,692.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.98,12.84,,111.18,percent of total billed charges,12.84% of total billed charges,138.98,12.84,,111.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,703.56,65,,562.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.84,35,,303.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,974.16,90,,779.33,percent of total billed charges,90% of total billed charges for outpatient setting,138.98,974.16,
SCREWDRIVER T15 CANN / AR-8943-09,71000586,CDM,272,RC,,,Outpatient,,,1155,1155,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.5,70,,646.8,percent of total billed charges,70% of total billed charges for outpatient setting,980.36,84.88,,784.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,577.5,50,,462,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,866.25,75,,693,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,70,,646.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924,80,,739.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,148.3,12.84,,118.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,750.75,65,,600.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.25,35,,323.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1039.5,90,,831.6,percent of total billed charges,90% of total billed charges for outpatient setting,148.3,1039.5,
SCROTAL SUPPORT LG / 7551932,6150365,CDM,270,RC,,,Outpatient,,,71.4,71.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.98,70,,39.98,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,84.88,,48.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.7,50,,28.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,75,,42.84,percent of total billed charges,75% of total billed charges for outpatient setting,49.98,70,,39.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,12.84,,7.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.12,80,,45.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,12.84,,7.34,percent of total billed charges,12.84% of total billed charges,9.17,12.84,,7.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.41,65,,37.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,35,,19.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.26,90,,51.41,percent of total billed charges,90% of total billed charges for outpatient setting,9.17,64.26,
SCROTAL SUPPORT MED / 202549,7650835,CDM,272,RC,,,Outpatient,,,40.95,40.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.67,70,,22.94,percent of total billed charges,70% of total billed charges for outpatient setting,34.76,84.88,,27.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.48,50,,16.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.71,75,,24.57,percent of total billed charges,75% of total billed charges for outpatient setting,28.67,70,,22.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,12.84,,4.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.76,80,,26.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.26,12.84,,4.21,percent of total billed charges,12.84% of total billed charges,5.26,12.84,,4.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.62,65,,21.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.33,35,,11.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.86,90,,29.49,percent of total billed charges,90% of total billed charges for outpatient setting,5.26,36.86,
SCROTAL SUPPORT XLG / 2570-01XL,6150364,CDM,270,RC,,,Outpatient,,,88.5,88.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.95,70,,49.56,percent of total billed charges,70% of total billed charges for outpatient setting,75.12,84.88,,60.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.25,50,,35.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.38,75,,53.1,percent of total billed charges,75% of total billed charges for outpatient setting,61.95,70,,49.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,12.84,,9.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.8,80,,56.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,12.84,,9.09,percent of total billed charges,12.84% of total billed charges,11.36,12.84,,9.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.53,65,,46.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,35,,24.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.65,90,,63.72,percent of total billed charges,90% of total billed charges for outpatient setting,11.36,79.65,
SCROTAL SUPPORT XXLG / 0910-05,70000021,CDM,270,RC,,,Outpatient,,,34.4,34.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,29.2,84.88,,23.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.2,50,,13.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.8,75,,20.64,percent of total billed charges,75% of total billed charges for outpatient setting,24.08,70,,19.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,12.84,,3.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.52,80,,22.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,12.84,,3.54,percent of total billed charges,12.84% of total billed charges,4.42,12.84,,3.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.36,65,,17.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.04,35,,9.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.96,90,,24.77,percent of total billed charges,90% of total billed charges for outpatient setting,4.42,30.96,
SCRUB 4OZ SOLN TECHNI CARE / C2224,69162864,CDM,272,RC,,,Outpatient,,,56.13,56.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.29,70,,31.43,percent of total billed charges,70% of total billed charges for outpatient setting,47.64,84.88,,38.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.07,50,,22.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.1,75,,33.68,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,70,,31.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.9,80,,35.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.48,65,,29.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.65,35,,15.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.52,90,,40.42,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,50.52,
SEAL SET MYOSURE / 40-902,69162576,CDM,272,RC,,,Outpatient,,,75.71,75.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53,70,,42.4,percent of total billed charges,70% of total billed charges for outpatient setting,64.26,84.88,,51.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.86,50,,30.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.78,75,,45.42,percent of total billed charges,75% of total billed charges for outpatient setting,53,70,,42.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,12.84,,7.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.57,80,,48.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,12.84,,7.78,percent of total billed charges,12.84% of total billed charges,9.72,12.84,,7.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.21,65,,39.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,35,,21.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,68.14,90,,54.51,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,68.14,
SEALANT 2ML VISTASEAL / VST02EA,7229977,CDM,272,RC,,,Outpatient,,,424.32,424.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.02,70,,237.62,percent of total billed charges,70% of total billed charges for outpatient setting,360.16,84.88,,288.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.16,50,,169.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.24,75,,254.59,percent of total billed charges,75% of total billed charges for outpatient setting,297.02,70,,237.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.48,12.84,,43.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.46,80,,271.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.48,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,54.48,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.81,65,,220.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.51,35,,118.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.89,90,,305.51,percent of total billed charges,90% of total billed charges for outpatient setting,54.48,381.89,
SEALANT 4ML VISTASEAL / VST04,7222182,CDM,272,RC,,,Outpatient,,,785.8,785.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.06,70,,440.05,percent of total billed charges,70% of total billed charges for outpatient setting,666.99,84.88,,533.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,392.9,50,,314.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.35,75,,471.48,percent of total billed charges,75% of total billed charges for outpatient setting,550.06,70,,440.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.9,12.84,,80.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.64,80,,502.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.9,12.84,,80.72,percent of total billed charges,12.84% of total billed charges,100.9,12.84,,80.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,510.77,65,,408.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.03,35,,220.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,707.22,90,,565.78,percent of total billed charges,90% of total billed charges for outpatient setting,100.9,707.22,
"SEALS GREEN, for 0-7FR /CS-G7",6153016,CDM,270,RC,,,Outpatient,,,138.95,138.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.27,70,,77.82,percent of total billed charges,70% of total billed charges for outpatient setting,117.94,84.88,,94.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.48,50,,55.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.21,75,,83.37,percent of total billed charges,75% of total billed charges for outpatient setting,97.27,70,,77.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,12.84,,14.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.16,80,,88.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,12.84,,14.27,percent of total billed charges,12.84% of total billed charges,17.84,12.84,,14.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.32,65,,72.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,35,,38.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.06,90,,100.05,percent of total billed charges,90% of total billed charges for outpatient setting,17.84,125.06,
"SECURE-C CORE 13x14, 7MM  414.207S",69169486,CDM,278,RC,C1889,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"SECURE-C CORE 13x14, 8mm   414.208S",69162165,CDM,278,RC,C1889,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"SECURE-C CORE 13x14, 9mm   414.209S",69169136,CDM,278,RC,C1889,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
SECURESTRAP 5MM / STRAP25,69161218,CDM,272,RC,,,Outpatient,,,2158.67,2158.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1511.07,70,,1208.86,percent of total billed charges,70% of total billed charges for outpatient setting,1832.28,84.88,,1465.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1079.34,50,,863.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1619,75,,1295.2,percent of total billed charges,75% of total billed charges for outpatient setting,1511.07,70,,1208.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.17,12.84,,221.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1726.94,80,,1381.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.17,12.84,,221.74,percent of total billed charges,12.84% of total billed charges,277.17,12.84,,221.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1403.14,65,,1122.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.53,35,,604.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1942.8,90,,1554.24,percent of total billed charges,90% of total billed charges for outpatient setting,277.17,1942.8,
SED RATE,210101,CDM,305,RC,85652,HCPCS,Outpatient,,,34.74,31.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,29.49,84.88,,23.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.63,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,26.06,75,,20.85,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,70,,19.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,80,,22.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.13,100,,,Fee Schedule,100% of Custom Fee Schedule,31.27,90,,25.02,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,31.27,
SEE CLEAR PLUME AWAY / SCO82500,6151202,CDM,272,RC,,,Outpatient,,,214.65,214.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.26,70,,120.21,percent of total billed charges,70% of total billed charges for outpatient setting,182.19,84.88,,145.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,107.33,50,,85.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.99,75,,128.79,percent of total billed charges,75% of total billed charges for outpatient setting,150.26,70,,120.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,12.84,,22.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.72,80,,137.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,12.84,,22.05,percent of total billed charges,12.84% of total billed charges,27.56,12.84,,22.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,139.52,65,,111.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.13,35,,60.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,193.19,90,,154.55,percent of total billed charges,90% of total billed charges for outpatient setting,27.56,193.19,
SEGMENTAL W/ TOE UPS,2600059,CDM,921,RC,93923,HCPCS,Outpatient,,,636,636,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
SELEGILINE (ELDEPRYL) TAB: 5 MG,3301955,CDM,259,RC,,,Outpatient,,,6.21,6.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,84.88,,4.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.11,50,,2.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.66,75,,3.73,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,70,,3.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,80,,3.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,0.8,12.84,,0.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.04,65,,3.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,35,,1.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.59,90,,4.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.8,5.59,
"SELENIUM, SERUM",220829,CDM,300,RC,84255,HCPCS,Outpatient,,,114.89,103.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.42,70,,64.34,percent of total billed charges,70% of total billed charges for outpatient setting,97.52,84.88,,78.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.84,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,86.17,75,,68.94,percent of total billed charges,75% of total billed charges for outpatient setting,80.42,70,,64.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.91,80,,73.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.41,100,,,Fee Schedule,100% of Custom Fee Schedule,103.4,90,,82.72,percent of total billed charges,90% of total billed charges for outpatient setting,25.53,103.4,
SELLA TURCICA,2400085,CDM,320,RC,70240,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SEMITENDINOSUS SGL STRD NON-BN TDN,69162036,CDM,278,RC,,,Outpatient,,,2420,2420,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1452,60,,1161.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2054.1,84.88,,1643.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,1210,50,,968,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1815,75,,1452,percent of total billed charges,75% of total billed charges for outpatient setting,1210,50,,968,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.73,12.84,,248.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1936,80,,1548.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.73,12.84,,248.58,percent of total billed charges,12.84% of total billed charges,310.73,12.84,,248.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2541,105,,2032.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847,35,,677.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1452,60,,1161.6,percent of total billed charges,60% of total billed charges for outpatient setting,310.73,2541,
SENNA (SENOKOT) 8.6 MG TAB,3301957,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SENNA (SENOKOT) TAB:,3301956,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SENNA (SENOKOT-S) TAB: U/D,3301958,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SENNA/DOCUSATE(SENOKOT-S),3302589,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SENNOSIDES (EX-LAX) MAX RELIEF TAB:,3301962,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SENNOSIDES (SENNA LAX) TAB:,3301959,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SENNOSIDES (SENNA-GEN NF) TAB:,3301960,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SENNOSIDES (SENOKOT CHILD) 75 ML SYRUP:,3301961,CDM,259,RC,,,Outpatient,,,15.91,15.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,84.88,,10.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.96,50,,6.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,75,,9.54,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,70,,8.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,80,,10.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,2.04,12.84,,1.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.34,65,,8.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.32,90,,11.46,percent of total billed charges,90% of total billed charges for outpatient setting,2.04,14.32,
SENNOSIDES/DOCU NA (8.6MG/50MG) TAB,3314265,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SENSIPAR 30 MG: TABS,3303139,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
SENSOR ESOPHAGEAL STETH 18FR / SMES400-1,6152731,CDM,270,RC,,,Outpatient,,,26.21,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.35,70,,14.68,percent of total billed charges,70% of total billed charges for outpatient setting,22.25,84.88,,17.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.11,50,,10.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.66,75,,15.73,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,70,,14.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.97,80,,16.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.04,65,,13.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,35,,7.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.59,90,,18.87,percent of total billed charges,90% of total billed charges for outpatient setting,3.37,23.59,
SENSOR O2 NASAL ASSRE ALAR/ 301-11214,69162747,CDM,270,RC,,,Outpatient,,,117.42,117.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.19,70,,65.75,percent of total billed charges,70% of total billed charges for outpatient setting,99.67,84.88,,79.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.71,50,,46.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.07,75,,70.46,percent of total billed charges,75% of total billed charges for outpatient setting,82.19,70,,65.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,12.84,,12.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.94,80,,75.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,12.84,,12.06,percent of total billed charges,12.84% of total billed charges,15.08,12.84,,12.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.32,65,,61.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.1,35,,32.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.68,90,,84.54,percent of total billed charges,90% of total billed charges for outpatient setting,15.08,105.68,
SENSOR QUANTO BIS MONITOR / 186-0106,69169298,CDM,272,RC,,,Outpatient,,,108,108,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,60.48,percent of total billed charges,70% of total billed charges for outpatient setting,91.67,84.88,,73.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,54,50,,43.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,75,,64.8,percent of total billed charges,75% of total billed charges for outpatient setting,75.6,70,,60.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.87,12.84,,11.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,80,,69.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.87,12.84,,11.1,percent of total billed charges,12.84% of total billed charges,13.87,12.84,,11.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.2,65,,56.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,35,,30.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.2,90,,77.76,percent of total billed charges,90% of total billed charges for outpatient setting,13.87,97.2,
"SEROTONIN, SERUM",220761,CDM,301,RC,84260,HCPCS,Outpatient,,,139.41,125.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.59,70,,78.07,percent of total billed charges,70% of total billed charges for outpatient setting,118.33,84.88,,94.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.2,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,104.56,75,,83.65,percent of total billed charges,75% of total billed charges for outpatient setting,97.59,70,,78.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.53,80,,89.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.74,100,,,Fee Schedule,100% of Custom Fee Schedule,125.47,90,,100.38,percent of total billed charges,90% of total billed charges for outpatient setting,30.98,125.47,
SERTRALINE (genZOLOFT) 50MG TAB,3301963,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SERTRALINE (ZOLOFT) 25MG: TAB,3303098,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
SERTRALINE (ZOLOFT) TAB:100MG UD,3301964,CDM,259,RC,,,Outpatient,,,7.5,7.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,70,,4.2,percent of total billed charges,70% of total billed charges for outpatient setting,6.37,84.88,,5.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.75,50,,3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.63,75,,4.5,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,70,,4.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,12.84,,0.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,80,,4.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,12.84,,0.77,percent of total billed charges,12.84% of total billed charges,0.96,12.84,,0.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.88,65,,3.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,35,,2.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.75,90,,5.4,percent of total billed charges,90% of total billed charges for outpatient setting,0.96,6.75,
SET 1000ML FEEDING KANGAROO / 773621,322206,CDM,271,RC,,,Outpatient,,,16.56,16.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.06,84.88,,11.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.42,75,,9.94,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,80,,10.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,35,,4.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
SET 103IN 60GTT DUO VNT / 2C8851,71000015,CDM,271,RC,,,Outpatient,,,43.4,43.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,70,,24.3,percent of total billed charges,70% of total billed charges for outpatient setting,36.84,84.88,,29.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.7,50,,17.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.55,75,,26.04,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,70,,24.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.72,80,,27.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,5.57,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.21,65,,22.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,35,,12.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.06,90,,31.25,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,39.06,
SET 10GTT 37IN SECONDARY / 2C7462,63923,CDM,272,RC,,,Outpatient,,,10.26,10.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,8.71,84.88,,6.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.13,50,,4.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.7,75,,6.16,percent of total billed charges,75% of total billed charges for outpatient setting,7.18,70,,5.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.21,80,,6.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.32,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.67,65,,5.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,35,,2.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.23,90,,7.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.32,9.23,
SET 15GTT/ML 113IN CARESITE / 354201,1774947,CDM,272,RC,,,Outpatient,,,23.49,23.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,19.94,84.88,,15.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.75,50,,9.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.62,75,,14.1,percent of total billed charges,75% of total billed charges for outpatient setting,16.44,70,,13.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,12.84,,2.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,80,,15.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.02,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.27,65,,12.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,35,,6.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.14,90,,16.91,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,21.14,
SET 170-260 10GTT Y TYPE / 2C8750,63927,CDM,272,RC,,,Outpatient,,,48.3,48.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.81,70,,27.05,percent of total billed charges,70% of total billed charges for outpatient setting,41,84.88,,32.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.15,50,,19.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.23,75,,28.98,percent of total billed charges,75% of total billed charges for outpatient setting,33.81,70,,27.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,12.84,,4.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.64,80,,30.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,12.84,,4.96,percent of total billed charges,12.84% of total billed charges,6.2,12.84,,4.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.4,65,,25.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,35,,13.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.47,90,,34.78,percent of total billed charges,90% of total billed charges for outpatient setting,6.2,43.47,
SET 20G  IV SYSTEM/383335,69160924,CDM,272,RC,,,Outpatient,,,25.79,25.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,70,,14.44,percent of total billed charges,70% of total billed charges for outpatient setting,21.89,84.88,,17.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.9,50,,10.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.34,75,,15.47,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,70,,14.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.63,80,,16.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.76,65,,13.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,35,,7.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.21,90,,18.57,percent of total billed charges,90% of total billed charges for outpatient setting,3.31,23.21,
SET 22G X .75 ANGIO IV SYSTEM / 383322,2350001,CDM,272,RC,,,Outpatient,,,25.87,25.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,70,,14.49,percent of total billed charges,70% of total billed charges for outpatient setting,21.96,84.88,,17.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.94,50,,10.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.4,75,,15.52,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,70,,14.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,80,,16.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,3.32,12.84,,2.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.82,65,,13.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.05,35,,7.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.28,90,,18.62,percent of total billed charges,90% of total billed charges for outpatient setting,3.32,23.28,
SET 3.8CM 0.038IN CRCTHYRTMY / G06245,71000993,CDM,272,RC,,,Outpatient,,,436,436,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.2,70,,244.16,percent of total billed charges,70% of total billed charges for outpatient setting,370.08,84.88,,296.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,218,50,,174.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327,75,,261.6,percent of total billed charges,75% of total billed charges for outpatient setting,305.2,70,,244.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.98,12.84,,44.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.8,80,,279.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.98,12.84,,44.78,percent of total billed charges,12.84% of total billed charges,55.98,12.84,,44.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,283.4,65,,226.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.6,35,,122.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,392.4,90,,313.92,percent of total billed charges,90% of total billed charges for outpatient setting,55.98,392.4,
SET 37IN EXTENSION MALE / ACT6227,71000014,CDM,271,RC,,,Outpatient,,,9.79,9.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.85,70,,5.48,percent of total billed charges,70% of total billed charges for outpatient setting,8.31,84.88,,6.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.9,50,,3.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.34,75,,5.87,percent of total billed charges,75% of total billed charges for outpatient setting,6.85,70,,5.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,80,,6.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,1.26,12.84,,1.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.36,65,,5.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.43,35,,2.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.81,90,,7.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.26,8.81,
SET 60GTT 103IN PRIMARY / SM872M,792243,CDM,272,RC,,,Outpatient,,,30.24,30.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,25.67,84.88,,20.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.12,50,,12.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.68,75,,18.14,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,70,,16.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,80,,19.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.66,65,,15.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,35,,8.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.22,90,,21.78,percent of total billed charges,90% of total billed charges for outpatient setting,3.88,27.22,
SET 60GTT 86IN IV FAT EMULS / 2C1146,656419,CDM,272,RC,,,Outpatient,,,32.48,32.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,70,,18.19,percent of total billed charges,70% of total billed charges for outpatient setting,27.57,84.88,,22.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.24,50,,12.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.36,75,,19.49,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,70,,18.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,80,,20.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,4.17,12.84,,3.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.11,65,,16.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,35,,9.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.23,90,,23.38,percent of total billed charges,90% of total billed charges for outpatient setting,4.17,29.23,
SET 60IN IV EXT PCA TUBING / V6222,1366158,CDM,272,RC,,,Outpatient,,,23.67,23.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.57,70,,13.26,percent of total billed charges,70% of total billed charges for outpatient setting,20.09,84.88,,16.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,50,,9.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.75,75,,14.2,percent of total billed charges,75% of total billed charges for outpatient setting,16.57,70,,13.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,12.84,,2.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,80,,15.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,12.84,,2.43,percent of total billed charges,12.84% of total billed charges,3.04,12.84,,2.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.39,65,,12.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,35,,6.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.3,90,,17.04,percent of total billed charges,90% of total billed charges for outpatient setting,3.04,21.3,
SET 8IN EXT PCA,368360,CDM,272,RC,,,Outpatient,,,18.53,18.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,15.73,84.88,,12.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.27,50,,7.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.9,75,,11.12,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,70,,10.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,80,,11.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.38,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,65,,9.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.49,35,,5.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.68,90,,13.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.38,16.68,
SET 8IN EXTENSION CARESITE / 470124,1692881,CDM,272,RC,,,Outpatient,,,15.93,15.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,84.88,,10.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.97,50,,6.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.95,75,,9.56,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,70,,8.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,80,,10.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.35,65,,8.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,35,,4.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.34,90,,11.47,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.34,
SET 9.5IN MAXPLUS NEEDLEFREE / MPX9102-C,71000603,CDM,272,RC,,,Outpatient,,,25.28,25.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,70,,14.16,percent of total billed charges,70% of total billed charges for outpatient setting,21.46,84.88,,17.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.64,50,,10.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.96,75,,15.17,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,70,,14.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,80,,16.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.43,65,,13.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,35,,7.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.75,90,,18.2,percent of total billed charges,90% of total billed charges for outpatient setting,3.25,22.75,
SET ARRAY VELYS / 451570011,71000426,CDM,272,RC,,,Outpatient,,,1484,1484,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.8,70,,831.04,percent of total billed charges,70% of total billed charges for outpatient setting,1259.62,84.88,,1007.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,742,50,,593.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1113,75,,890.4,percent of total billed charges,75% of total billed charges for outpatient setting,1038.8,70,,831.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.55,12.84,,152.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1187.2,80,,949.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.55,12.84,,152.44,percent of total billed charges,12.84% of total billed charges,190.55,12.84,,152.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,964.6,65,,771.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.4,35,,415.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1335.6,90,,1068.48,percent of total billed charges,90% of total billed charges for outpatient setting,190.55,1335.6,
SET CADD EXT 60IN / 21-7047-24,69169027,CDM,272,RC,,,Outpatient,,,14.02,14.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,11.9,84.88,,9.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.01,50,,5.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.52,75,,8.42,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,70,,7.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,80,,8.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,1.8,12.84,,1.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.11,65,,7.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,35,,3.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.62,90,,10.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,12.62,
SET CANNULA TROCAR GRAY ORNG / 9718,6150862,CDM,270,RC,,,Outpatient,,,75.32,75.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.72,70,,42.18,percent of total billed charges,70% of total billed charges for outpatient setting,63.93,84.88,,51.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.66,50,,30.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.49,75,,45.19,percent of total billed charges,75% of total billed charges for outpatient setting,52.72,70,,42.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,12.84,,7.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.26,80,,48.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.67,12.84,,7.74,percent of total billed charges,12.84% of total billed charges,9.67,12.84,,7.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.96,65,,39.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.36,35,,21.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.79,90,,54.23,percent of total billed charges,90% of total billed charges for outpatient setting,9.67,67.79,
SET CYSTO IRRG TUBING / 2C4040,6150081,CDM,272,RC,,,Outpatient,,,32.16,32.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.51,70,,18.01,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,84.88,,21.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.08,50,,12.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.12,75,,19.3,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,70,,18.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,80,,20.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,4.13,12.84,,3.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.9,65,,16.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,35,,9.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.94,90,,23.15,percent of total billed charges,90% of total billed charges for outpatient setting,4.13,28.94,
SET EPIDURAL MALE LUER LOCK/2L3504,5150224,CDM,272,RC,,,Outpatient,,,87.37,87.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.16,70,,48.93,percent of total billed charges,70% of total billed charges for outpatient setting,74.16,84.88,,59.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.69,50,,34.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.53,75,,52.42,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,70,,48.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,12.84,,8.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.9,80,,55.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,11.22,12.84,,8.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,56.79,65,,45.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.58,35,,24.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,78.63,90,,62.9,percent of total billed charges,90% of total billed charges for outpatient setting,11.22,78.63,
SET EXTENSION / 2N3341,5150035,CDM,272,RC,,,Outpatient,,,25.6,25.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.92,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,84.88,,17.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.8,50,,10.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.2,75,,15.36,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.48,80,,16.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.64,65,,13.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.96,35,,7.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.04,90,,18.43,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,23.04,
SET EXTENSION 96IN / 2C9206,6150088,CDM,272,RC,,,Outpatient,,,44.35,44.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.05,70,,24.84,percent of total billed charges,70% of total billed charges for outpatient setting,37.64,84.88,,30.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.18,50,,17.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.26,75,,26.61,percent of total billed charges,75% of total billed charges for outpatient setting,31.05,70,,24.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,12.84,,4.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.48,80,,28.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,12.84,,4.55,percent of total billed charges,12.84% of total billed charges,5.69,12.84,,4.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.83,65,,23.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.52,35,,12.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.92,90,,31.94,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,39.92,
SET EXTENSION SET W/ FILTER,7651117,CDM,272,RC,,,Outpatient,,,11.25,11.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,9.55,84.88,,7.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.63,50,,4.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.44,75,,6.75,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,80,,7.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.31,65,,5.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,35,,3.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.13,90,,8.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.44,10.13,
SET GENESYS PROCEDURE / M006580211,70000550,CDM,272,RC,,,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,70,,1456,percent of total billed charges,70% of total billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1820,70,,1456,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1690,65,,1352,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2340,90,,1872,percent of total billed charges,90% of total billed charges for outpatient setting,333.84,2340,
SET INTERLINK EXTENSION / 2C6671,5150026,CDM,272,RC,,,Outpatient,,,21.22,21.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,70,,11.88,percent of total billed charges,70% of total billed charges for outpatient setting,18.01,84.88,,14.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.61,50,,8.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.92,75,,12.74,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,70,,11.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.98,80,,13.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,2.72,12.84,,2.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.79,65,,11.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,35,,5.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.1,90,,15.28,percent of total billed charges,90% of total billed charges for outpatient setting,2.72,19.1,
SET IV 2.2ML 14IN EXT / 2C8632,49802,CDM,272,RC,,,Outpatient,,,23.94,23.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,84.88,,16.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.97,50,,9.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.96,75,,14.37,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,70,,13.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.15,80,,15.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,3.07,12.84,,2.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.56,65,,12.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,35,,6.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.55,90,,17.24,percent of total billed charges,90% of total billed charges for outpatient setting,3.07,21.55,
SET IV ADMIN 15DR / V1416,70000417,CDM,272,RC,,,Outpatient,,,14.21,14.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,84.88,,9.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.11,50,,5.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.66,75,,8.53,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,80,,9.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.24,65,,7.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,35,,3.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.79,90,,10.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.79,
SET IV ADMIN 3SIT LL108IN / 2C8537,5050031,CDM,272,RC,,,Outpatient,,,30.8,30.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.56,70,,17.25,percent of total billed charges,70% of total billed charges for outpatient setting,26.14,84.88,,20.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.4,50,,12.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.1,75,,18.48,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,70,,17.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.64,80,,19.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.02,65,,16.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,35,,8.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.72,90,,22.18,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,27.72,
SET IV EXT 2 SITES 42IN NDLESS / 2C8612,5150025,CDM,272,RC,,,Outpatient,,,23.67,23.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.57,70,,13.26,percent of total billed charges,70% of total billed charges for outpatient setting,20.09,84.88,,16.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.84,50,,9.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.75,75,,14.2,percent of total billed charges,75% of total billed charges for outpatient setting,16.57,70,,13.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,12.84,,2.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,80,,15.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,12.84,,2.43,percent of total billed charges,12.84% of total billed charges,3.04,12.84,,2.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.39,65,,12.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,35,,6.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.3,90,,17.04,percent of total billed charges,90% of total billed charges for outpatient setting,3.04,21.3,
SET IV EXT CONTROLLER FLOW / 2C8891,70000448,CDM,272,RC,,,Outpatient,,,39.45,39.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.62,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,33.49,84.88,,26.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.73,50,,15.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.59,75,,23.67,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.56,80,,25.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.64,65,,20.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.81,35,,11.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.51,90,,28.41,percent of total billed charges,90% of total billed charges for outpatient setting,5.07,35.51,
SET IV SECONDARY 60GTT / 2H7463,69160747,CDM,272,RC,,,Outpatient,,,15.39,15.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.77,70,,8.62,percent of total billed charges,70% of total billed charges for outpatient setting,13.06,84.88,,10.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.7,50,,6.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.54,75,,9.23,percent of total billed charges,75% of total billed charges for outpatient setting,10.77,70,,8.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.31,80,,9.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.98,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10,65,,8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,35,,4.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.85,90,,11.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.98,13.85,
SET IV SECONDARY IVPB / 2C7451,6150087,CDM,272,RC,,,Outpatient,,,12.51,12.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.76,70,,7.01,percent of total billed charges,70% of total billed charges for outpatient setting,10.62,84.88,,8.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.26,50,,5.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.38,75,,7.5,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,70,,7.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,80,,8.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.13,65,,6.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.38,35,,3.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.26,90,,9.01,percent of total billed charges,90% of total billed charges for outpatient setting,1.61,11.26,
SET IV TUBING 60GTT CLR VALVES / 2C8546,6150086,CDM,272,RC,,,Outpatient,,,32.72,32.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.9,70,,18.32,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,84.88,,22.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.36,50,,13.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.54,75,,19.63,percent of total billed charges,75% of total billed charges for outpatient setting,22.9,70,,18.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.18,80,,20.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,4.2,12.84,,3.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.27,65,,17.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,35,,9.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.45,90,,23.56,percent of total billed charges,90% of total billed charges for outpatient setting,4.2,29.45,
SET JEJUNAL FEEDING TUBE / G22639,70000586,CDM,272,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.19,65,,224.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.55,389.34,
SET PIN DRILL GENESIS TK / 114968,69161088,CDM,272,RC,,,Outpatient,,,229.15,229.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.41,70,,128.33,percent of total billed charges,70% of total billed charges for outpatient setting,194.5,84.88,,155.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.58,50,,91.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.86,75,,137.49,percent of total billed charges,75% of total billed charges for outpatient setting,160.41,70,,128.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.32,80,,146.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.95,65,,119.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.2,35,,64.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.24,90,,164.99,percent of total billed charges,90% of total billed charges for outpatient setting,29.42,206.24,
SET REFLUX Y 8  2L3506 no longer made,5150032,CDM,270,RC,,,Outpatient,,,30.23,30.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.16,70,,16.93,percent of total billed charges,70% of total billed charges for outpatient setting,25.66,84.88,,20.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.12,50,,12.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.67,75,,18.14,percent of total billed charges,75% of total billed charges for outpatient setting,21.16,70,,16.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.18,80,,19.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.88,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.65,65,,15.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,35,,8.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.21,90,,21.77,percent of total billed charges,90% of total billed charges for outpatient setting,3.88,27.21,
SET RETRACTOR WILSON HOOK / TLC5042M,1114483,CDM,272,RC,,,Outpatient,,,1136,1136,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.2,70,,636.16,percent of total billed charges,70% of total billed charges for outpatient setting,964.24,84.88,,771.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,568,50,,454.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852,75,,681.6,percent of total billed charges,75% of total billed charges for outpatient setting,795.2,70,,636.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.86,12.84,,116.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.8,80,,727.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.86,12.84,,116.69,percent of total billed charges,12.84% of total billed charges,145.86,12.84,,116.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,738.4,65,,590.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.6,35,,318.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1022.4,90,,817.92,percent of total billed charges,90% of total billed charges for outpatient setting,145.86,1022.4,
SET SCREW DRIVER 2MM / 00-5987-071-00,69169407,CDM,272,RC,,,Outpatient,,,368,368,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.6,70,,206.08,percent of total billed charges,70% of total billed charges for outpatient setting,312.36,84.88,,249.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,184,50,,147.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276,75,,220.8,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,70,,206.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.4,80,,235.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,47.25,12.84,,37.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,239.2,65,,191.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.8,35,,103.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,331.2,90,,264.96,percent of total billed charges,90% of total billed charges for outpatient setting,47.25,331.2,
SET SECOND INTERLNK LEVER LOCK / 2C7461,5050036,CDM,272,RC,,,Outpatient,,,8.13,8.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,70,,4.55,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,84.88,,5.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.07,50,,3.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.1,75,,4.88,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,70,,4.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,80,,5.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.28,65,,4.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,35,,2.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.32,90,,5.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.32,
SET SECOND INTRLINK LVR LCK // BHL2C7451,2450021,CDM,272,RC,,,Outpatient,,,11.39,11.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,70,,6.38,percent of total billed charges,70% of total billed charges for outpatient setting,9.67,84.88,,7.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.7,50,,4.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.54,75,,6.83,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,70,,6.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,80,,7.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,1.46,12.84,,1.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.4,65,,5.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,35,,3.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.25,90,,8.2,percent of total billed charges,90% of total billed charges for outpatient setting,1.46,10.25,
SET SECONDARY DETACHED NEEDLE,7650810,CDM,272,RC,,,Outpatient,,,91.43,91.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64,70,,51.2,percent of total billed charges,70% of total billed charges for outpatient setting,77.61,84.88,,62.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.72,50,,36.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.57,75,,54.86,percent of total billed charges,75% of total billed charges for outpatient setting,64,70,,51.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,12.84,,9.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.14,80,,58.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,12.84,,9.39,percent of total billed charges,12.84% of total billed charges,11.74,12.84,,9.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.43,65,,47.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,35,,25.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.29,90,,65.83,percent of total billed charges,90% of total billed charges for outpatient setting,11.74,82.29,
SET SMALLBORE EXT 13IN // 473105,69162023,CDM,272,RC,,,Outpatient,,,15.96,15.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.17,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,84.88,,10.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.98,50,,6.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,75,,9.58,percent of total billed charges,75% of total billed charges for outpatient setting,11.17,70,,8.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,80,,10.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,2.05,12.84,,1.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.37,65,,8.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,35,,4.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.36,90,,11.49,percent of total billed charges,90% of total billed charges for outpatient setting,2.05,14.36,
SET SOLUTION W/ DUOVENT SPIKE / 1C8507,70000194,CDM,272,RC,,,Outpatient,,,32.79,32.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.95,70,,18.36,percent of total billed charges,70% of total billed charges for outpatient setting,27.83,84.88,,22.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.4,50,,13.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.59,75,,19.67,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,70,,18.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.23,80,,20.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,4.21,12.84,,3.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.31,65,,17.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,35,,9.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.51,90,,23.61,percent of total billed charges,90% of total billed charges for outpatient setting,4.21,29.51,
SET Y-SITE 0.2 MCRN FILTER / 20668-28,71000309,CDM,272,RC,,,Outpatient,,,18.63,18.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.04,70,,10.43,percent of total billed charges,70% of total billed charges for outpatient setting,15.81,84.88,,12.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.32,50,,7.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.97,75,,11.18,percent of total billed charges,75% of total billed charges for outpatient setting,13.04,70,,10.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.9,80,,11.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,2.39,12.84,,1.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.11,65,,9.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.52,35,,5.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.77,90,,13.42,percent of total billed charges,90% of total billed charges for outpatient setting,2.39,16.77,
SEVELAMER (RENAGEL) : 403 MG,3301965,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SEVOFLURANE (ULTANE) 250 ML 15 MIN INCRE,3301966,CDM,250,RC,,,Outpatient,,,3.08,3.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.31,75,,1.85,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.77,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.77,
SEVOFLURANE (ULTANE) 250ML SOL PEN BTL:,3301967,CDM,250,RC,,,Outpatient,,,961.92,961.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.34,70,,538.67,percent of total billed charges,70% of total billed charges for outpatient setting,816.48,84.88,,653.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,480.96,50,,384.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,721.44,75,,577.15,percent of total billed charges,75% of total billed charges for outpatient setting,673.34,70,,538.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.51,12.84,,98.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.54,80,,615.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.51,12.84,,98.81,percent of total billed charges,12.84% of total billed charges,123.51,12.84,,98.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,625.25,65,,500.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.67,35,,269.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,865.73,90,,692.58,percent of total billed charges,90% of total billed charges for outpatient setting,123.51,865.73,
SEX HORMONE BINDING GLOBULIN,220760,CDM,301,RC,84270,HCPCS,Outpatient,,,97.79,88.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.45,70,,54.76,percent of total billed charges,70% of total billed charges for outpatient setting,83,84.88,,66.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,73.34,75,,58.67,percent of total billed charges,75% of total billed charges for outpatient setting,68.45,70,,54.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.23,80,,62.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.21,100,,,Fee Schedule,100% of Custom Fee Schedule,88.01,90,,70.41,percent of total billed charges,90% of total billed charges for outpatient setting,6.24,88.01,
SGOT,200665,CDM,300,RC,84450,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
SGOT/AST,201175,CDM,301,RC,84450,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
SGPT,200670,CDM,300,RC,84460,HCPCS,Outpatient,,,23.85,21.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,20.24,84.88,,16.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.89,75,,14.31,percent of total billed charges,75% of total billed charges for outpatient setting,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,80,,15.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.04,100,,,Fee Schedule,100% of Custom Fee Schedule,21.47,90,,17.18,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,21.47,
SGPT/ALT,200495,CDM,300,RC,84460,HCPCS,Outpatient,,,23.85,21.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,20.24,84.88,,16.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.89,75,,14.31,percent of total billed charges,75% of total billed charges for outpatient setting,16.7,70,,13.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,80,,15.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.04,100,,,Fee Schedule,100% of Custom Fee Schedule,21.47,90,,17.18,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,21.47,
SHAFT 51-100MM FIBULA / 3102-4263,7241022,CDM,278,RC,C1713,HCPCS,Outpatient,,,2896.88,2896.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1738.13,60,,1390.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2458.87,84.88,,1967.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2172.66,75,,1738.13,percent of total billed charges,75% of total billed charges for outpatient setting,1448.44,50,,1158.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.96,12.84,,297.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2317.5,80,,1854,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.96,12.84,,297.57,percent of total billed charges,12.84% of total billed charges,371.96,12.84,,297.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3041.72,105,,2433.38,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1013.91,35,,811.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1738.13,60,,1390.5,percent of total billed charges,60% of total billed charges for outpatient setting,371.96,3041.72,
SHAFT 55MM SCREWDRIVER / 314.453,782431,CDM,272,RC,,,Outpatient,,,1258.04,1258.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.63,70,,704.5,percent of total billed charges,70% of total billed charges for outpatient setting,1067.82,84.88,,854.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,629.02,50,,503.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,943.53,75,,754.82,percent of total billed charges,75% of total billed charges for outpatient setting,880.63,70,,704.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.53,12.84,,129.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.43,80,,805.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.53,12.84,,129.22,percent of total billed charges,12.84% of total billed charges,161.53,12.84,,129.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,817.73,65,,654.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.31,35,,352.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1132.24,90,,905.79,percent of total billed charges,90% of total billed charges for outpatient setting,161.53,1132.24,
SHAFT SM POWERPICK / AR-9100PP-00,71000449,CDM,272,RC,,,Outpatient,,,424.2,424.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,360.06,84.88,,288.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,212.1,50,,169.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,75,,254.52,percent of total billed charges,75% of total billed charges for outpatient setting,296.94,70,,237.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.36,80,,271.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,54.47,12.84,,43.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.73,65,,220.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.47,35,,118.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.78,90,,305.42,percent of total billed charges,90% of total billed charges for outpatient setting,54.47,381.78,
SHAMPOO BODY WASH ALOE VST 2OZ / MSC092S,5150040,CDM,270,RC,,,Outpatient,,,2.61,2.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,70,,1.46,percent of total billed charges,70% of total billed charges for outpatient setting,2.22,84.88,,1.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.31,50,,1.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.96,75,,1.57,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,70,,1.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,80,,1.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.7,65,,1.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,35,,0.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.35,90,,1.88,percent of total billed charges,90% of total billed charges for outpatient setting,0.34,2.35,
SHEATH /TUBING 4MM/0 DEG STORZ / 1912000,69161832,CDM,272,RC,,,Outpatient,,,252.2,252.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.54,70,,141.23,percent of total billed charges,70% of total billed charges for outpatient setting,214.07,84.88,,171.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,126.1,50,,100.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.15,75,,151.32,percent of total billed charges,75% of total billed charges for outpatient setting,176.54,70,,141.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.38,12.84,,25.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.76,80,,161.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.38,12.84,,25.9,percent of total billed charges,12.84% of total billed charges,32.38,12.84,,25.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.93,65,,131.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.27,35,,70.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.98,90,,181.58,percent of total billed charges,90% of total billed charges for outpatient setting,32.38,226.98,
SHEATH 12/14FR 24CM UROPASS / 61224BX,770964,CDM,272,RC,,,Outpatient,,,405.6,405.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.92,70,,227.14,percent of total billed charges,70% of total billed charges for outpatient setting,344.27,84.88,,275.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.8,50,,162.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.2,75,,243.36,percent of total billed charges,75% of total billed charges for outpatient setting,283.92,70,,227.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,12.84,,41.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.48,80,,259.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,12.84,,41.66,percent of total billed charges,12.84% of total billed charges,52.08,12.84,,41.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.64,65,,210.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.96,35,,113.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.04,90,,292.03,percent of total billed charges,90% of total billed charges for outpatient setting,52.08,365.04,
SHEATH 12/14FR 46CM UROPASS / 61246BX,1725932,CDM,272,RC,,,Outpatient,,,405.6,405.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.92,70,,227.14,percent of total billed charges,70% of total billed charges for outpatient setting,344.27,84.88,,275.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.8,50,,162.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.2,75,,243.36,percent of total billed charges,75% of total billed charges for outpatient setting,283.92,70,,227.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,12.84,,41.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.48,80,,259.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,12.84,,41.66,percent of total billed charges,12.84% of total billed charges,52.08,12.84,,41.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.64,65,,210.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.96,35,,113.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,365.04,90,,292.03,percent of total billed charges,90% of total billed charges for outpatient setting,52.08,365.04,
SHEATH 13/15FRx24CM UROPASS / 61324BX,1725933,CDM,272,RC,,,Outpatient,,,472,472,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.4,70,,264.32,percent of total billed charges,70% of total billed charges for outpatient setting,400.63,84.88,,320.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,236,50,,188.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354,75,,283.2,percent of total billed charges,75% of total billed charges for outpatient setting,330.4,70,,264.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,12.84,,48.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.6,80,,302.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,12.84,,48.48,percent of total billed charges,12.84% of total billed charges,60.6,12.84,,48.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,306.8,65,,245.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.2,35,,132.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,424.8,90,,339.84,percent of total billed charges,90% of total billed charges for outpatient setting,60.6,424.8,
SHEATH PINNACLE/6F x 45CM/RSR01,69159907,CDM,272,RC,C1894,HCPCS,Outpatient,,,625.59,625.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.91,70,,350.33,percent of total billed charges,70% of total billed charges for outpatient setting,531,84.88,,424.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.19,75,,375.35,percent of total billed charges,75% of total billed charges for outpatient setting,437.91,70,,350.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,12.84,,64.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.47,80,,400.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,12.84,,64.26,percent of total billed charges,12.84% of total billed charges,80.33,12.84,,64.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,406.63,65,,325.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.96,35,,175.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,563.03,90,,450.42,percent of total billed charges,90% of total billed charges for outpatient setting,80.33,563.03,
SHEATH URETERAL ACC 13/15FX46CM / 250211,69162535,CDM,272,RC,,,Outpatient,,,407.15,407.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.01,70,,228.01,percent of total billed charges,70% of total billed charges for outpatient setting,345.59,84.88,,276.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.58,50,,162.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305.36,75,,244.29,percent of total billed charges,75% of total billed charges for outpatient setting,285.01,70,,228.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.28,12.84,,41.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.72,80,,260.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.28,12.84,,41.82,percent of total billed charges,12.84% of total billed charges,52.28,12.84,,41.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.65,65,,211.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.5,35,,114,percent of total billed charges,35% of total Billed charges for Outpatient Setting,366.44,90,,293.15,percent of total billed charges,90% of total billed charges for outpatient setting,52.28,366.44,
SHEATH URETERAL ACC13/15FX28CM / 250207,69162534,CDM,272,RC,,,Outpatient,,,407.15,407.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.01,70,,228.01,percent of total billed charges,70% of total billed charges for outpatient setting,345.59,84.88,,276.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,203.58,50,,162.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305.36,75,,244.29,percent of total billed charges,75% of total billed charges for outpatient setting,285.01,70,,228.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.28,12.84,,41.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.72,80,,260.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.28,12.84,,41.82,percent of total billed charges,12.84% of total billed charges,52.28,12.84,,41.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,264.65,65,,211.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.5,35,,114,percent of total billed charges,35% of total Billed charges for Outpatient Setting,366.44,90,,293.15,percent of total billed charges,90% of total billed charges for outpatient setting,52.28,366.44,
SHEEHY FLUOROPLASTIC PR / 14142,69161412,CDM,272,RC,,,Outpatient,,,98.49,98.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,83.6,84.88,,66.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.25,50,,39.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.87,75,,59.1,percent of total billed charges,75% of total billed charges for outpatient setting,68.94,70,,55.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.79,80,,63.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,12.65,12.84,,10.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.02,65,,51.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,35,,27.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.64,90,,70.91,percent of total billed charges,90% of total billed charges for outpatient setting,12.65,88.64,
SHEET SET DISPOSABLE / NON47200,70000817,CDM,270,RC,,,Outpatient,,,16.44,16.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.51,70,,9.21,percent of total billed charges,70% of total billed charges for outpatient setting,13.95,84.88,,11.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.22,50,,6.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.33,75,,9.86,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,70,,9.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,12.84,,1.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,80,,10.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,12.84,,1.69,percent of total billed charges,12.84% of total billed charges,2.11,12.84,,1.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.69,65,,8.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,35,,4.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.8,90,,11.84,percent of total billed charges,90% of total billed charges for outpatient setting,2.11,14.8,
SHEETING 5X5CM SILASTIC / 1532510,702102,CDM,272,RC,,,Outpatient,,,105.35,105.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.75,70,,59,percent of total billed charges,70% of total billed charges for outpatient setting,89.42,84.88,,71.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.68,50,,42.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.01,75,,63.21,percent of total billed charges,75% of total billed charges for outpatient setting,73.75,70,,59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,12.84,,10.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.28,80,,67.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,12.84,,10.82,percent of total billed charges,12.84% of total billed charges,13.53,12.84,,10.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.48,65,,54.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.87,35,,29.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.82,90,,75.86,percent of total billed charges,90% of total billed charges for outpatient setting,13.53,94.82,
SHEETS IOL GLIDE / 581033,71000131,CDM,272,RC,,,Outpatient,,,11.78,11.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.25,70,,6.6,percent of total billed charges,70% of total billed charges for outpatient setting,10,84.88,,8,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.89,50,,4.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.84,75,,7.07,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,70,,6.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.42,80,,7.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,1.51,12.84,,1.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.66,65,,6.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.12,35,,3.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.6,90,,8.48,percent of total billed charges,90% of total billed charges for outpatient setting,1.51,10.6,
SHELL 48MM ACETABULAR / 1217-32-048,71000698,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 50MM ACETABULAR / 1217-30-050,71000709,CDM,278,RC,C1776,HCPCS,Outpatient,,,5516,5516,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3309.6,60,,2647.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4681.98,84.88,,3745.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4137,75,,3309.6,percent of total billed charges,75% of total billed charges for outpatient setting,2758,50,,2206.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4412.8,80,,3530.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5791.8,105,,4633.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.6,35,,1544.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3309.6,60,,2647.68,percent of total billed charges,60% of total billed charges for outpatient setting,708.25,5791.8,
SHELL 50MM ACETABULAR / 1217-32-050,69169885,CDM,278,RC,C1713,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 52MM ACETABULAR / 1217-32-052,69169749,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 54MM ACETABULAR / 1217-30-054,71000538,CDM,278,RC,C1713,HCPCS,Outpatient,,,5516,5516,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3309.6,60,,2647.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4681.98,84.88,,3745.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4137,75,,3309.6,percent of total billed charges,75% of total billed charges for outpatient setting,2758,50,,2206.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4412.8,80,,3530.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5791.8,105,,4633.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.6,35,,1544.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3309.6,60,,2647.68,percent of total billed charges,60% of total billed charges for outpatient setting,708.25,5791.8,
SHELL 54MM ACETABULAR / 1217-32-054,69162290,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 56MM ACETABULAR / 1217-30-056,71000471,CDM,278,RC,C1776,HCPCS,Outpatient,,,5516,5516,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3309.6,60,,2647.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4681.98,84.88,,3745.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4137,75,,3309.6,percent of total billed charges,75% of total billed charges for outpatient setting,2758,50,,2206.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4412.8,80,,3530.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5791.8,105,,4633.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.6,35,,1544.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3309.6,60,,2647.68,percent of total billed charges,60% of total billed charges for outpatient setting,708.25,5791.8,
SHELL 56MM ACETABULAR / 1217-32-056,71000420,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 58MM ACETABULAR / 1217-30-058,71000899,CDM,278,RC,C1776,HCPCS,Outpatient,,,5516,5516,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3309.6,60,,2647.68,percent of total billed charges,60% of total Billed charges for outpatient setting,4681.98,84.88,,3745.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4137,75,,3309.6,percent of total billed charges,75% of total billed charges for outpatient setting,2758,50,,2206.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4412.8,80,,3530.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,708.25,12.84,,566.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5791.8,105,,4633.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.6,35,,1544.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3309.6,60,,2647.68,percent of total billed charges,60% of total billed charges for outpatient setting,708.25,5791.8,
SHELL 58MM ACETABULAR / 1217-32-058,71000545,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 60MM ACETABULAR / 1217-32-060,71000903,CDM,278,RC,C1776,HCPCS,Outpatient,,,3246,3246,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1947.6,60,,1558.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2755.2,84.88,,2204.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.5,75,,1947.6,percent of total billed charges,75% of total billed charges for outpatient setting,1623,50,,1298.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2596.8,80,,2077.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,416.79,12.84,,333.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3408.3,105,,2726.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.1,35,,908.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1947.6,60,,1558.08,percent of total billed charges,60% of total billed charges for outpatient setting,416.79,3408.3,
SHELL 64MM OSSEOTI G7 / 110010250,69169881,CDM,278,RC,C1713,HCPCS,Outpatient,,,8900.5,8900.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5340.3,60,,4272.24,percent of total billed charges,60% of total Billed charges for outpatient setting,7554.74,84.88,,6043.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6675.38,75,,5340.3,percent of total billed charges,75% of total billed charges for outpatient setting,4450.25,50,,3560.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.82,12.84,,914.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7120.4,80,,5696.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.82,12.84,,914.26,percent of total billed charges,12.84% of total billed charges,1142.82,12.84,,914.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9345.53,105,,7476.42,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3115.18,35,,2492.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5340.3,60,,4272.24,percent of total billed charges,60% of total billed charges for outpatient setting,1142.82,9345.53,
SHIELD 24MM NIPPLE REGULAR / 89902,69161491,CDM,272,RC,,,Outpatient,,,31.05,31.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.74,70,,17.39,percent of total billed charges,70% of total billed charges for outpatient setting,26.36,84.88,,21.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.53,50,,12.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.29,75,,18.63,percent of total billed charges,75% of total billed charges for outpatient setting,21.74,70,,17.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,12.84,,3.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,80,,19.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.99,12.84,,3.19,percent of total billed charges,12.84% of total billed charges,3.99,12.84,,3.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.18,65,,16.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.87,35,,8.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.95,90,,22.36,percent of total billed charges,90% of total billed charges for outpatient setting,3.99,27.95,
SHIELD EYE LEFT/RIGHT / 0008618,6150232,CDM,270,RC,,,Outpatient,,,28.81,28.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,84.88,,19.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.41,50,,11.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.61,75,,17.29,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,70,,16.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.05,80,,18.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,3.7,12.84,,2.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.73,65,,14.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,35,,8.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.93,90,,20.74,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,25.93,
SHOE LG POST OP FEMALE / 11334,6150889,CDM,270,RC,,,Outpatient,,,55.51,55.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,47.12,84.88,,37.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.76,50,,22.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,75,,33.3,percent of total billed charges,75% of total billed charges for outpatient setting,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.41,80,,35.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.08,65,,28.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,35,,15.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.96,90,,39.97,percent of total billed charges,90% of total billed charges for outpatient setting,7.13,49.96,
SHOE POST OP LG MALE / 11424,6152663,CDM,270,RC,,,Outpatient,,,55.51,55.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,47.12,84.88,,37.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.76,50,,22.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,75,,33.3,percent of total billed charges,75% of total billed charges for outpatient setting,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.41,80,,35.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.08,65,,28.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,35,,15.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.96,90,,39.97,percent of total billed charges,90% of total billed charges for outpatient setting,7.13,49.96,
SHOE POST OP MED FEMALE / 79-81145,6150888,CDM,270,RC,,,Outpatient,,,24.24,24.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.97,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,20.57,84.88,,16.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.12,50,,9.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.18,75,,14.54,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,70,,13.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.39,80,,15.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,3.11,12.84,,2.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.76,65,,12.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.48,35,,6.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.82,90,,17.46,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,21.82,
SHOE POST OP MED MALE / 11423,6150890,CDM,270,RC,,,Outpatient,,,54.68,54.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,70,,30.62,percent of total billed charges,70% of total billed charges for outpatient setting,46.41,84.88,,37.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.34,50,,21.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.01,75,,32.81,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,70,,30.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,12.84,,5.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.74,80,,34.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,12.84,,5.62,percent of total billed charges,12.84% of total billed charges,7.02,12.84,,5.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.54,65,,28.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.14,35,,15.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.21,90,,39.37,percent of total billed charges,90% of total billed charges for outpatient setting,7.02,49.21,
SHOE POST OP SMALL FEMALE / 11332,6150891,CDM,270,RC,,,Outpatient,,,56.32,56.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.42,70,,31.54,percent of total billed charges,70% of total billed charges for outpatient setting,47.8,84.88,,38.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.16,50,,22.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.24,75,,33.79,percent of total billed charges,75% of total billed charges for outpatient setting,39.42,70,,31.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.23,12.84,,5.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.06,80,,36.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.23,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,7.23,12.84,,5.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.61,65,,29.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.71,35,,15.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.69,90,,40.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.23,50.69,
SHOE POST OP XLG MALE / 11425,69169067,CDM,270,RC,,,Outpatient,,,55.51,55.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,47.12,84.88,,37.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.76,50,,22.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,75,,33.3,percent of total billed charges,75% of total billed charges for outpatient setting,38.86,70,,31.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.41,80,,35.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,7.13,12.84,,5.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.08,65,,28.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,35,,15.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.96,90,,39.97,percent of total billed charges,90% of total billed charges for outpatient setting,7.13,49.96,
SHOE ROCKER SMALL LONG / 4934-8-100,70000785,CDM,278,RC,C1713,HCPCS,Outpatient,,,3400,3400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,60,,1632,percent of total billed charges,60% of total Billed charges for outpatient setting,2885.92,84.88,,2308.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2550,75,,2040,percent of total billed charges,75% of total billed charges for outpatient setting,1700,50,,1360,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2720,80,,2176,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3570,105,,2856,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190,35,,952,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2040,60,,1632,percent of total billed charges,60% of total billed charges for outpatient setting,436.56,3570,
SHOULDER 1 VW LEFT,2400491,CDM,320,RC,73020,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SHOULDER 1 VW RIGHT,2400480,CDM,320,RC,73020,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SHOULDER 2 VWS BILATERAL,2400487,CDM,320,RC,73030,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
SHOULDER 2 VWS LEFT,2400486,CDM,320,RC,73030,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SHOULDER 2 VWS RIGHT,2400485,CDM,320,RC,73030,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SHOULDER ARTHROGRAPHY LEFT,2401490,CDM,322,RC,73040,HCPCS,Outpatient,,,1141.31,855.98,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
SHOULDER ARTHROGRAPHY RIGHT,2400490,CDM,322,RC,73040,HCPCS,Outpatient,,,1141.31,855.98,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
SHOULDER IMMOBILIZER UNIVERSAL / A110001,6152600,CDM,272,RC,,,Outpatient,,,58.17,58.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.72,70,,32.58,percent of total billed charges,70% of total billed charges for outpatient setting,49.37,84.88,,39.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.09,50,,23.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.63,75,,34.9,percent of total billed charges,75% of total billed charges for outpatient setting,40.72,70,,32.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,12.84,,5.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.54,80,,37.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,12.84,,5.98,percent of total billed charges,12.84% of total billed charges,7.47,12.84,,5.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.81,65,,30.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,35,,16.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.35,90,,41.88,percent of total billed charges,90% of total billed charges for outpatient setting,7.47,52.35,
SHOULDER MOD HEAD 42X18X46MM / 113032,69162550,CDM,278,RC,,,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
SHOULDER MODULAR HEAD 46X18MM / 113042,69162387,CDM,278,RC,,,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
SHOULDER MODULAR HEAD 54 X 21MM 113063,69161605,CDM,278,RC,,,Outpatient,,,3564,3564,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2138.4,60,,1710.72,percent of total billed charges,60% of total Billed charges for outpatient setting,3025.12,84.88,,2420.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1782,50,,1425.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2673,75,,2138.4,percent of total billed charges,75% of total billed charges for outpatient setting,1782,50,,1425.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.62,12.84,,366.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2851.2,80,,2280.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.62,12.84,,366.1,percent of total billed charges,12.84% of total billed charges,457.62,12.84,,366.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3742.2,105,,2993.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.4,35,,997.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2138.4,60,,1710.72,percent of total billed charges,60% of total billed charges for outpatient setting,457.62,3742.2,
SHOULDER ONE VIEW LEFT,2400481,CDM,320,RC,73020,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SHOULDER STEM 10X55MM / 113610,69169685,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER STEM 12 X 55MM MICRO/113612,69169616,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
SHOULDER STEM 12X83MM MINI / 113632,69161587,CDM,278,RC,,,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
SHOULDER STEM 13 X 55MM MICRO/113613,69162377,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
SHOULDER STEM 13X83MM MINI / 113633,69161570,CDM,278,RC,,,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER STEM 14X55MM MICRO / 113614,69169363,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
SHOULDER STEM 15X55MM /113615,69169745,CDM,278,RC,C1713,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
SHOULDER STEM 7X55MM MICRO / 113607,69169686,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER STEM 7X83MM MINI / 113627,69162019,CDM,278,RC,C1713,HCPCS,Outpatient,,,8156,8156,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4893.6,60,,3914.88,percent of total billed charges,60% of total Billed charges for outpatient setting,6922.81,84.88,,5538.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6117,75,,4893.6,percent of total billed charges,75% of total billed charges for outpatient setting,4078,50,,3262.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.23,12.84,,837.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6524.8,80,,5219.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.23,12.84,,837.78,percent of total billed charges,12.84% of total billed charges,1047.23,12.84,,837.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8563.8,105,,6851.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2854.6,35,,2283.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4893.6,60,,3914.88,percent of total billed charges,60% of total billed charges for outpatient setting,1047.23,8563.8,
SHOULDER STEM 8X 55MM MICRO/113608,69169697,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER STEM 8X83MM LONG / 113628,69162551,CDM,278,RC,,,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
SHOULDER STEM 9 X 55MM MICRO/113609,69169629,CDM,278,RC,,,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER STEM 9X83MM / 113629,69162654,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
SHOULDER SYS 36MM +3 / 110031419,69169556,CDM,278,RC,C1713,HCPCS,Outpatient,,,3561.08,3561.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2136.65,60,,1709.32,percent of total billed charges,60% of total Billed charges for outpatient setting,3022.64,84.88,,2418.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2670.81,75,,2136.65,percent of total billed charges,75% of total billed charges for outpatient setting,1780.54,50,,1424.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.24,12.84,,365.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2848.86,80,,2279.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.24,12.84,,365.79,percent of total billed charges,12.84% of total billed charges,457.24,12.84,,365.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3739.13,105,,2991.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246.38,35,,997.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2136.65,60,,1709.32,percent of total billed charges,60% of total billed charges for outpatient setting,457.24,3739.13,
SHOULDER SYST 36MM BEARING / 110031426,70779677,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SHOULDER SYST 36MM STND / 110031424,69169584,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SHOULDER SYST 40MM +3 / 110031428,69169617,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SHOULDER SYST 40MM BEARING / 110031427,69169698,CDM,278,RC,C1713,HCPCS,Outpatient,,,3325,3325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,60,,1596,percent of total billed charges,60% of total Billed charges for outpatient setting,2822.26,84.88,,2257.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.75,75,,1995,percent of total billed charges,75% of total billed charges for outpatient setting,1662.5,50,,1330,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,80,,2128,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,426.93,12.84,,341.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3491.25,105,,2793,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.75,35,,931,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1995,60,,1596,percent of total billed charges,60% of total billed charges for outpatient setting,426.93,3491.25,
SHOULDER SYSTEM 36MM / 110031418,69169557,CDM,278,RC,,,Outpatient,,,2275,2275,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,60,,1092,percent of total billed charges,60% of total Billed charges for outpatient setting,1931.02,84.88,,1544.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1706.25,75,,1365,percent of total billed charges,75% of total billed charges for outpatient setting,1137.5,50,,910,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,80,,1456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,292.11,12.84,,233.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2388.75,105,,1911,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.25,35,,637,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1365,60,,1092,percent of total billed charges,60% of total billed charges for outpatient setting,292.11,2388.75,
SHOULDER SYSTEM STND ADAPTOR / 118001,69161606,CDM,278,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.56,60,,207.65,percent of total billed charges,60% of total Billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,432.6,65,,346.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,259.56,60,,207.65,percent of total billed charges,60% of total billed charges for outpatient setting,55.55,432.6,
SIALOGRAPHY,2400145,CDM,320,RC,70390,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
SICKLE CELL SCREEN,200295,CDM,305,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
SICKLE CELL SCREEN,201250,CDM,300,RC,85660,HCPCS,Outpatient,,,24.8,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,21.05,84.88,,16.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.46,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.6,75,,14.88,percent of total billed charges,75% of total billed charges for outpatient setting,17.36,70,,13.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,80,,15.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.47,100,,,Fee Schedule,100% of Custom Fee Schedule,22.32,90,,17.86,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.32,
SIGMOIDOSCOPIC SUCTION / 0033050,6150344,CDM,270,RC,,,Outpatient,,,35.76,35.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,70,,20.02,percent of total billed charges,70% of total billed charges for outpatient setting,30.35,84.88,,24.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.88,50,,14.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.82,75,,21.46,percent of total billed charges,75% of total billed charges for outpatient setting,25.03,70,,20.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,12.84,,3.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.61,80,,22.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,12.84,,3.67,percent of total billed charges,12.84% of total billed charges,4.59,12.84,,3.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.24,65,,18.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.52,35,,10.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.18,90,,25.74,percent of total billed charges,90% of total billed charges for outpatient setting,4.59,32.18,
SIGNIFY 10CC BIOATV CRUNCH / 8112.0210S,69169476,CDM,278,RC,C9359,HCPCS,Outpatient,,,4320,4320,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2592,60,,2073.6,percent of total billed charges,60% of total Billed charges for outpatient setting,3666.82,84.88,,2933.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,3240,75,,2592,percent of total billed charges,75% of total billed charges for outpatient setting,2160,50,,1728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.69,12.84,,443.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3456,80,,2764.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.69,12.84,,443.75,percent of total billed charges,12.84% of total billed charges,554.69,12.84,,443.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4536,105,,3628.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,35,,1209.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2592,60,,2073.6,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,4536,
SIGNIFY 2CC BIOACTIVE CRUNCH  8112.0202S,69162025,CDM,278,RC,,,Outpatient,,,2649.68,2649.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,60,,1271.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2249.05,84.88,,1799.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1987.26,75,,1589.81,percent of total billed charges,75% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,80,,1695.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2782.16,105,,2225.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.39,35,,741.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1589.81,60,,1271.85,percent of total billed charges,60% of total billed charges for outpatient setting,340.22,2782.16,
SIGNIFY 5CC BIOACTIVE CRUNCH  8112.0205S,69169478,CDM,278,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,60,,1152,percent of total billed charges,60% of total Billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2520,105,,2016,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1440,60,,1152,percent of total billed charges,60% of total billed charges for outpatient setting,308.16,2520,
SIGNIFY BIOACTVE PUTTY 10CC / 8112.0010S,69162248,CDM,278,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
SIGNIFY BIOACTVE PUTTY 2CC / 8112.0002S,69169510,CDM,278,RC,C9359,HCPCS,Outpatient,,,1859.55,1859.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.73,60,,892.58,percent of total billed charges,60% of total Billed charges for outpatient setting,1578.39,84.88,,1262.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1394.66,75,,1115.73,percent of total billed charges,75% of total billed charges for outpatient setting,929.78,50,,743.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.77,12.84,,191.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1487.64,80,,1190.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.77,12.84,,191.02,percent of total billed charges,12.84% of total billed charges,238.77,12.84,,191.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1859.55,65,,1487.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.84,35,,520.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1115.73,60,,892.58,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,1859.55,
SIGNIFY BIOACTVE PUTTY 5CC / 8112.0005S,69169558,CDM,278,RC,C9359,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,2000,
SILVER NITRATE APPL  TOP:,3301968,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SILVER SULFAD (SILVADENE) CRM 1% 50GM,3301971,CDM,259,RC,,,Outpatient,,,66.24,66.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,56.22,84.88,,44.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.12,50,,26.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.68,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,80,,42.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.06,65,,34.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,35,,18.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.62,90,,47.7,percent of total billed charges,90% of total billed charges for outpatient setting,8.51,59.62,
SILVER SULFAD (SSD) CRM: 50 GM,3301969,CDM,259,RC,,,Outpatient,,,22.19,22.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,70,,12.42,percent of total billed charges,70% of total billed charges for outpatient setting,18.83,84.88,,15.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,50,,8.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.64,75,,13.31,percent of total billed charges,75% of total billed charges for outpatient setting,15.53,70,,12.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,80,,14.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,2.85,12.84,,2.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.42,65,,11.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,35,,6.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.97,90,,15.98,percent of total billed charges,90% of total billed charges for outpatient setting,2.85,19.97,
SILVER SULFAD(SILVADENE) CRM: 20 GM,3301970,CDM,259,RC,,,Outpatient,,,11.8,11.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,70,,6.61,percent of total billed charges,70% of total billed charges for outpatient setting,10.02,84.88,,8.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.9,50,,4.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.85,75,,7.08,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,70,,6.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,80,,7.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.52,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.67,65,,6.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,35,,3.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.62,90,,8.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,10.62,
SIMETHICONE (genMYLICON) 80 MG CHEW TAB,3301973,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SIMETHICONE (INFANT)40MG/0.6MLS 30ML,3301974,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SIMETHICONE CHEW  80 MG,3301975,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SIMPLEX SPEED SET (BONE CEMENT),69162134,CDM,278,RC,C1713,HCPCS,Outpatient,,,238,238,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.8,60,,114.24,percent of total billed charges,60% of total Billed charges for outpatient setting,202.01,84.88,,161.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.5,75,,142.8,percent of total billed charges,75% of total billed charges for outpatient setting,119,50,,95.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,12.84,,24.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.4,80,,152.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,12.84,,24.45,percent of total billed charges,12.84% of total billed charges,30.56,12.84,,24.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,238,65,,190.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.3,35,,66.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,142.8,60,,114.24,percent of total billed charges,60% of total billed charges for outpatient setting,30.56,238,
SIMVASTATIN (genericZOCOR) 20 MG TAB,3301980,CDM,259,RC,,,Outpatient,,,13.39,13.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,84.88,,9.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.7,50,,5.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.04,75,,8.03,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,70,,7.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,80,,8.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.7,65,,6.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,35,,3.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.05,90,,9.64,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.05,
SIMVASTATIN (genericZOCOR) 40 MG TAB,3301977,CDM,259,RC,,,Outpatient,,,12.63,12.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.84,70,,7.07,percent of total billed charges,70% of total billed charges for outpatient setting,10.72,84.88,,8.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.32,50,,5.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.47,75,,7.58,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,70,,7.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,80,,8.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.21,65,,6.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.42,35,,3.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.37,90,,9.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.37,
SIMVASTATIN (ZOCOR) 10 MG TAB:,3301978,CDM,259,RC,,,Outpatient,,,7.64,7.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,70,,4.28,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,84.88,,5.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.82,50,,3.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.73,75,,4.58,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,70,,4.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,80,,4.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,0.98,12.84,,0.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.97,65,,3.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.67,35,,2.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.88,90,,5.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.98,6.88,
SIMVASTATIN (ZOCOR) 40 MG TAB :     90'S,3301979,CDM,259,RC,,,Outpatient,,,11.93,11.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.35,70,,6.68,percent of total billed charges,70% of total billed charges for outpatient setting,10.13,84.88,,8.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.97,50,,4.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.95,75,,7.16,percent of total billed charges,75% of total billed charges for outpatient setting,8.35,70,,6.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,80,,7.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,1.53,12.84,,1.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.75,65,,6.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.18,35,,3.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.74,90,,8.59,percent of total billed charges,90% of total billed charges for outpatient setting,1.53,10.74,
SIMVASTATIN (ZOCOR) 5 MG TAB : U/D,3301976,CDM,259,RC,,,Outpatient,,,5.74,5.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.02,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,4.87,84.88,,3.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.87,50,,2.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.31,75,,3.45,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,80,,3.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.73,65,,2.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,35,,1.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.17,90,,4.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.17,
SINCALIDE (genericKINEVAC) 5 MCG INJ,3301981,CDM,636,RC,J2805,HCPCS,Outpatient,,,310.15,310.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.11,70,,173.69,percent of total billed charges,70% of total billed charges for outpatient setting,263.26,84.88,,210.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.99,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,232.61,75,,186.09,percent of total billed charges,75% of total billed charges for outpatient setting,217.11,70,,173.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.82,12.84,,31.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.12,80,,198.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.82,12.84,,31.86,percent of total billed charges,12.84% of total billed charges,39.82,12.84,,31.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,65,,161.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.48,100,,,Fee Schedule,100% of Custom Fee Schedule,279.14,90,,223.31,percent of total billed charges,90% of total billed charges for outpatient setting,39.82,279.14,
SINEMET 50/200: CR TAB,3302873,CDM,259,RC,,,Outpatient,,,8.95,8.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,70,,5.02,percent of total billed charges,70% of total billed charges for outpatient setting,7.6,84.88,,6.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.48,50,,3.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.71,75,,5.37,percent of total billed charges,75% of total billed charges for outpatient setting,6.27,70,,5.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.16,80,,5.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,1.15,12.84,,0.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.82,65,,4.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,35,,2.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.06,90,,6.45,percent of total billed charges,90% of total billed charges for outpatient setting,1.15,8.06,
SINGLE PLANE BODY SECTION,2400820,CDM,320,RC,76100,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SINGULAIR 5MG: TAB,3302838,CDM,259,RC,,,Outpatient,,,10.83,10.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.58,70,,6.06,percent of total billed charges,70% of total billed charges for outpatient setting,9.19,84.88,,7.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.42,50,,4.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.12,75,,6.5,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,70,,6.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,80,,6.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.04,65,,5.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,35,,3.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.75,90,,7.8,percent of total billed charges,90% of total billed charges for outpatient setting,1.39,9.75,
SINU-FOAM DISSOLVABLE DRSG / RR650,69161030,CDM,272,RC,,,Outpatient,,,357.2,357.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.04,70,,200.03,percent of total billed charges,70% of total billed charges for outpatient setting,303.19,84.88,,242.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,178.6,50,,142.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.9,75,,214.32,percent of total billed charges,75% of total billed charges for outpatient setting,250.04,70,,200.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,12.84,,36.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.76,80,,228.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,12.84,,36.69,percent of total billed charges,12.84% of total billed charges,45.86,12.84,,36.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.18,65,,185.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.02,35,,100.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.48,90,,257.18,percent of total billed charges,90% of total billed charges for outpatient setting,45.86,321.48,
SINUS BALLOON CATH INFLATION / BID30,69161518,CDM,272,RC,,,Outpatient,,,332.18,332.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.53,70,,186.02,percent of total billed charges,70% of total billed charges for outpatient setting,281.95,84.88,,225.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,166.09,50,,132.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.14,75,,199.31,percent of total billed charges,75% of total billed charges for outpatient setting,232.53,70,,186.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,12.84,,34.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.74,80,,212.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,12.84,,34.12,percent of total billed charges,12.84% of total billed charges,42.65,12.84,,34.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,215.92,65,,172.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.26,35,,93.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,298.96,90,,239.17,percent of total billed charges,90% of total billed charges for outpatient setting,42.65,298.96,
SINUSES 3+ VW,2410080,CDM,320,RC,70220,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SINUSES 3+ VWS,2400080,CDM,320,RC,70220,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SINUSES WATERS,2400075,CDM,320,RC,70210,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SITE INTERLINK INJECTION / N8000,5150036,CDM,272,RC,,,Outpatient,,,15.08,15.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,70,,8.45,percent of total billed charges,70% of total billed charges for outpatient setting,12.8,84.88,,10.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.54,50,,6.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.31,75,,9.05,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,70,,8.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.06,80,,9.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.8,65,,7.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,35,,4.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.57,90,,10.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,13.57,
SITZ BATHS/C11705-MAV,5150214,CDM,270,RC,,,Outpatient,,,42.4,42.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.68,70,,23.74,percent of total billed charges,70% of total billed charges for outpatient setting,35.99,84.88,,28.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.2,50,,16.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.8,75,,25.44,percent of total billed charges,75% of total billed charges for outpatient setting,29.68,70,,23.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.44,12.84,,4.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.92,80,,27.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.44,12.84,,4.35,percent of total billed charges,12.84% of total billed charges,5.44,12.84,,4.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.56,65,,22.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,35,,11.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.16,90,,30.53,percent of total billed charges,90% of total billed charges for outpatient setting,5.44,38.16,
SIZER 190CC BREAST / GS10512-190MP,7670517,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 210CC BREAST / GS10512-210MP,7670516,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 215CC BREAST LUXE / GS10621-215MP,7378995,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 325CC BREAST LUXE / GS10621-325MP,7378990,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 410CC BREAST / GS10512-410MP,71000265,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 425CC BREAST / GS10512-425MP,71000266,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 440CC BREAST / GS10512-440MP,71000267,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 470CC BREAST / GS10512-470MP,71000268,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 475CC BREAST / GS10610-475LP,7670477,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 500CC BREAST / GS10610-500LP,7670476,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZER 510CC BREAST / GS10512-510MP,71000269,CDM,278,RC,,,Outpatient,,,880,880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,60,,422.4,percent of total billed charges,60% of total Billed charges for outpatient setting,746.94,84.88,,597.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,660,75,,528,percent of total billed charges,75% of total billed charges for outpatient setting,440,50,,352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704,80,,563.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,112.99,12.84,,90.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,880,65,,704,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,35,,246.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,528,60,,422.4,percent of total billed charges,60% of total billed charges for outpatient setting,112.99,880,
SIZERS 351-2300SZ,69161222,CDM,278,RC,,,Outpatient,,,255.65,255.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.39,60,,122.71,percent of total billed charges,60% of total Billed charges for outpatient setting,217,84.88,,173.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,127.83,50,,102.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.74,75,,153.39,percent of total billed charges,75% of total billed charges for outpatient setting,127.83,50,,102.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.52,80,,163.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,32.83,12.84,,26.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,255.65,65,,204.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.48,35,,71.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.39,60,,122.71,percent of total billed charges,60% of total billed charges for outpatient setting,32.83,255.65,
SIZERS 351-3330SZ,69161183,CDM,278,RC,,,Outpatient,,,2750,2750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,60,,1320,percent of total billed charges,60% of total Billed charges for outpatient setting,2334.2,84.88,,1867.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,1375,50,,1100,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2062.5,75,,1650,percent of total billed charges,75% of total billed charges for outpatient setting,1375,50,,1100,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2200,80,,1760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2887.5,105,,2310,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.5,35,,770,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1650,60,,1320,percent of total billed charges,60% of total billed charges for outpatient setting,353.1,2887.5,
SIZERS 351-3420SZ,69161184,CDM,278,RC,,,Outpatient,,,2750,2750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,60,,1320,percent of total billed charges,60% of total Billed charges for outpatient setting,2334.2,84.88,,1867.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,1375,50,,1100,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2062.5,75,,1650,percent of total billed charges,75% of total billed charges for outpatient setting,1375,50,,1100,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2200,80,,1760,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,353.1,12.84,,282.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2887.5,105,,2310,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.5,35,,770,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1650,60,,1320,percent of total billed charges,60% of total billed charges for outpatient setting,353.1,2887.5,
SKELAXIN(METAXALONE)TAB: 800 MG,3302767,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
SKIN MARKER XL MINI NS / 1450XL-1000,69159936,CDM,272,RC,,,Outpatient,,,2.78,2.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.95,70,,1.56,percent of total billed charges,70% of total billed charges for outpatient setting,2.36,84.88,,1.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.39,50,,1.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.09,75,,1.67,percent of total billed charges,75% of total billed charges for outpatient setting,1.95,70,,1.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.36,12.84,,0.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.22,80,,1.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.36,12.84,,0.29,percent of total billed charges,12.84% of total billed charges,0.36,12.84,,0.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.81,65,,1.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,35,,0.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.5,90,,2,percent of total billed charges,90% of total billed charges for outpatient setting,0.36,2.5,
SKIN PREP TRAY BETADINE / DYND70660,6150139,CDM,272,RC,,,Outpatient,,,33.52,33.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.46,70,,18.77,percent of total billed charges,70% of total billed charges for outpatient setting,28.45,84.88,,22.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.76,50,,13.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.14,75,,20.11,percent of total billed charges,75% of total billed charges for outpatient setting,23.46,70,,18.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.82,80,,21.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,4.3,12.84,,3.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.79,65,,17.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.73,35,,9.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.17,90,,24.14,percent of total billed charges,90% of total billed charges for outpatient setting,4.3,30.17,
SKIN PREP TRAY CHLORHEX / DYND70663,69160613,CDM,272,RC,,,Outpatient,,,32.4,32.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,27.5,84.88,,22,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.2,50,,12.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,75,,19.44,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,70,,18.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,80,,20.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,4.16,12.84,,3.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.06,65,,16.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,35,,9.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,29.16,90,,23.33,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,29.16,
SKIN PREP TRAY DRY / DYND70661,69161275,CDM,272,RC,,,Outpatient,,,17.19,17.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,14.59,84.88,,11.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.6,50,,6.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.89,75,,10.31,percent of total billed charges,75% of total billed charges for outpatient setting,12.03,70,,9.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,80,,11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,2.21,12.84,,1.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.17,65,,8.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,35,,4.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.47,90,,12.38,percent of total billed charges,90% of total billed charges for outpatient setting,2.21,15.47,
SKIN TEMP STRIP / 81-010003,69159790,CDM,270,RC,,,Outpatient,,,4.14,4.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,70,,2.32,percent of total billed charges,70% of total billed charges for outpatient setting,3.51,84.88,,2.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.07,50,,1.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.11,75,,2.49,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,70,,2.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,80,,2.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.53,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.69,65,,2.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.45,35,,1.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.73,90,,2.98,percent of total billed charges,90% of total billed charges for outpatient setting,0.53,3.73,
SKIN TEMP THERMISTOR 400 SER / STS-400,69161467,CDM,271,RC,,,Outpatient,,,28.4,28.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.88,70,,15.9,percent of total billed charges,70% of total billed charges for outpatient setting,24.11,84.88,,19.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.2,50,,11.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.3,75,,17.04,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,70,,15.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,12.84,,2.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.72,80,,18.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,12.84,,2.92,percent of total billed charges,12.84% of total billed charges,3.65,12.84,,2.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.46,65,,14.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,35,,7.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.56,90,,20.45,percent of total billed charges,90% of total billed charges for outpatient setting,3.65,25.56,
SKULL COMPLETE,2400095,CDM,320,RC,70260,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SKULL LESS THAN 4 VWS,2400090,CDM,320,RC,70250,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SKULL PINS DISPOSABLE / A1072,69162087,CDM,272,RC,,,Outpatient,,,218,218,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.6,70,,122.08,percent of total billed charges,70% of total billed charges for outpatient setting,185.04,84.88,,148.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,109,50,,87.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.5,75,,130.8,percent of total billed charges,75% of total billed charges for outpatient setting,152.6,70,,122.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.99,12.84,,22.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.4,80,,139.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.99,12.84,,22.39,percent of total billed charges,12.84% of total billed charges,27.99,12.84,,22.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.7,65,,113.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,35,,61.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.2,90,,156.96,percent of total billed charges,90% of total billed charges for outpatient setting,27.99,196.2,
SLEEVE 0MM TAPER TYPE 1 / 650-1066,71000050,CDM,278,RC,C1776,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SLEEVE 11X100MM / CTS12,69159863,CDM,272,RC,,,Outpatient,,,49,49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,41.59,84.88,,33.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,75,,29.4,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,80,,31.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.85,65,,25.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.1,90,,35.28,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.1,
SLEEVE 12X100MM / CTS22,69161059,CDM,272,RC,,,Outpatient,,,109.08,109.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,70,,61.09,percent of total billed charges,70% of total billed charges for outpatient setting,92.59,84.88,,74.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,54.54,50,,43.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.81,75,,65.45,percent of total billed charges,75% of total billed charges for outpatient setting,76.36,70,,61.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,12.84,,11.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.26,80,,69.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,12.84,,11.21,percent of total billed charges,12.84% of total billed charges,14.01,12.84,,11.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,70.9,65,,56.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.18,35,,30.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,98.17,90,,78.54,percent of total billed charges,90% of total billed charges for outpatient setting,14.01,98.17,
SLEEVE 13MM HUMERAL SHLDR / 113581,1150672,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SLEEVE 1MM TAPER TYPE -3 / 650-1065,71000600,CDM,278,RC,C1776,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SLEEVE 5MM XCEL / CB5LT,69159297,CDM,272,RC,,,Outpatient,,,241.67,241.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.17,70,,135.34,percent of total billed charges,70% of total billed charges for outpatient setting,205.13,84.88,,164.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,120.84,50,,96.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.25,75,,145,percent of total billed charges,75% of total billed charges for outpatient setting,169.17,70,,135.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,12.84,,24.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.34,80,,154.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,12.84,,24.82,percent of total billed charges,12.84% of total billed charges,31.03,12.84,,24.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,157.09,65,,125.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.58,35,,67.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,217.5,90,,174,percent of total billed charges,90% of total billed charges for outpatient setting,31.03,217.5,
SLEEVE 5X100MM / CTS02,69159862,CDM,272,RC,,,Outpatient,,,58.8,58.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.16,70,,32.93,percent of total billed charges,70% of total billed charges for outpatient setting,49.91,84.88,,39.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.4,50,,23.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.1,75,,35.28,percent of total billed charges,75% of total billed charges for outpatient setting,41.16,70,,32.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,80,,37.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.22,65,,30.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.58,35,,16.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.92,90,,42.34,percent of total billed charges,90% of total billed charges for outpatient setting,7.55,52.92,
SLEEVE 5X50MM  CTS01,69161521,CDM,272,RC,,,Outpatient,,,70.18,70.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,70,,39.3,percent of total billed charges,70% of total billed charges for outpatient setting,59.57,84.88,,47.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.09,50,,28.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.64,75,,42.11,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,70,,39.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,12.84,,7.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.14,80,,44.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,12.84,,7.21,percent of total billed charges,12.84% of total billed charges,9.01,12.84,,7.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.62,65,,36.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.56,35,,19.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.16,90,,50.53,percent of total billed charges,90% of total billed charges for outpatient setting,9.01,63.16,
SLEEVE -6 TAPER TYPE 1 / 650-1064,71000333,CDM,278,RC,C1776,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SLEEVE BREAST DELIVERY ASST / HA-005,69169816,CDM,272,RC,,,Outpatient,,,582.4,582.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.68,70,,326.14,percent of total billed charges,70% of total billed charges for outpatient setting,494.34,84.88,,395.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,291.2,50,,232.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,436.8,75,,349.44,percent of total billed charges,75% of total billed charges for outpatient setting,407.68,70,,326.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.78,12.84,,59.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.92,80,,372.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.78,12.84,,59.82,percent of total billed charges,12.84% of total billed charges,74.78,12.84,,59.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,378.56,65,,302.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,35,,163.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,524.16,90,,419.33,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,524.16,
SLEEVE KIT INFUSE CENTURION / 8065752900,69161294,CDM,272,RC,,,Outpatient,,,122.76,122.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.93,70,,68.74,percent of total billed charges,70% of total billed charges for outpatient setting,104.2,84.88,,83.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.38,50,,49.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.07,75,,73.66,percent of total billed charges,75% of total billed charges for outpatient setting,85.93,70,,68.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.76,12.84,,12.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.21,80,,78.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.76,12.84,,12.61,percent of total billed charges,12.84% of total billed charges,15.76,12.84,,12.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.79,65,,63.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.97,35,,34.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.48,90,,88.38,percent of total billed charges,90% of total billed charges for outpatient setting,15.76,110.48,
SLEEVE XCEL 11MM / CB11LT,69159320,CDM,272,RC,,,Outpatient,,,105.99,105.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.19,70,,59.35,percent of total billed charges,70% of total billed charges for outpatient setting,89.96,84.88,,71.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,53,50,,42.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.49,75,,63.59,percent of total billed charges,75% of total billed charges for outpatient setting,74.19,70,,59.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.79,80,,67.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,13.61,12.84,,10.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.89,65,,55.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,35,,29.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.39,90,,76.31,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,95.39,
SLEEVE XCEL 12MM / CB12LT,69159321,CDM,272,RC,,,Outpatient,,,305.36,305.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.75,70,,171,percent of total billed charges,70% of total billed charges for outpatient setting,259.19,84.88,,207.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,152.68,50,,122.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.02,75,,183.22,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,70,,171,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,12.84,,31.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.29,80,,195.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,12.84,,31.37,percent of total billed charges,12.84% of total billed charges,39.21,12.84,,31.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,198.48,65,,158.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,35,,85.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,274.82,90,,219.86,percent of total billed charges,90% of total billed charges for outpatient setting,39.21,274.82,
SLEVE 1 OPTION TPR / 650-1068,71000399,CDM,278,RC,C1713,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,60,,192,percent of total billed charges,60% of total Billed charges for outpatient setting,339.52,84.88,,271.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,75,,240,percent of total billed charges,75% of total billed charges for outpatient setting,200,50,,160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320,80,,256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,51.36,12.84,,41.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400,65,,320,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,35,,112,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240,60,,192,percent of total billed charges,60% of total billed charges for outpatient setting,51.36,400,
SLING ARM DELUXE LG / 79-84007,6150170,CDM,270,RC,,,Outpatient,,,19.94,19.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,70,,11.17,percent of total billed charges,70% of total billed charges for outpatient setting,16.93,84.88,,13.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.97,50,,7.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.96,75,,11.97,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,70,,11.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.95,80,,12.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.96,65,,10.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,35,,5.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.95,90,,14.36,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.95,
SLING ARM DELUXE MED / 79-84005,6150169,CDM,270,RC,,,Outpatient,,,19.94,19.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,70,,11.17,percent of total billed charges,70% of total billed charges for outpatient setting,16.93,84.88,,13.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.97,50,,7.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.96,75,,11.97,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,70,,11.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.95,80,,12.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,2.56,12.84,,2.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.96,65,,10.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,35,,5.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.95,90,,14.36,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,17.95,
SLING ARM DELUXE SMALL / VP20104-020,6155970,CDM,270,RC,,,Outpatient,,,43.2,43.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,70,,24.19,percent of total billed charges,70% of total billed charges for outpatient setting,36.67,84.88,,29.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.6,50,,17.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,75,,25.92,percent of total billed charges,75% of total billed charges for outpatient setting,30.24,70,,24.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.56,80,,27.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,5.55,12.84,,4.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.08,65,,22.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,35,,12.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.88,90,,31.1,percent of total billed charges,90% of total billed charges for outpatient setting,5.55,38.88,
SLING ARM DELUXE XL / 79-84008,69160812,CDM,270,RC,,,Outpatient,,,18.99,18.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.29,70,,10.63,percent of total billed charges,70% of total billed charges for outpatient setting,16.12,84.88,,12.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.5,50,,7.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.24,75,,11.39,percent of total billed charges,75% of total billed charges for outpatient setting,13.29,70,,10.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.44,12.84,,1.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,80,,12.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.44,12.84,,1.95,percent of total billed charges,12.84% of total billed charges,2.44,12.84,,1.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.34,65,,9.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.65,35,,5.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.09,90,,13.67,percent of total billed charges,90% of total billed charges for outpatient setting,2.44,17.09,
SLING SHOT 2L LG / 08504,69160718,CDM,271,RC,,,Outpatient,,,184.55,184.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.19,70,,103.35,percent of total billed charges,70% of total billed charges for outpatient setting,156.65,84.88,,125.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.28,50,,73.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.41,75,,110.73,percent of total billed charges,75% of total billed charges for outpatient setting,129.19,70,,103.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,12.84,,18.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.64,80,,118.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.7,12.84,,18.96,percent of total billed charges,12.84% of total billed charges,23.7,12.84,,18.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.96,65,,95.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.59,35,,51.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,166.1,90,,132.88,percent of total billed charges,90% of total billed charges for outpatient setting,23.7,166.1,
SLING SHOT MEDIUM / 08503,69160727,CDM,271,RC,,,Outpatient,,,133.88,133.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,70,,74.98,percent of total billed charges,70% of total billed charges for outpatient setting,113.64,84.88,,90.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.94,50,,53.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.41,75,,80.33,percent of total billed charges,75% of total billed charges for outpatient setting,93.72,70,,74.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,12.84,,13.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.1,80,,85.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.19,12.84,,13.75,percent of total billed charges,12.84% of total billed charges,17.19,12.84,,13.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.02,65,,69.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.86,35,,37.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.49,90,,96.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.19,120.49,
SLING SHOT SMALL /08502,69160728,CDM,271,RC,,,Outpatient,,,266.12,266.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.28,70,,149.02,percent of total billed charges,70% of total billed charges for outpatient setting,225.88,84.88,,180.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.06,50,,106.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.59,75,,159.67,percent of total billed charges,75% of total billed charges for outpatient setting,186.28,70,,149.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,12.84,,27.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.9,80,,170.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,12.84,,27.34,percent of total billed charges,12.84% of total billed charges,34.17,12.84,,27.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,172.98,65,,138.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.14,35,,74.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,239.51,90,,191.61,percent of total billed charges,90% of total billed charges for outpatient setting,34.17,239.51,
SLIPPER 2XL GRAY PATIENT / S11218XXL,564109,CDM,271,RC,,,Outpatient,,,4.23,4.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,3.59,84.88,,2.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.12,50,,1.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.17,75,,2.54,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,80,,2.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.75,65,,2.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,35,,1.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.81,90,,3.05,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.81,
SLIPPER LG BLUE PATIENT / S11218XXL,564077,CDM,271,RC,,,Outpatient,,,4.23,4.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,3.59,84.88,,2.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.12,50,,1.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.17,75,,2.54,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,70,,2.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,80,,2.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.75,65,,2.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,35,,1.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.81,90,,3.05,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.81,
SLOW FE: TAB,3303243,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
SMALL BOWEL,2400630,CDM,320,RC,74250,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
SMALL INTESTINE FOLLOW THRU STUDY,2400631,CDM,320,RC,74248,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.46,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
"SMEAR;SPECIAL STAIN/INC BODIES,PARASITES",201538,CDM,300,RC,87207,HCPCS,Outpatient,,,26.96,24.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.87,70,,15.1,percent of total billed charges,70% of total billed charges for outpatient setting,22.88,84.88,,18.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.29,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.22,75,,16.18,percent of total billed charges,75% of total billed charges for outpatient setting,18.87,70,,15.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.57,80,,17.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.75,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,100,,,Fee Schedule,100% of Custom Fee Schedule,24.26,90,,19.41,percent of total billed charges,90% of total billed charges for outpatient setting,5.99,24.26,
SMITH AB,220863,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
SNAP N PEEL SHEATH & DILATOR/61012BX,6152725,CDM,270,RC,,,Outpatient,,,142.03,142.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,120.56,84.88,,96.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.02,50,,56.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.52,75,,85.22,percent of total billed charges,75% of total billed charges for outpatient setting,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.62,80,,90.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.32,65,,73.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.71,35,,39.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.83,90,,102.26,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,127.83,
SNARE 10MM HOT/COLD / SD-400U-10,70000827,CDM,272,RC,,,Outpatient,,,101.85,101.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,70,,57.04,percent of total billed charges,70% of total billed charges for outpatient setting,86.45,84.88,,69.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.93,50,,40.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.39,75,,61.11,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,70,,57.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,12.84,,10.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,80,,65.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,12.84,,10.46,percent of total billed charges,12.84% of total billed charges,13.08,12.84,,10.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.2,65,,52.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,35,,28.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.67,90,,73.34,percent of total billed charges,90% of total billed charges for outpatient setting,13.08,91.67,
SNARE 10MM SPIRAL / SD-210U-10,101285,CDM,272,RC,,,Outpatient,,,56.7,56.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.69,70,,31.75,percent of total billed charges,70% of total billed charges for outpatient setting,48.13,84.88,,38.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.35,50,,22.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.53,75,,34.02,percent of total billed charges,75% of total billed charges for outpatient setting,39.69,70,,31.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,12.84,,5.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.36,80,,36.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.28,12.84,,5.82,percent of total billed charges,12.84% of total billed charges,7.28,12.84,,5.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.86,65,,29.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,35,,15.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.03,90,,40.82,percent of total billed charges,90% of total billed charges for outpatient setting,7.28,51.03,
SNARE 15MM MASTER PLUS / SD-400U-15,7204834,CDM,272,RC,,,Outpatient,,,101.85,101.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,70,,57.04,percent of total billed charges,70% of total billed charges for outpatient setting,86.45,84.88,,69.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.93,50,,40.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.39,75,,61.11,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,70,,57.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,12.84,,10.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,80,,65.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,12.84,,10.46,percent of total billed charges,12.84% of total billed charges,13.08,12.84,,10.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.2,65,,52.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,35,,28.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.67,90,,73.34,percent of total billed charges,90% of total billed charges for outpatient setting,13.08,91.67,
SNARE 15MM SPIRAL / SD-210U-15,70000700,CDM,272,RC,,,Outpatient,,,66.84,66.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,70,,37.43,percent of total billed charges,70% of total billed charges for outpatient setting,56.73,84.88,,45.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.42,50,,26.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.13,75,,40.1,percent of total billed charges,75% of total billed charges for outpatient setting,46.79,70,,37.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,12.84,,6.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.47,80,,42.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,8.58,12.84,,6.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.45,65,,34.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.39,35,,18.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.16,90,,48.13,percent of total billed charges,90% of total billed charges for outpatient setting,8.58,60.16,
SNARE 20MM SPIRAL / SD-230U-20,70000162,CDM,272,RC,,,Outpatient,,,115.86,115.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.1,70,,64.88,percent of total billed charges,70% of total billed charges for outpatient setting,98.34,84.88,,78.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.93,50,,46.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.9,75,,69.52,percent of total billed charges,75% of total billed charges for outpatient setting,81.1,70,,64.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,12.84,,11.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.69,80,,74.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,12.84,,11.9,percent of total billed charges,12.84% of total billed charges,14.88,12.84,,11.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.31,65,,60.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.55,35,,32.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.27,90,,83.42,percent of total billed charges,90% of total billed charges for outpatient setting,14.88,104.27,
SNARE ENDO POLYPECTOMY 2.3MM / 100605,70000076,CDM,272,RC,,,Outpatient,,,66.24,66.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,56.22,84.88,,44.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.12,50,,26.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.68,75,,39.74,percent of total billed charges,75% of total billed charges for outpatient setting,46.37,70,,37.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,80,,42.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,8.51,12.84,,6.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.06,65,,34.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,35,,18.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.62,90,,47.7,percent of total billed charges,90% of total billed charges for outpatient setting,8.51,59.62,
SNARE MEDIUM OVAL 27MM / M00562671,70000800,CDM,272,RC,,,Outpatient,,,152.75,152.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.93,70,,85.54,percent of total billed charges,70% of total billed charges for outpatient setting,129.65,84.88,,103.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.38,50,,61.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.56,75,,91.65,percent of total billed charges,75% of total billed charges for outpatient setting,106.93,70,,85.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.61,12.84,,15.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.2,80,,97.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.61,12.84,,15.69,percent of total billed charges,12.84% of total billed charges,19.61,12.84,,15.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.29,65,,79.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.46,35,,42.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.48,90,,109.98,percent of total billed charges,90% of total billed charges for outpatient setting,19.61,137.48,
SNARE SENSATION OVAL MEDIUM / M00562673,70000203,CDM,272,RC,,,Outpatient,,,67.76,67.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.43,70,,37.94,percent of total billed charges,70% of total billed charges for outpatient setting,57.51,84.88,,46.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.88,50,,27.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.82,75,,40.66,percent of total billed charges,75% of total billed charges for outpatient setting,47.43,70,,37.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,12.84,,6.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.21,80,,43.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,12.84,,6.96,percent of total billed charges,12.84% of total billed charges,8.7,12.84,,6.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.04,65,,35.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.72,35,,18.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.98,90,,48.78,percent of total billed charges,90% of total billed charges for outpatient setting,8.7,60.98,
SNARE WIRE TONSIL / MDS5026708,69161879,CDM,272,RC,,,Outpatient,,,3.8,3.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,70,,2.13,percent of total billed charges,70% of total billed charges for outpatient setting,3.23,84.88,,2.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.9,50,,1.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,75,,2.28,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,70,,2.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.04,80,,2.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.47,65,,1.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,35,,1.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.42,90,,2.74,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,3.42,
SOD CHL .45% INJ 1000ML/ 2B1314,3359017,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% 50ML MINI BAG/ 2B1306,3359015,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% INJ 1000ML/ 2B1324,3359022,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% INJ 150ML/ 2B1321,3359019,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% INJ 250ML/ 2B1322Q,3359020,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% INJ 500ML/ 2B1323Q,3359021,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL .9% INJ SNG PK 100ML/ 2B1307,3359016,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD CHL 3% INJ 500ML/ 2B1353Q,3359023,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
SOD POLY SULF 15GM/60ML LIQ :  U/D,3302006,CDM,259,RC,,,Outpatient,,,26.16,26.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,84.88,,17.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.08,50,,10.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.62,75,,15.7,percent of total billed charges,75% of total billed charges for outpatient setting,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,80,,16.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17,65,,13.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.16,35,,7.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.54,90,,18.83,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,23.54,
SOD THIOSULF (CYANIDE ANTIDOTE) KIT :PKG,3301982,CDM,250,RC,,,Outpatient,,,830.51,830.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.36,70,,465.09,percent of total billed charges,70% of total billed charges for outpatient setting,704.94,84.88,,563.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,415.26,50,,332.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,622.88,75,,498.3,percent of total billed charges,75% of total billed charges for outpatient setting,581.36,70,,465.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.64,12.84,,85.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,664.41,80,,531.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.64,12.84,,85.31,percent of total billed charges,12.84% of total billed charges,106.64,12.84,,85.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,539.83,65,,431.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.68,35,,232.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,747.46,90,,597.97,percent of total billed charges,90% of total billed charges for outpatient setting,106.64,747.46,
SOD. TETRADECYL SULF:UD CHARGE,3303302,CDM,250,RC,,,Outpatient,,,47.4,47.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.18,70,,26.54,percent of total billed charges,70% of total billed charges for outpatient setting,40.23,84.88,,32.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.7,50,,18.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.55,75,,28.44,percent of total billed charges,75% of total billed charges for outpatient setting,33.18,70,,26.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.92,80,,30.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,6.09,12.84,,4.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.81,65,,24.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.59,35,,13.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.66,90,,34.13,percent of total billed charges,90% of total billed charges for outpatient setting,6.09,42.66,
SODIUM,200525,CDM,300,RC,84295,HCPCS,Outpatient,,,21.65,19.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,18.38,84.88,,14.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.24,75,,12.99,percent of total billed charges,75% of total billed charges for outpatient setting,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,80,,13.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,100,,,Fee Schedule,100% of Custom Fee Schedule,19.49,90,,15.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,19.49,
SODIUM,5100048,CDM,300,RC,84295,HCPCS,Outpatient,,,83.71,75.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,71.05,84.88,,56.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.78,75,,50.22,percent of total billed charges,75% of total billed charges for outpatient setting,58.6,70,,46.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.97,80,,53.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,100,,,Fee Schedule,100% of Custom Fee Schedule,75.34,90,,60.27,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,75.34,
SODIUM  RANDOM URINE,200931,CDM,300,RC,84300,HCPCS,Outpatient,,,22.77,20.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,19.33,84.88,,15.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.08,75,,13.66,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,80,,14.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,100,,,Fee Schedule,100% of Custom Fee Schedule,20.49,90,,16.39,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,20.49,
SODIUM ACET  SDV 2MEQ/ML : 20ML,3301983,CDM,250,RC,,,Outpatient,,,30.78,30.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.55,70,,17.24,percent of total billed charges,70% of total billed charges for outpatient setting,26.13,84.88,,20.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.39,50,,12.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.09,75,,18.47,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,70,,17.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.62,80,,19.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.01,65,,16.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.77,35,,8.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.7,90,,22.16,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,27.7,
SODIUM BICARB PED SYRINGE 4.2% 10ML,3301987,CDM,250,RC,,,Outpatient,,,64.02,64.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.81,70,,35.85,percent of total billed charges,70% of total billed charges for outpatient setting,54.34,84.88,,43.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.01,50,,25.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.02,75,,38.42,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,70,,35.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.22,80,,40.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.61,65,,33.29,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,35,,17.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.62,90,,46.1,percent of total billed charges,90% of total billed charges for outpatient setting,8.22,57.62,
SODIUM BICARB SDV 4%(NEUT):5ML,3302800,CDM,250,RC,,,Outpatient,,,17.83,17.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,70,,9.98,percent of total billed charges,70% of total billed charges for outpatient setting,15.13,84.88,,12.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.92,50,,7.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.37,75,,10.7,percent of total billed charges,75% of total billed charges for outpatient setting,12.48,70,,9.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.26,80,,11.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,2.29,12.84,,1.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.59,65,,9.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,35,,4.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.05,90,,12.84,percent of total billed charges,90% of total billed charges for outpatient setting,2.29,16.05,
SODIUM BICARB SDV 8.4% : 50ML,3301989,CDM,250,RC,,,Outpatient,,,61.19,61.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.83,70,,34.26,percent of total billed charges,70% of total billed charges for outpatient setting,51.94,84.88,,41.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.6,50,,24.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.89,75,,36.71,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,70,,34.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,12.84,,6.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.95,80,,39.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,12.84,,6.29,percent of total billed charges,12.84% of total billed charges,7.86,12.84,,6.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.77,65,,31.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.42,35,,17.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.07,90,,44.06,percent of total billed charges,90% of total billed charges for outpatient setting,7.86,55.07,
SODIUM BICARB SYRINGE 8.4%  50ML,3301986,CDM,250,RC,,,Outpatient,,,105.65,105.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.96,70,,59.17,percent of total billed charges,70% of total billed charges for outpatient setting,89.68,84.88,,71.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.83,50,,42.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.24,75,,63.39,percent of total billed charges,75% of total billed charges for outpatient setting,73.96,70,,59.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,12.84,,10.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.52,80,,67.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,12.84,,10.86,percent of total billed charges,12.84% of total billed charges,13.57,12.84,,10.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.67,65,,54.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.98,35,,29.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.09,90,,76.07,percent of total billed charges,90% of total billed charges for outpatient setting,13.57,95.09,
SODIUM BICARB TAB 650MG,3301985,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
SODIUM BLD,201255,CDM,300,RC,84295,HCPCS,Outpatient,,,21.65,19.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,18.38,84.88,,14.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.26,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.24,75,,12.99,percent of total billed charges,75% of total billed charges for outpatient setting,15.16,70,,12.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,80,,13.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,100,,,Fee Schedule,100% of Custom Fee Schedule,19.49,90,,15.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,19.49,
SODIUM CHLORIDE 0.9% SOLN 3000ML IRRIG,3302597,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SODIUM CHLORIDE 4MEQ/ML CONC  30ML,3301997,CDM,250,RC,,,Outpatient,,,37.81,37.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,70,,21.18,percent of total billed charges,70% of total billed charges for outpatient setting,32.09,84.88,,25.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.91,50,,15.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.36,75,,22.69,percent of total billed charges,75% of total billed charges for outpatient setting,26.47,70,,21.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,80,,24.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,4.85,12.84,,3.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.58,65,,19.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,35,,10.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.03,90,,27.22,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,34.03,
SODIUM CHLORIDE FTV 0.9% : 10ML,3301993,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SODIUM CHLORIDE INH SOL 0.9% 3ML,3301996,CDM,250,RC,,,Outpatient,,,3.15,3.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,84.88,,2.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.58,50,,1.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.36,75,,1.89,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,70,,1.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.52,80,,2.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.05,65,,1.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,35,,0.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.84,90,,2.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.84,
SODIUM CHLORIDE INHALATION SOLN 0.9% 3ML,3303157,CDM,272,RC,A4216,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SODIUM CHLORIDE INJ 0.9% : 100ML,3301995,CDM,258,RC,J7050,HCPCS,Outpatient,,,75.62,75.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.19,84.88,,51.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.72,75,,45.38,percent of total billed charges,75% of total billed charges for outpatient setting,52.93,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.5,80,,48.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,9.71,12.84,,7.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.15,65,,39.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,100,,,Fee Schedule,100% of Custom Fee Schedule,68.06,90,,54.45,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,68.06,
SODIUM CHLORIDE OPTH SOL 5% : 15ML,3301998,CDM,250,RC,,,Outpatient,,,30.6,30.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.42,70,,17.14,percent of total billed charges,70% of total billed charges for outpatient setting,25.97,84.88,,20.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.3,50,,12.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,75,,18.36,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,70,,17.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,12.84,,3.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,80,,19.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,3.93,12.84,,3.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.89,65,,15.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.71,35,,8.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.54,90,,22.03,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,27.54,
SODIUM CHLORIDE PF SDV 0.9% : 10ML,3301992,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SODIUM CHLORIDE SDV 0.9% : 10ML,3301994,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SODIUM CHLORIDE TAB: 1 GM,3301990,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SODIUM CITR SOL (BICITRA) 16OZ 30ML UD,3303120,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SODIUM CL (LUBRIDERM) LOT : UNSCNT 60Z,3301999,CDM,259,RC,,,Outpatient,,,9.52,9.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,70,,5.33,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,84.88,,6.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.76,50,,3.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.14,75,,5.71,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,70,,5.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,80,,6.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.19,65,,4.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,35,,2.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.57,90,,6.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.57,
SODIUM HYAL (PROVISC)SYRING 10MG:0.550ML,3302000,CDM,250,RC,,,Outpatient,,,374.3,374.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.01,70,,209.61,percent of total billed charges,70% of total billed charges for outpatient setting,317.71,84.88,,254.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,187.15,50,,149.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.73,75,,224.58,percent of total billed charges,75% of total billed charges for outpatient setting,262.01,70,,209.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.06,12.84,,38.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.44,80,,239.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.06,12.84,,38.45,percent of total billed charges,12.84% of total billed charges,48.06,12.84,,38.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,243.3,65,,194.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.01,35,,104.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,336.87,90,,269.5,percent of total billed charges,90% of total billed charges for outpatient setting,48.06,336.87,
SODIUM HYPOCL (DAKINS) SOL 0.25% 480ML,3302001,CDM,259,RC,,,Outpatient,,,14.68,14.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,12.46,84.88,,9.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.34,50,,5.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.01,75,,8.81,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,70,,8.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.74,80,,9.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.88,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.54,65,,7.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.14,35,,4.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.21,90,,10.57,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,13.21,
SODIUM LAURY (CARRAKLENZ W/AL) LOT :16OZ,3302002,CDM,259,RC,,,Outpatient,,,45.5,45.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,70,,25.48,percent of total billed charges,70% of total billed charges for outpatient setting,38.62,84.88,,30.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.75,50,,18.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.13,75,,27.3,percent of total billed charges,75% of total billed charges for outpatient setting,31.85,70,,25.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.4,80,,29.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,5.84,12.84,,4.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.58,65,,23.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,35,,12.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,90% of total billed charges for outpatient setting,5.84,40.95,
SODIUM MOR (MORRHUATE) MDV 5% : 30ML,3302003,CDM,250,RC,,,Outpatient,,,189.04,189.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.33,70,,105.86,percent of total billed charges,70% of total billed charges for outpatient setting,160.46,84.88,,128.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.52,50,,75.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.78,75,,113.42,percent of total billed charges,75% of total billed charges for outpatient setting,132.33,70,,105.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.23,80,,120.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122.88,65,,98.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.16,35,,52.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.14,90,,136.11,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.14,
SODIUM PHOS  3MMOL/ML 15 ML INJ :,3303345,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SODIUM PHOS (FLEET PHOS) SOL : 90ML,3302004,CDM,259,RC,,,Outpatient,,,8.33,8.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,70,,4.66,percent of total billed charges,70% of total billed charges for outpatient setting,7.07,84.88,,5.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.17,50,,3.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,75,,5,percent of total billed charges,75% of total billed charges for outpatient setting,5.83,70,,4.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,12.84,,0.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,80,,5.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,1.07,12.84,,0.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.41,65,,4.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,35,,2.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.5,90,,6,percent of total billed charges,90% of total billed charges for outpatient setting,1.07,7.5,
SODIUM PHOS MB/ OSMOPREP: 1.5 GM,3303317,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
SODIUM POLYSTY SULF(SPS)susp 15GM/60ML,3302007,CDM,259,RC,,,Outpatient,,,148.81,148.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.17,70,,83.34,percent of total billed charges,70% of total billed charges for outpatient setting,126.31,84.88,,101.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.41,50,,59.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.61,75,,89.29,percent of total billed charges,75% of total billed charges for outpatient setting,104.17,70,,83.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.11,12.84,,15.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.05,80,,95.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.11,12.84,,15.29,percent of total billed charges,12.84% of total billed charges,19.11,12.84,,15.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,65,,77.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,35,,41.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.93,90,,107.14,percent of total billed charges,90% of total billed charges for outpatient setting,19.11,133.93,
SODIUM POT CA MAG (BSS) OPTH SOL  15ML,3302010,CDM,259,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,15.28,84.88,,12.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,9,50,,7.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,75,,10.8,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,70,,10.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,80,,11.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,2.31,12.84,,1.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.7,65,,9.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,35,,5.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.2,90,,12.96,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,16.2,
SODIUM POT CA MAG (BSS) OPTH SOL : 500ML,3302009,CDM,259,RC,,,Outpatient,,,61.33,61.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.93,70,,34.34,percent of total billed charges,70% of total billed charges for outpatient setting,52.06,84.88,,41.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.67,50,,24.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46,75,,36.8,percent of total billed charges,75% of total billed charges for outpatient setting,42.93,70,,34.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,12.84,,6.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.06,80,,39.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,7.87,12.84,,6.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,39.86,65,,31.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,35,,17.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,55.2,90,,44.16,percent of total billed charges,90% of total billed charges for outpatient setting,7.87,55.2,
SODIUM THIOSULF SDV 25% : 50ML,3302008,CDM,250,RC,,,Outpatient,,,68.06,68.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.64,70,,38.11,percent of total billed charges,70% of total billed charges for outpatient setting,57.77,84.88,,46.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.03,50,,27.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.05,75,,40.84,percent of total billed charges,75% of total billed charges for outpatient setting,47.64,70,,38.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,12.84,,6.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.45,80,,43.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.74,12.84,,6.99,percent of total billed charges,12.84% of total billed charges,8.74,12.84,,6.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.24,65,,35.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.82,35,,19.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,61.25,90,,49,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,61.25,
SOFT PULLUP PROBE COVERS / E8348PC,69159920,CDM,270,RC,,,Outpatient,,,49,49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,41.59,84.88,,33.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,75,,29.4,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,70,,27.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,80,,31.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.85,65,,25.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.1,90,,35.28,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.1,
SOLUTION D5RL 1000cc,7651116,CDM,258,RC,,,Outpatient,,,170.76,170.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,144.94,84.88,,115.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.38,50,,68.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.07,75,,102.46,percent of total billed charges,75% of total billed charges for outpatient setting,119.53,70,,95.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.61,80,,109.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,21.93,12.84,,17.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.99,65,,88.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,35,,47.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,90% of total billed charges for outpatient setting,21.93,153.68,
SOLUTION PLASMA LYTE / 2B2544X,70000581,CDM,258,RC,,,Outpatient,,,23.55,23.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,70,,13.19,percent of total billed charges,70% of total billed charges for outpatient setting,19.99,84.88,,15.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.78,50,,9.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.66,75,,14.13,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,70,,13.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,12.84,,2.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.84,80,,15.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,3.02,12.84,,2.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.31,65,,12.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,35,,6.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.2,90,,16.96,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,21.2,
SOLUTION SODIUM CHLORIDE 3000/2B7127,5050030,CDM,258,RC,,,Outpatient,,,43.95,43.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.77,70,,24.62,percent of total billed charges,70% of total billed charges for outpatient setting,37.3,84.88,,29.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.98,50,,17.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.96,75,,26.37,percent of total billed charges,75% of total billed charges for outpatient setting,30.77,70,,24.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.16,80,,28.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,5.64,12.84,,4.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.57,65,,22.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,35,,12.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.56,90,,31.65,percent of total billed charges,90% of total billed charges for outpatient setting,5.64,39.56,
SOLUTION TRANSFER DEVICE,3302220,CDM,272,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SORBITOL SOL 70 :,3302011,CDM,259,RC,,,Outpatient,,,22.84,22.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.99,70,,12.79,percent of total billed charges,70% of total billed charges for outpatient setting,19.39,84.88,,15.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.42,50,,9.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.13,75,,13.7,percent of total billed charges,75% of total billed charges for outpatient setting,15.99,70,,12.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,12.84,,2.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.27,80,,14.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,12.84,,2.34,percent of total billed charges,12.84% of total billed charges,2.93,12.84,,2.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.85,65,,11.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.99,35,,6.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.56,90,,16.45,percent of total billed charges,90% of total billed charges for outpatient setting,2.93,20.56,
SOTALOL (BETAPACE) TAB : 80MG,3302012,CDM,259,RC,,,Outpatient,,,6.34,6.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.44,70,,3.55,percent of total billed charges,70% of total billed charges for outpatient setting,5.38,84.88,,4.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.17,50,,2.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.76,75,,3.81,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,70,,3.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,80,,4.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,0.81,12.84,,0.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.12,65,,3.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.22,35,,1.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.71,90,,4.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.81,5.71,
SOTALOL (BETAPACE) TAB : 80MG UD,3302013,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
SPACER +9MM HUM SHOULDER / 1307-30-009,793841,CDM,278,RC,C1821,HCPCS,Outpatient,,,3150,3150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,60,,1512,percent of total billed charges,60% of total Billed charges for outpatient setting,2673.72,84.88,,2138.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2362.5,75,,1890,percent of total billed charges,75% of total billed charges for outpatient setting,1575,50,,1260,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,80,,2016,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,404.46,12.84,,323.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3307.5,105,,2646,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,35,,882,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1890,60,,1512,percent of total billed charges,60% of total billed charges for outpatient setting,404.46,3307.5,
SPACER 10X22 10-16MM / 1172.2024S,7264857,CDM,278,RC,C1821,HCPCS,Outpatient,,,22750,22750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13650,60,,10920,percent of total billed charges,60% of total Billed charges for outpatient setting,19310.2,84.88,,15448.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17062.5,75,,13650,percent of total billed charges,75% of total billed charges for outpatient setting,11375,50,,9100,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18200,80,,14560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23887.5,105,,19110,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7962.5,35,,6370,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13650,60,,10920,percent of total billed charges,60% of total billed charges for outpatient setting,2921.1,23887.5,
SPACER 10X22 6-12MM / 1172.2010S,69169529,CDM,278,RC,C1821,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 10X22/7-13MM / 1172.2021S,69169560,CDM,278,RC,C1821,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 10X22/9-15MM / 1172.2013S,69169559,CDM,278,RC,C1821,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 10X26 6-12MM / 1172.2110S,69169602,CDM,278,RC,C1821,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 10X26MM SABLE / 1172.2113S,7264851,CDM,278,RC,C1821,HCPCS,Outpatient,,,22750,22750,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13650,60,,10920,percent of total billed charges,60% of total Billed charges for outpatient setting,19310.2,84.88,,15448.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17062.5,75,,13650,percent of total billed charges,75% of total billed charges for outpatient setting,11375,50,,9100,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18200,80,,14560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,2921.1,12.84,,2336.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23887.5,105,,19110,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7962.5,35,,6370,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13650,60,,10920,percent of total billed charges,60% of total billed charges for outpatient setting,2921.1,23887.5,
SPACER 12X14MM SPINAL COAL / 1136.2478,2468509,CDM,278,RC,C1821,HCPCS,Outpatient,,,7502,7502,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4501.2,60,,3600.96,percent of total billed charges,60% of total Billed charges for outpatient setting,6367.7,84.88,,5094.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.5,75,,4501.2,percent of total billed charges,75% of total billed charges for outpatient setting,3751,50,,3000.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.26,12.84,,770.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6001.6,80,,4801.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.26,12.84,,770.61,percent of total billed charges,12.84% of total billed charges,963.26,12.84,,770.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7877.1,105,,6301.68,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625.7,35,,2100.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4501.2,60,,3600.96,percent of total billed charges,60% of total billed charges for outpatient setting,963.26,7877.1,
SPACER 14X12X12MM ACDF / 365.412,310433,CDM,278,RC,C1821,HCPCS,Outpatient,,,3251.5,3251.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950.9,60,,1560.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2759.87,84.88,,2207.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2438.63,75,,1950.9,percent of total billed charges,75% of total billed charges for outpatient setting,1625.75,50,,1300.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.49,12.84,,333.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2601.2,80,,2080.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.49,12.84,,333.99,percent of total billed charges,12.84% of total billed charges,417.49,12.84,,333.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3414.08,105,,2731.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1138.03,35,,910.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1950.9,60,,1560.72,percent of total billed charges,60% of total billed charges for outpatient setting,417.49,3414.08,
SPACER 20X50MM ELSA / 1122.0150,2105887,CDM,278,RC,C1821,HCPCS,Outpatient,,,32375,32375,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19425,60,,15540,percent of total billed charges,60% of total Billed charges for outpatient setting,27479.9,84.88,,21983.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24281.25,75,,19425,percent of total billed charges,75% of total billed charges for outpatient setting,16187.5,50,,12950,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4156.95,12.84,,3325.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25900,80,,20720,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4156.95,12.84,,3325.56,percent of total billed charges,12.84% of total billed charges,4156.95,12.84,,3325.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33993.75,105,,27195,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.25,35,,9065,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19425,60,,15540,percent of total billed charges,60% of total billed charges for outpatient setting,4156.95,33993.75,
SPACER 20X55 7-14MM ELSA / 1122.0055,69169385,CDM,278,RC,C1713,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 7MM BONE FORCE CERVICL / 865.407S,69161780,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
SPACER 8MM BONE FORCE CERVICL / 865.408S,69161921,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
SPACER 8X22 6-12MM / 1172.0010S,7264868,CDM,278,RC,C1821,HCPCS,Outpatient,,,13000,13000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,60,,6240,percent of total billed charges,60% of total Billed charges for outpatient setting,11034.4,84.88,,8827.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9750,75,,7800,percent of total billed charges,75% of total billed charges for outpatient setting,6500,50,,5200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400,80,,8320,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,1669.2,12.84,,1335.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13650,105,,10920,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,35,,3640,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7800,60,,6240,percent of total billed charges,60% of total billed charges for outpatient setting,1669.2,13650,
SPACER 9MM BONE FORCE CERVICL / 865.409S,69162826,CDM,278,RC,C1821,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
SPACER ACDF 14X16X7MM  / 365.707,69169186,CDM,278,RC,C1821,HCPCS,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
SPACER ACDF 14X16X8MM  / 365.708,69169187,CDM,278,RC,,,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.04,60,,1635.23,percent of total billed charges,60% of total Billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,1703.37,50,,1362.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3577.07,105,,2861.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2044.04,60,,1635.23,percent of total billed charges,60% of total billed charges for outpatient setting,437.42,3577.07,
SPACER BONE FORCE CERVICL 5MM / 865.405S,69161741,CDM,278,RC,C1821,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
SPACER BONE FORCE CERVICL 6MM / 865.406S,69161718,CDM,278,RC,C1821,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
SPACER CALBR L 18X45MM/7-10MM / 194.845,69162411,CDM,278,RC,,,Outpatient,,,16100,16100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9660,60,,7728,percent of total billed charges,60% of total Billed charges for outpatient setting,13665.68,84.88,,10932.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,8050,50,,6440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12075,75,,9660,percent of total billed charges,75% of total billed charges for outpatient setting,8050,50,,6440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.24,12.84,,1653.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12880,80,,10304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.24,12.84,,1653.79,percent of total billed charges,12.84% of total billed charges,2067.24,12.84,,1653.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16905,105,,13524,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5635,35,,4508,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9660,60,,7728,percent of total billed charges,60% of total billed charges for outpatient setting,2067.24,16905,
SPACER CALBR L 18X50MM 7-10MM / 194.850,69162410,CDM,278,RC,,,Outpatient,,,16100,16100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9660,60,,7728,percent of total billed charges,60% of total Billed charges for outpatient setting,13665.68,84.88,,10932.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,8050,50,,6440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12075,75,,9660,percent of total billed charges,75% of total billed charges for outpatient setting,8050,50,,6440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.24,12.84,,1653.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12880,80,,10304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.24,12.84,,1653.79,percent of total billed charges,12.84% of total billed charges,2067.24,12.84,,1653.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16905,105,,13524,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5635,35,,4508,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9660,60,,7728,percent of total billed charges,60% of total billed charges for outpatient setting,2067.24,16905,
SPACER CALIBER 10X26/9 13MM /194.426,69162409,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
SPACER CALIBER 10X26MM/ 7MM /194.273,69162738,CDM,278,RC,,,Outpatient,,,9800,9800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5880,60,,4704,percent of total billed charges,60% of total Billed charges for outpatient setting,8318.24,84.88,,6654.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7350,75,,5880,percent of total billed charges,75% of total billed charges for outpatient setting,4900,50,,3920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840,80,,6272,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,1258.32,12.84,,1006.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10290,105,,8232,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3430,35,,2744,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5880,60,,4704,percent of total billed charges,60% of total billed charges for outpatient setting,1258.32,10290,
SPACER COAL AGX RT 8X14 6MM / 3128.1276,70000560,CDM,278,RC,C1821,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
SPACER MIS 12X14 10MM / 3136.1110,69162946,CDM,278,RC,C1821,HCPCS,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
SPACER MIS 12X14 5MM / 3136.1105,69162822,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 6MM / 3136.1106,69162698,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 7MM / 3136.1107,69162697,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 8MM / 3136.1108,69162719,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 8MM / 3136.1608,1939303,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 9MM / 3136.1109,69162744,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 12X14 9MM / 3136.1609,1939304,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 14X12 12MM / 3136.1609,1939356,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 14X16 10MM / 3136.2110,69162835,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 14X16 12MM / 3136.2112,1939322,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 14x16 6MM / 3136.2106,69162937,CDM,278,RC,C1821,HCPCS,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
SPACER MIS 14x16 7MM / 3136.2107,69162823,CDM,278,RC,C1821,HCPCS,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
SPACER MIS 14X16 8MM / 3136.2108,69162836,CDM,278,RC,C1821,HCPCS,Outpatient,,,6820,6820,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4092,60,,3273.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5788.82,84.88,,4631.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115,75,,4092,percent of total billed charges,75% of total billed charges for outpatient setting,3410,50,,2728,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5456,80,,4364.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,875.69,12.84,,700.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7161,105,,5728.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2387,35,,1909.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4092,60,,3273.6,percent of total billed charges,60% of total billed charges for outpatient setting,875.69,7161,
SPACER MIS 14x16 9MM / 3136.2109,69162894,CDM,278,RC,C1821,HCPCS,Outpatient,,,6000,6000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,60,,2880,percent of total billed charges,60% of total Billed charges for outpatient setting,5092.8,84.88,,4074.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4500,75,,3600,percent of total billed charges,75% of total billed charges for outpatient setting,3000,50,,2400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800,80,,3840,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,770.4,12.84,,616.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6300,105,,5040,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100,35,,1680,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3600,60,,2880,percent of total billed charges,60% of total billed charges for outpatient setting,770.4,6300,
SPACER MIS 24x30MM 11MM / 3135.0211,69169443,CDM,278,RC,C1821,HCPCS,Outpatient,,,17000,17000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10200,60,,8160,percent of total billed charges,60% of total Billed charges for outpatient setting,14429.6,84.88,,11543.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12750,75,,10200,percent of total billed charges,75% of total billed charges for outpatient setting,8500,50,,6800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13600,80,,10880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17850,105,,14280,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5950,35,,4760,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10200,60,,8160,percent of total billed charges,60% of total billed charges for outpatient setting,2182.8,17850,
SPACER MIS 26x34MM / 3135.0613,69169508,CDM,278,RC,C1821,HCPCS,Outpatient,,,17000,17000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10200,60,,8160,percent of total billed charges,60% of total Billed charges for outpatient setting,14429.6,84.88,,11543.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12750,75,,10200,percent of total billed charges,75% of total billed charges for outpatient setting,8500,50,,6800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13600,80,,10880,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,2182.8,12.84,,1746.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17850,105,,14280,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5950,35,,4760,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10200,60,,8160,percent of total billed charges,60% of total billed charges for outpatient setting,2182.8,17850,
SPACER NIKO 12x14 CORPECTOMY / 342.821,69169352,CDM,278,RC,C1821,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
SPACER NIKO 25MM CORPECTOMY  / 342.925,69169424,CDM,278,RC,C1821,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
SPACER NIKO CORPECTOMY 23MM 342.823,69162273,CDM,278,RC,,,Outpatient,,,7708,7708,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4624.8,60,,3699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,6542.55,84.88,,5234.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,3854,50,,3083.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5781,75,,4624.8,percent of total billed charges,75% of total billed charges for outpatient setting,3854,50,,3083.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.71,12.84,,791.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6166.4,80,,4933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.71,12.84,,791.77,percent of total billed charges,12.84% of total billed charges,989.71,12.84,,791.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8093.4,105,,6474.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2697.8,35,,2158.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4624.8,60,,3699.84,percent of total billed charges,60% of total billed charges for outpatient setting,989.71,8093.4,
SPACER NIKO CORPECTOMY 29MM / 342.929,69162627,CDM,278,RC,C1821,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
SPACER NIKO CORPECTOMY SM 19MM / 342.819,69162610,CDM,278,RC,C1821,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
SPACER SM 12X14 CORPCTMY / 342.825,69162462,CDM,278,RC,C1821,HCPCS,Outpatient,,,7708,7708,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4624.8,60,,3699.84,percent of total billed charges,60% of total Billed charges for outpatient setting,6542.55,84.88,,5234.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5781,75,,4624.8,percent of total billed charges,75% of total billed charges for outpatient setting,3854,50,,3083.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.71,12.84,,791.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6166.4,80,,4933.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.71,12.84,,791.77,percent of total billed charges,12.84% of total billed charges,989.71,12.84,,791.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8093.4,105,,6474.72,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2697.8,35,,2158.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4624.8,60,,3699.84,percent of total billed charges,60% of total billed charges for outpatient setting,989.71,8093.4,
SPACER SMALL 15 DEG 11MM / 3108.0211,69162816,CDM,278,RC,C1821,HCPCS,Outpatient,,,19422,19422,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11653.2,60,,9322.56,percent of total billed charges,60% of total Billed charges for outpatient setting,16485.39,84.88,,13188.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14566.5,75,,11653.2,percent of total billed charges,75% of total billed charges for outpatient setting,9711,50,,7768.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.78,12.84,,1995.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15537.6,80,,12430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.78,12.84,,1995.02,percent of total billed charges,12.84% of total billed charges,2493.78,12.84,,1995.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20393.1,105,,16314.48,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6797.7,35,,5438.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11653.2,60,,9322.56,percent of total billed charges,60% of total billed charges for outpatient setting,2493.78,20393.1,
"SPECIAL STAIN, GROUP I FOR MICROORGANISM",900031,CDM,310,RC,88312,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,178.52,
SPECIAL STAINS,202047,CDM,310,RC,88313,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,121.4,
SPECIAL STAINS GROUP II,900032,CDM,310,RC,88313,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,121.4,
SPECIAL STAINS I&R HIST W/FRZ TISSUE,202045,CDM,310,RC,88314,HCPCS,Outpatient,,,150.11,135.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.08,70,,84.06,percent of total billed charges,70% of total billed charges for outpatient setting,127.41,84.88,,101.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.58,75,,90.06,percent of total billed charges,75% of total billed charges for outpatient setting,105.08,70,,84.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.09,80,,96.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.1,90,,108.08,percent of total billed charges,90% of total billed charges for outpatient setting,38.17,135.1,
SPECIAL STAINS REFERENCE,200398,CDM,310,RC,88313,HCPCS,Outpatient,,,134.89,121.4,,48.53,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,114.49,84.88,,91.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,101.17,75,,80.94,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,70,,75.54,percent of total billed charges,70% of total billed charges for outpatient setting,51.56,170,,,Fee Schedule,170% of Medicare OPPS rate,65.21,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.08,175,,,Fee Schedule,175% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.91,80,,86.33,percent of total billed charges,80% of total billed charges for outpatient setting,42.46,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,37.91,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,30.33,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,121.4,90,,97.12,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,121.4,
SPECIALTY MOUTHWASH 6OZ,3304418,CDM,259,RC,,,Outpatient,,,52.86,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,44.87,84.88,,35.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.43,50,,21.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.65,75,,31.72,percent of total billed charges,75% of total billed charges for outpatient setting,37,70,,29.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.29,80,,33.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,6.79,12.84,,5.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.36,65,,27.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,35,,14.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.57,90,,38.06,percent of total billed charges,90% of total billed charges for outpatient setting,6.79,47.57,
SPECIMEN SOCK/65652-122,6152918,CDM,270,RC,,,Outpatient,,,34.16,34.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.91,70,,19.13,percent of total billed charges,70% of total billed charges for outpatient setting,29,84.88,,23.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.08,50,,13.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.62,75,,20.5,percent of total billed charges,75% of total billed charges for outpatient setting,23.91,70,,19.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,12.84,,3.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.33,80,,21.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,12.84,,3.51,percent of total billed charges,12.84% of total billed charges,4.39,12.84,,3.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.2,65,,17.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,35,,9.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.74,90,,24.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.39,30.74,
SPECIMEN TRAP MUCOUS 40CC,5150084,CDM,270,RC,,,Outpatient,,,48.04,48.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.63,70,,26.9,percent of total billed charges,70% of total billed charges for outpatient setting,40.78,84.88,,32.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,50,,19.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.03,75,,28.82,percent of total billed charges,75% of total billed charges for outpatient setting,33.63,70,,26.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,12.84,,4.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.43,80,,30.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,12.84,,4.94,percent of total billed charges,12.84% of total billed charges,6.17,12.84,,4.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.23,65,,24.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.81,35,,13.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,43.24,90,,34.59,percent of total billed charges,90% of total billed charges for outpatient setting,6.17,43.24,
SPEED CINCH CRVD NDL 2-0 FBR WR,69162564,CDM,272,RC,,,Outpatient,,,1708.77,1708.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.14,70,,956.91,percent of total billed charges,70% of total billed charges for outpatient setting,1450.4,84.88,,1160.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,854.39,50,,683.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1281.58,75,,1025.26,percent of total billed charges,75% of total billed charges for outpatient setting,1196.14,70,,956.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.41,12.84,,175.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1367.02,80,,1093.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.41,12.84,,175.53,percent of total billed charges,12.84% of total billed charges,219.41,12.84,,175.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1110.7,65,,888.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.07,35,,478.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1537.89,90,,1230.31,percent of total billed charges,90% of total billed charges for outpatient setting,219.41,1537.89,
SPEEDGUIDE T10 2.7MM / 703887,1627327,CDM,272,RC,,,Outpatient,,,1253.12,1253.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.18,70,,701.74,percent of total billed charges,70% of total billed charges for outpatient setting,1063.65,84.88,,850.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,626.56,50,,501.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,939.84,75,,751.87,percent of total billed charges,75% of total billed charges for outpatient setting,877.18,70,,701.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.5,80,,802,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,160.9,12.84,,128.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,814.53,65,,651.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.59,35,,350.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1127.81,90,,902.25,percent of total billed charges,90% of total billed charges for outpatient setting,160.9,1127.81,
SPEEDGUIDE T8 2.0MM / 703927,69162842,CDM,272,RC,,,Outpatient,,,1027.86,1027.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.5,70,,575.6,percent of total billed charges,70% of total billed charges for outpatient setting,872.45,84.88,,697.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,513.93,50,,411.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,770.9,75,,616.72,percent of total billed charges,75% of total billed charges for outpatient setting,719.5,70,,575.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.98,12.84,,105.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.29,80,,657.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.98,12.84,,105.58,percent of total billed charges,12.84% of total billed charges,131.98,12.84,,105.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,668.11,65,,534.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.75,35,,287.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,925.07,90,,740.06,percent of total billed charges,90% of total billed charges for outpatient setting,131.98,925.07,
SPEEDGUIDE T8 2.4/2.7MM / 703888,70000313,CDM,272,RC,,,Outpatient,,,1139.2,1139.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.44,70,,637.95,percent of total billed charges,70% of total billed charges for outpatient setting,966.95,84.88,,773.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,569.6,50,,455.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,854.4,75,,683.52,percent of total billed charges,75% of total billed charges for outpatient setting,797.44,70,,637.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.27,12.84,,117.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.36,80,,729.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.27,12.84,,117.02,percent of total billed charges,12.84% of total billed charges,146.27,12.84,,117.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,740.48,65,,592.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.72,35,,318.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1025.28,90,,820.22,percent of total billed charges,90% of total billed charges for outpatient setting,146.27,1025.28,
SPHENOID BALLOON SZ 5 1830517SPH,69161898,CDM,272,RC,,,Outpatient,,,1457.4,1457.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.18,70,,816.14,percent of total billed charges,70% of total billed charges for outpatient setting,1237.04,84.88,,989.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,728.7,50,,582.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1093.05,75,,874.44,percent of total billed charges,75% of total billed charges for outpatient setting,1020.18,70,,816.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.13,12.84,,149.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1165.92,80,,932.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.13,12.84,,149.7,percent of total billed charges,12.84% of total billed charges,187.13,12.84,,149.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,947.31,65,,757.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.09,35,,408.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1311.66,90,,1049.33,percent of total billed charges,90% of total billed charges for outpatient setting,187.13,1311.66,
SPHENOID BALLOON SZ 6 / 1830617SPH,69161912,CDM,272,RC,,,Outpatient,,,1501.12,1501.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.78,70,,840.62,percent of total billed charges,70% of total billed charges for outpatient setting,1274.15,84.88,,1019.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,750.56,50,,600.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1125.84,75,,900.67,percent of total billed charges,75% of total billed charges for outpatient setting,1050.78,70,,840.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.74,12.84,,154.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200.9,80,,960.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.74,12.84,,154.19,percent of total billed charges,12.84% of total billed charges,192.74,12.84,,154.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,975.73,65,,780.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.39,35,,420.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1351.01,90,,1080.81,percent of total billed charges,90% of total billed charges for outpatient setting,192.74,1351.01,
SPHERICAL 3.5MM BUR/H9110,69159887,CDM,272,RC,,,Outpatient,,,228.84,228.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.19,70,,128.15,percent of total billed charges,70% of total billed charges for outpatient setting,194.24,84.88,,155.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.42,50,,91.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.63,75,,137.3,percent of total billed charges,75% of total billed charges for outpatient setting,160.19,70,,128.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,12.84,,23.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.07,80,,146.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,29.38,12.84,,23.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.75,65,,119,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.09,35,,64.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,205.96,90,,164.77,percent of total billed charges,90% of total billed charges for outpatient setting,29.38,205.96,
SPINE ENTIRE AP & LAT,2400200,CDM,320,RC,72082,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,60.5,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SPINE SCOLIOSIS SUP & ERECT,2400250,CDM,320,RC,72082,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,60.5,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SPINE SINGLE VW SPEC LEVEL,2400205,CDM,320,RC,72020,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SPINE STIM ACCESS KIT / 3550-38,69162218,CDM,272,RC,,,Outpatient,,,423.95,423.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,359.85,84.88,,287.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,211.98,50,,169.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.96,75,,254.37,percent of total billed charges,75% of total billed charges for outpatient setting,296.77,70,,237.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.16,80,,271.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,275.57,65,,220.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.38,35,,118.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,381.56,90,,305.25,percent of total billed charges,90% of total billed charges for outpatient setting,54.44,381.56,
SPINE STIM ACCESS KIT / 3550-P4,69162215,CDM,272,RC,,,Outpatient,,,1081.5,1081.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.05,70,,605.64,percent of total billed charges,70% of total billed charges for outpatient setting,917.98,84.88,,734.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,540.75,50,,432.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,811.13,75,,648.9,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,70,,605.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.2,80,,692.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,138.86,12.84,,111.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,702.98,65,,562.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.53,35,,302.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,973.35,90,,778.68,percent of total billed charges,90% of total billed charges for outpatient setting,138.86,973.35,
SPINE STIM CHARGING SYSTEM / 97754,69162219,CDM,272,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1560,65,,1248,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,90,,1728,percent of total billed charges,90% of total billed charges for outpatient setting,308.16,2160,
SPINE STIM CONTROLLER  / 97745,69162817,CDM,272,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1430,65,,1144,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,90,,1584,percent of total billed charges,90% of total billed charges for outpatient setting,282.48,1980,
SPINE STIM GENERATOR/ 97715,69162818,CDM,278,RC,C1820,HCPCS,Outpatient,,,31600,31600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18960,60,,15168,percent of total billed charges,60% of total Billed charges for outpatient setting,26822.08,84.88,,21457.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23700,75,,18960,percent of total billed charges,75% of total billed charges for outpatient setting,15800,50,,12640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057.44,12.84,,3245.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25280,80,,20224,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057.44,12.84,,3245.95,percent of total billed charges,12.84% of total billed charges,4057.44,12.84,,3245.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33180,105,,26544,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11060,35,,8848,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18960,60,,15168,percent of total billed charges,60% of total billed charges for outpatient setting,4057.44,33180,
SPINE STIM IPG INTERNAL PULSE GEN  97712,69162407,CDM,278,RC,C1820,HCPCS,Outpatient,,,26000,26000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15600,60,,12480,percent of total billed charges,60% of total Billed charges for outpatient setting,22068.8,84.88,,17655.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19500,75,,15600,percent of total billed charges,75% of total billed charges for outpatient setting,13000,50,,10400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3338.4,12.84,,2670.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20800,80,,16640,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3338.4,12.84,,2670.72,percent of total billed charges,12.84% of total billed charges,3338.4,12.84,,2670.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27300,105,,21840,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9100,35,,7280,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15600,60,,12480,percent of total billed charges,60% of total billed charges for outpatient setting,3338.4,27300,
SPINE STIM IPG(Internal Pulse Gen) 97714,69162221,CDM,278,RC,C1820,HCPCS,Outpatient,,,33000,33000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19800,60,,15840,percent of total billed charges,60% of total Billed charges for outpatient setting,28010.4,84.88,,22408.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24750,75,,19800,percent of total billed charges,75% of total billed charges for outpatient setting,16500,50,,13200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26400,80,,21120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,4237.2,12.84,,3389.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34650,105,,27720,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11550,35,,9240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19800,60,,15840,percent of total billed charges,60% of total billed charges for outpatient setting,4237.2,34650,
SPINE STIM LEAD KIT 39565-65,69162217,CDM,278,RC,C1778,HCPCS,Outpatient,,,7600,7600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4560,60,,3648,percent of total billed charges,60% of total Billed charges for outpatient setting,6450.88,84.88,,5160.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5700,75,,4560,percent of total billed charges,75% of total billed charges for outpatient setting,3800,50,,3040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6080,80,,4864,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7980,105,,6384,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,35,,2128,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4560,60,,3648,percent of total billed charges,60% of total billed charges for outpatient setting,975.84,7980,
SPINE STIM MRI LEAD / 977C165,69162463,CDM,278,RC,C1778,HCPCS,Outpatient,,,10600,10600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6360,60,,5088,percent of total billed charges,60% of total Billed charges for outpatient setting,8997.28,84.88,,7197.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7950,75,,6360,percent of total billed charges,75% of total billed charges for outpatient setting,5300,50,,4240,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1361.04,12.84,,1088.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8480,80,,6784,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1361.04,12.84,,1088.83,percent of total billed charges,12.84% of total billed charges,1361.04,12.84,,1088.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11130,105,,8904,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3710,35,,2968,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6360,60,,5088,percent of total billed charges,60% of total billed charges for outpatient setting,1361.04,11130,
SPINE STIM PATIENT PROGRAMMER / 97740,69162220,CDM,272,RC,C1787,HCPCS,Outpatient,,,3406.73,3406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2384.71,70,,1907.77,percent of total billed charges,70% of total billed charges for outpatient setting,2891.63,84.88,,2313.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2555.05,75,,2044.04,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.38,80,,2180.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,437.42,12.84,,349.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2214.37,65,,1771.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.36,35,,953.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3066.06,90,,2452.85,percent of total billed charges,90% of total billed charges for outpatient setting,437.42,3066.06,
SPINE STIM POCKET SIZER / 3550-69,69162216,CDM,272,RC,,,Outpatient,,,0.09,0.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,70,,0.05,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,84.88,,0.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.05,50,,0.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.07,75,,0.06,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,70,,0.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,12.84,,0.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,80,,0.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,12.84,,0.01,percent of total billed charges,12.84% of total billed charges,0.01,12.84,,0.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.06,65,,0.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,35,,0.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.08,90,,0.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,0.08,
SPINE STIM RECHARGER / 97755,69162819,CDM,272,RC,,,Outpatient,,,3217.46,3217.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2252.22,70,,1801.78,percent of total billed charges,70% of total billed charges for outpatient setting,2730.98,84.88,,2184.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1608.73,50,,1286.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2413.1,75,,1930.48,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.12,12.84,,330.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2573.97,80,,2059.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.12,12.84,,330.5,percent of total billed charges,12.84% of total billed charges,413.12,12.84,,330.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2091.35,65,,1673.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.11,35,,900.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2895.71,90,,2316.57,percent of total billed charges,90% of total billed charges for outpatient setting,413.12,2895.71,
SPINE THORACIC TWO VIEWS,2400230,CDM,320,RC,72070,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
SPINE THORACOLUMBAR TWO VIEWS,2400245,CDM,320,RC,72080,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
SPIRIVA HANDIHALER(TIOTROPIUM BR.):18MCG,3303000,CDM,250,RC,,,Outpatient,,,152.63,152.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.84,70,,85.47,percent of total billed charges,70% of total billed charges for outpatient setting,129.55,84.88,,103.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.32,50,,61.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.47,75,,91.58,percent of total billed charges,75% of total billed charges for outpatient setting,106.84,70,,85.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.1,80,,97.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.21,65,,79.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.42,35,,42.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.37,90,,109.9,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,137.37,
SPIROMETER 4000ML ADULT / 8884719010,671312,CDM,270,RC,,,Outpatient,,,17.55,17.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,84.88,,11.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.78,50,,7.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.16,75,,10.53,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,80,,11.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.41,65,,9.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,35,,4.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.8,90,,12.64,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,15.8,
SPIROMETER 5000ML ADULT / 8884719009,5150184,CDM,270,RC,,,Outpatient,,,16.58,16.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,70,,9.29,percent of total billed charges,70% of total billed charges for outpatient setting,14.07,84.88,,11.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.29,50,,6.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.44,75,,9.95,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,70,,9.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.26,80,,10.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.78,65,,8.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,35,,4.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.92,90,,11.94,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.92,
SPIROMETER INCENTIVE CHILD / 001905A,5150185,CDM,270,RC,,,Outpatient,,,27.73,27.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,70,,15.53,percent of total billed charges,70% of total billed charges for outpatient setting,23.54,84.88,,18.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.87,50,,11.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.8,75,,16.64,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,70,,15.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,12.84,,2.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.18,80,,17.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,12.84,,2.85,percent of total billed charges,12.84% of total billed charges,3.56,12.84,,2.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.02,65,,14.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.71,35,,7.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.96,90,,19.97,percent of total billed charges,90% of total billed charges for outpatient setting,3.56,24.96,
SPIRONOLACTONE(genALDACTONE) 25MG TAB,3302014,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SPIRONOLACTONE:50 MG TAB,3303225,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
SPLINT 3 IN ORTHO GLASS ROLL / OG3L,69162284,CDM,270,RC,,,Outpatient,,,40.35,40.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,70,,22.6,percent of total billed charges,70% of total billed charges for outpatient setting,34.25,84.88,,27.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.18,50,,16.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.26,75,,24.21,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,70,,22.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,12.84,,4.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,80,,25.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,5.18,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.23,65,,20.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.12,35,,11.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.32,90,,29.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,36.32,
SPLINT 3X12IN ORTHO GLASS / OG-3PC,69162595,CDM,270,RC,,,Outpatient,,,39.45,39.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.62,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,33.49,84.88,,26.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.73,50,,15.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.59,75,,23.67,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,70,,22.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.56,80,,25.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.64,65,,20.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.81,35,,11.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.51,90,,28.41,percent of total billed charges,90% of total billed charges for outpatient setting,5.07,35.51,
SPLINT 3X15 PLASTER X-FAST / 7390,761800,CDM,270,RC,,,Outpatient,,,1.11,1.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,70,,0.62,percent of total billed charges,70% of total billed charges for outpatient setting,0.94,84.88,,0.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.56,50,,0.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.83,75,,0.66,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,70,,0.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,12.84,,0.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,80,,0.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,12.84,,0.11,percent of total billed charges,12.84% of total billed charges,0.14,12.84,,0.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.72,65,,0.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,35,,0.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1,90,,0.8,percent of total billed charges,90% of total billed charges for outpatient setting,0.14,1,
SPLINT 3X35IN ORTHO GLASS / OG-335PC,69162596,CDM,270,RC,,,Outpatient,,,80.02,80.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.01,70,,44.81,percent of total billed charges,70% of total billed charges for outpatient setting,67.92,84.88,,54.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.01,50,,32.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.02,75,,48.02,percent of total billed charges,75% of total billed charges for outpatient setting,56.01,70,,44.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,12.84,,8.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.02,80,,51.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,12.84,,8.22,percent of total billed charges,12.84% of total billed charges,10.27,12.84,,8.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.01,65,,41.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.01,35,,22.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,72.02,90,,57.62,percent of total billed charges,90% of total billed charges for outpatient setting,10.27,72.02,
SPLINT 4 IN ORTHO GLASS ROLL / OG4L,69162285,CDM,270,RC,,,Outpatient,,,218.68,218.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.08,70,,122.46,percent of total billed charges,70% of total billed charges for outpatient setting,185.62,84.88,,148.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.34,50,,87.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.01,75,,131.21,percent of total billed charges,75% of total billed charges for outpatient setting,153.08,70,,122.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.08,12.84,,22.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.94,80,,139.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.08,12.84,,22.46,percent of total billed charges,12.84% of total billed charges,28.08,12.84,,22.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.14,65,,113.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.54,35,,61.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.81,90,,157.45,percent of total billed charges,90% of total billed charges for outpatient setting,28.08,196.81,
SPLINT 4X15 PLASTER X-FAST / 7391,6150320,CDM,270,RC,,,Outpatient,,,1.27,1.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,70,,0.71,percent of total billed charges,70% of total billed charges for outpatient setting,1.08,84.88,,0.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.64,50,,0.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.95,75,,0.76,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,70,,0.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,12.84,,0.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,80,,0.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,12.84,,0.13,percent of total billed charges,12.84% of total billed charges,0.16,12.84,,0.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.83,65,,0.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.44,35,,0.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.14,90,,0.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,1.14,
SPLINT 4X15IN ORTHO GLASS / OG-4PC,69162561,CDM,270,RC,,,Outpatient,,,37.31,37.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,31.67,84.88,,25.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.66,50,,14.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.98,75,,22.38,percent of total billed charges,75% of total billed charges for outpatient setting,26.12,70,,20.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,80,,23.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,4.79,12.84,,3.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.25,65,,19.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,35,,10.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.58,90,,26.86,percent of total billed charges,90% of total billed charges for outpatient setting,4.79,33.58,
SPLINT 4X30IN ORTHO GLASS / OG-430PC,69162597,CDM,270,RC,,,Outpatient,,,71.12,71.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.78,70,,39.82,percent of total billed charges,70% of total billed charges for outpatient setting,60.37,84.88,,48.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.56,50,,28.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.34,75,,42.67,percent of total billed charges,75% of total billed charges for outpatient setting,49.78,70,,39.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.13,12.84,,7.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,80,,45.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.13,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,9.13,12.84,,7.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,46.23,65,,36.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.89,35,,19.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,64.01,90,,51.21,percent of total billed charges,90% of total billed charges for outpatient setting,9.13,64.01,
SPLINT 5X30 PLASTER X-FAST / 7392,6150446,CDM,270,RC,,,Outpatient,,,2.61,2.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,70,,1.46,percent of total billed charges,70% of total billed charges for outpatient setting,2.22,84.88,,1.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.31,50,,1.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.96,75,,1.57,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,70,,1.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,80,,1.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.7,65,,1.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.91,35,,0.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.35,90,,1.88,percent of total billed charges,90% of total billed charges for outpatient setting,0.34,2.35,
SPLINT 6 IN ORTHO GLASS ROLL / OG-6L2,69162581,CDM,270,RC,,,Outpatient,,,415.13,415.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.59,70,,232.47,percent of total billed charges,70% of total billed charges for outpatient setting,352.36,84.88,,281.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.57,50,,166.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.35,75,,249.08,percent of total billed charges,75% of total billed charges for outpatient setting,290.59,70,,232.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.1,80,,265.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,53.3,12.84,,42.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,269.83,65,,215.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.3,35,,116.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,373.62,90,,298.9,percent of total billed charges,90% of total billed charges for outpatient setting,53.3,373.62,
SPONGE 2X2 3 PLY / 9022,5150105,CDM,272,RC,,,Outpatient,,,11.43,11.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,84.88,,7.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.72,50,,4.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.43,65,,5.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,35,,3.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.29,90,,8.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.29,
SPONGE 2X2 DRAIN / 441408,69160959,CDM,272,RC,,,Outpatient,,,0.77,0.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,70,,0.43,percent of total billed charges,70% of total billed charges for outpatient setting,0.65,84.88,,0.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.39,50,,0.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.58,75,,0.46,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,70,,0.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,80,,0.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.5,65,,0.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.27,35,,0.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.69,90,,0.55,percent of total billed charges,90% of total billed charges for outpatient setting,0.1,0.69,
SPONGE 4X4 STERILE  / 442214,6150470,CDM,272,RC,A6402,HCPCS,Outpatient,,,3.62,3.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,70,,2.02,percent of total billed charges,70% of total billed charges for outpatient setting,3.07,84.88,,2.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.72,75,,2.18,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,70,,2.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,12.84,,0.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,80,,2.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.46,12.84,,0.37,percent of total billed charges,12.84% of total billed charges,0.46,12.84,,0.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.35,65,,1.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,90,,2.61,percent of total billed charges,90% of total billed charges for outpatient setting,0.46,3.26,
SPONGE 4X4 STERILE  PRECUT /BW707,69161887,CDM,272,RC,,,Outpatient,,,5.11,5.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,4.34,84.88,,3.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.56,50,,2.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.83,75,,3.06,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.09,80,,3.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.32,65,,2.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,35,,1.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.6,90,,3.68,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.6,
SPONGE 4X4 STRL EACH / 6939,70000201,CDM,272,RC,,,Outpatient,,,5.76,5.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,84.88,,3.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.88,50,,2.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.32,75,,3.46,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.61,80,,3.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.74,65,,2.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,35,,1.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.18,90,,4.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.18,
SPONGE 4X4IN RAYTEC / NON21430LF,6150473,CDM,272,RC,A6402,HCPCS,Outpatient,,,4.86,4.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,4.13,84.88,,3.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.65,75,,2.92,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.89,80,,3.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.16,65,,2.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,90,,3.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.37,
SPONGE BIOPREP FEM / 0206-714-000,232328,CDM,272,RC,,,Outpatient,,,219.15,219.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.41,70,,122.73,percent of total billed charges,70% of total billed charges for outpatient setting,186.01,84.88,,148.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.58,50,,87.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.36,75,,131.49,percent of total billed charges,75% of total billed charges for outpatient setting,153.41,70,,122.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.512,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.32,80,,140.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,28.14,12.84,,22.51,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,142.45,65,,113.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,35,,61.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,197.24,90,,157.79,percent of total billed charges,90% of total billed charges for outpatient setting,28.14,197.24,
SPONGE GAUZE 2X2 8PLY NS / KC2146,7650360,CDM,272,RC,,,Outpatient,,,12.06,12.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,10.24,84.88,,8.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.03,50,,4.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,75,,7.24,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,70,,6.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.65,80,,7.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,1.55,12.84,,1.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.84,65,,6.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.22,35,,3.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.85,90,,8.68,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,10.85,
SPONGE GAUZE 4X4 ST U/S / 6939,5150109,CDM,272,RC,,,Outpatient,,,5.16,5.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,70,,2.89,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,84.88,,3.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.58,50,,2.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.87,75,,3.1,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,70,,2.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,80,,3.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.35,65,,2.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,35,,1.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.64,90,,3.71,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.64,
SPONGE MEDIUM TONSIL  / 7201,69161463,CDM,272,RC,,,Outpatient,,,11.07,11.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.75,70,,6.2,percent of total billed charges,70% of total billed charges for outpatient setting,9.4,84.88,,7.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.54,50,,4.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.3,75,,6.64,percent of total billed charges,75% of total billed charges for outpatient setting,7.75,70,,6.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.86,80,,7.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.42,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.2,65,,5.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,35,,3.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.96,90,,7.97,percent of total billed charges,90% of total billed charges for outpatient setting,1.42,9.96,
SPONGE MICROSORB 2X2 4PLY,5150098,CDM,272,RC,,,Outpatient,,,0.41,0.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,70,,0.23,percent of total billed charges,70% of total billed charges for outpatient setting,0.35,84.88,,0.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.21,50,,0.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.31,75,,0.25,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,70,,0.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,12.84,,0.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.33,80,,0.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,12.84,,0.04,percent of total billed charges,12.84% of total billed charges,0.05,12.84,,0.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.27,65,,0.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,35,,0.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.37,90,,0.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.05,0.37,
SPONGE RAYTEC 3X3IN STRL / DMA84416,70000392,CDM,272,RC,,,Outpatient,,,5.26,5.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,4.46,84.88,,3.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.63,50,,2.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.95,75,,3.16,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,70,,2.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,80,,3.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.42,65,,2.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.84,35,,1.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.73,90,,3.78,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.73,
SPONGE SOF-WICK 4X4  JJ2375,5150091,CDM,272,RC,,,Outpatient,,,0.16,0.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,70,,0.09,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,84.88,,0.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.08,50,,0.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.12,75,,0.1,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,70,,0.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.02,12.84,,0.016,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.13,80,,0.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.02,12.84,,0.02,percent of total billed charges,12.84% of total billed charges,0.02,12.84,,0.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.1,65,,0.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,35,,0.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.14,90,,0.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.02,0.14,
SPONGE TONSIL LARGE/7202,6150054,CDM,272,RC,,,Outpatient,,,11.25,11.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,9.55,84.88,,7.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.63,50,,4.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.44,75,,6.75,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,70,,6.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,80,,7.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,1.44,12.84,,1.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.31,65,,5.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,35,,3.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.13,90,,8.1,percent of total billed charges,90% of total billed charges for outpatient setting,1.44,10.13,
"SPONGE TONSIL, SMALL  23275-610",6152890,CDM,270,RC,,,Outpatient,,,64.04,64.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.83,70,,35.86,percent of total billed charges,70% of total billed charges for outpatient setting,54.36,84.88,,43.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.02,50,,25.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.03,75,,38.42,percent of total billed charges,75% of total billed charges for outpatient setting,44.83,70,,35.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.23,80,,40.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,8.22,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.63,65,,33.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,35,,17.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.64,90,,46.11,percent of total billed charges,90% of total billed charges for outpatient setting,8.22,57.64,
SPOT / GIS-44,6051154,CDM,272,RC,,,Outpatient,,,164.39,164.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.07,70,,92.06,percent of total billed charges,70% of total billed charges for outpatient setting,139.53,84.88,,111.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,82.2,50,,65.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.29,75,,98.63,percent of total billed charges,75% of total billed charges for outpatient setting,115.07,70,,92.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,12.84,,16.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.51,80,,105.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,12.84,,16.89,percent of total billed charges,12.84% of total billed charges,21.11,12.84,,16.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,106.85,65,,85.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.54,35,,46.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,147.95,90,,118.36,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,147.95,
SPOT TATTOO / GIS-45,70000651,CDM,272,RC,,,Outpatient,,,199.5,199.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,169.34,84.88,,135.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.75,50,,79.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.63,75,,119.7,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,70,,111.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,80,,127.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,25.62,12.84,,20.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.68,65,,103.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.83,35,,55.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,179.55,
SRF SHARK LIVER OIL (FORMULATION R)OINT:,3302015,CDM,259,RC,,,Outpatient,,,8.84,8.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,70,,4.95,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,84.88,,6,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.42,50,,3.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.63,75,,5.3,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,70,,4.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.07,80,,5.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,1.14,12.84,,0.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.75,65,,4.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,35,,2.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.96,90,,6.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.14,7.96,
SSA/SSB SJORGRENS AB,220512,CDM,302,RC,86235,HCPCS,Outpatient,,,80.69,72.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,68.49,84.88,,54.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.52,75,,48.42,percent of total billed charges,75% of total billed charges for outpatient setting,56.48,70,,45.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.55,80,,51.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,72.62,90,,58.1,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,72.62,
SSEP  LOWER LIMBS,6000653,CDM,740,RC,95926,HCPCS,Outpatient,,,681.48,681.48,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477.04,70,,381.63,percent of total billed charges,70% of total billed charges for outpatient setting,578.44,84.88,,462.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,511.11,75,,408.89,percent of total billed charges,75% of total billed charges for outpatient setting,477.04,70,,381.63,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,545.18,80,,436.14,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,323,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,151.97,100,,,Fee Schedule,100% of Custom Fee Schedule,613.33,90,,490.66,percent of total billed charges,90% of total billed charges for outpatient setting,87.5,613.33,
SSEP UPPER AND  LOWER LIMBS,6000650,CDM,740,RC,95938,HCPCS,Outpatient,,,681.48,681.48,XPCG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.04,70,,381.63,percent of total billed charges,70% of total billed charges for outpatient setting,578.44,84.88,,462.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,340.74,50,,272.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511.11,75,,408.89,percent of total billed charges,75% of total billed charges for outpatient setting,477.04,70,,381.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.18,80,,436.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,87.5,12.84,,70,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.52,35,,190.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,613.33,90,,490.66,percent of total billed charges,90% of total billed charges for outpatient setting,87.5,613.33,
STADOL NS (BUTORPHANOL) NASAL:10MG/ML,3302887,CDM,259,RC,,,Outpatient,,,404.05,404.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.84,70,,226.27,percent of total billed charges,70% of total billed charges for outpatient setting,342.96,84.88,,274.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.03,50,,161.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.04,75,,242.43,percent of total billed charges,75% of total billed charges for outpatient setting,282.84,70,,226.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.88,12.84,,41.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.24,80,,258.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.88,12.84,,41.5,percent of total billed charges,12.84% of total billed charges,51.88,12.84,,41.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,262.63,65,,210.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.42,35,,113.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,363.65,90,,290.92,percent of total billed charges,90% of total billed charges for outpatient setting,51.88,363.65,
STAGRAFT DBM PASTE / 92-2022,69162473,CDM,278,RC,C1713,HCPCS,Outpatient,,,1514.1,1514.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,60,,726.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.17,84.88,,1028.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,75,,908.46,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,80,,969.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.1,65,,1211.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,35,,423.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.46,60,,726.77,percent of total billed charges,60% of total billed charges for outpatient setting,194.41,1514.1,
STALEVO: CARBIDOPA/LEVODOPA/ENTACAPONE,3303298,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
STAPLE 13W 10L CMPRSSN / AR-8718-1310,71000022,CDM,278,RC,C1713,HCPCS,Outpatient,,,2990,2990,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794,60,,1435.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2537.91,84.88,,2030.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2242.5,75,,1794,percent of total billed charges,75% of total billed charges for outpatient setting,1495,50,,1196,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392,80,,1913.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,383.92,12.84,,307.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3139.5,105,,2511.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.5,35,,837.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1794,60,,1435.2,percent of total billed charges,60% of total billed charges for outpatient setting,383.92,3139.5,
STAPLE 13W 10L DYNANITE / AR-8718DS-1310,71000023,CDM,278,RC,C1713,HCPCS,Outpatient,,,3790,3790,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2274,60,,1819.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3216.95,84.88,,2573.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2842.5,75,,2274,percent of total billed charges,75% of total billed charges for outpatient setting,1895,50,,1516,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.64,12.84,,389.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3032,80,,2425.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.64,12.84,,389.31,percent of total billed charges,12.84% of total billed charges,486.64,12.84,,389.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3979.5,105,,3183.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.5,35,,1061.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2274,60,,1819.2,percent of total billed charges,60% of total billed charges for outpatient setting,486.64,3979.5,
STAPLE COMPRESS SS 10IX15L / AR-8003-15,69169102,CDM,278,RC,,,Outpatient,,,1838.55,1838.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.13,60,,882.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1560.56,84.88,,1248.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1378.91,75,,1103.13,percent of total billed charges,75% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470.84,80,,1176.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1838.55,65,,1470.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,35,,514.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.13,60,,882.5,percent of total billed charges,60% of total billed charges for outpatient setting,236.07,1838.55,
STAPLE COMPRESSION 10IX10L / AR-8003-10,69162828,CDM,278,RC,C1781,HCPCS,Outpatient,,,1838.55,1838.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.13,60,,882.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1560.56,84.88,,1248.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1378.91,75,,1103.13,percent of total billed charges,75% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470.84,80,,1176.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1838.55,65,,1470.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,35,,514.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.13,60,,882.5,percent of total billed charges,60% of total billed charges for outpatient setting,236.07,1838.55,
STAPLE COMPRESSION 15X10L / AR-8004-10,69162567,CDM,278,RC,C1781,HCPCS,Outpatient,,,1838.55,1838.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.13,60,,882.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1560.56,84.88,,1248.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1378.91,75,,1103.13,percent of total billed charges,75% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470.84,80,,1176.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1838.55,65,,1470.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,35,,514.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.13,60,,882.5,percent of total billed charges,60% of total billed charges for outpatient setting,236.07,1838.55,
STAPLE COMPRESSION 20X20MM / AR-8005-20,69162736,CDM,278,RC,,,Outpatient,,,1838.55,1838.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.13,60,,882.5,percent of total billed charges,60% of total Billed charges for outpatient setting,1560.56,84.88,,1248.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1378.91,75,,1103.13,percent of total billed charges,75% of total billed charges for outpatient setting,919.28,50,,735.42,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470.84,80,,1176.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,236.07,12.84,,188.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1838.55,65,,1470.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.49,35,,514.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1103.13,60,,882.5,percent of total billed charges,60% of total billed charges for outpatient setting,236.07,1838.55,
STAPLE REMOVER PRECISE,7651112,CDM,272,RC,,,Outpatient,,,31.96,31.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.37,70,,17.9,percent of total billed charges,70% of total billed charges for outpatient setting,27.13,84.88,,21.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.98,50,,12.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.97,75,,19.18,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,70,,17.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.57,80,,20.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.77,65,,16.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.19,35,,8.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.76,90,,23.01,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,28.76,
STAPLE REMOVER SKIN / PSX,5150154,CDM,272,RC,,,Outpatient,,,16.02,16.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.21,70,,8.97,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,84.88,,10.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.01,50,,6.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.02,75,,9.62,percent of total billed charges,75% of total billed charges for outpatient setting,11.21,70,,8.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,12.84,,1.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.82,80,,10.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,12.84,,1.65,percent of total billed charges,12.84% of total billed charges,2.06,12.84,,1.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.41,65,,8.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,35,,4.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.42,90,,11.54,percent of total billed charges,90% of total billed charges for outpatient setting,2.06,14.42,
STAPLER  29MM CIRCULAR STD SHFT / CDH29A,69169321,CDM,272,RC,,,Outpatient,,,1153.49,1153.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.44,70,,645.95,percent of total billed charges,70% of total billed charges for outpatient setting,979.08,84.88,,783.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,576.75,50,,461.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,865.12,75,,692.1,percent of total billed charges,75% of total billed charges for outpatient setting,807.44,70,,645.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.11,12.84,,118.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.79,80,,738.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.11,12.84,,118.49,percent of total billed charges,12.84% of total billed charges,148.11,12.84,,118.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,749.77,65,,599.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.72,35,,322.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1038.14,90,,830.51,percent of total billed charges,90% of total billed charges for outpatient setting,148.11,1038.14,
STAPLER 60MM ECHELON FLEX / EC60A,584076,CDM,272,RC,,,Outpatient,,,1092.02,1092.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.41,70,,611.53,percent of total billed charges,70% of total billed charges for outpatient setting,926.91,84.88,,741.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,546.01,50,,436.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,819.02,75,,655.22,percent of total billed charges,75% of total billed charges for outpatient setting,764.41,70,,611.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.22,12.84,,112.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.62,80,,698.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.22,12.84,,112.18,percent of total billed charges,12.84% of total billed charges,140.22,12.84,,112.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,709.81,65,,567.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.21,35,,305.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,982.82,90,,786.26,percent of total billed charges,90% of total billed charges for outpatient setting,140.22,982.82,
STAPLER 60MM PROXI LINEAR RELOAD,6150276,CDM,272,RC,,,Outpatient,,,386.61,386.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.63,70,,216.5,percent of total billed charges,70% of total billed charges for outpatient setting,328.15,84.88,,262.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,193.31,50,,154.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.96,75,,231.97,percent of total billed charges,75% of total billed charges for outpatient setting,270.63,70,,216.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.64,12.84,,39.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.29,80,,247.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.64,12.84,,39.71,percent of total billed charges,12.84% of total billed charges,49.64,12.84,,39.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,251.3,65,,201.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.31,35,,108.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,347.95,90,,278.36,percent of total billed charges,90% of total billed charges for outpatient setting,49.64,347.95,
STAPLER ABSORBTACK 5MM / ABSTACK30X,69160451,CDM,272,RC,,,Outpatient,,,1500,1500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,70,,840,percent of total billed charges,70% of total billed charges for outpatient setting,1273.2,84.88,,1018.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,750,50,,600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1125,75,,900,percent of total billed charges,75% of total billed charges for outpatient setting,1050,70,,840,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.6,12.84,,154.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,80,,960,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.6,12.84,,154.08,percent of total billed charges,12.84% of total billed charges,192.6,12.84,,154.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,975,65,,780,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525,35,,420,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1350,90,,1080,percent of total billed charges,90% of total billed charges for outpatient setting,192.6,1350,
STAPLER CIRCULAR 28MM / EEA28,69169282,CDM,272,RC,,,Outpatient,,,1114.64,1114.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.25,70,,624.2,percent of total billed charges,70% of total billed charges for outpatient setting,946.11,84.88,,756.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,557.32,50,,445.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,835.98,75,,668.78,percent of total billed charges,75% of total billed charges for outpatient setting,780.25,70,,624.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.12,12.84,,114.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,891.71,80,,713.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.12,12.84,,114.5,percent of total billed charges,12.84% of total billed charges,143.12,12.84,,114.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,724.52,65,,579.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.12,35,,312.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1003.18,90,,802.54,percent of total billed charges,90% of total billed charges for outpatient setting,143.12,1003.18,
STAPLER CONTOUR BLUE CS40B,69161265,CDM,272,RC,,,Outpatient,,,2123.06,2123.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.14,70,,1188.91,percent of total billed charges,70% of total billed charges for outpatient setting,1802.05,84.88,,1441.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,1061.53,50,,849.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1592.3,75,,1273.84,percent of total billed charges,75% of total billed charges for outpatient setting,1486.14,70,,1188.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.6,12.84,,218.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1698.45,80,,1358.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.6,12.84,,218.08,percent of total billed charges,12.84% of total billed charges,272.6,12.84,,218.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1379.99,65,,1103.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.07,35,,594.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1910.75,90,,1528.6,percent of total billed charges,90% of total billed charges for outpatient setting,272.6,1910.75,
STAPLER CONTOUR RELOAD BLUE / CR40B,69161266,CDM,272,RC,,,Outpatient,,,346.08,346.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.26,70,,193.81,percent of total billed charges,70% of total billed charges for outpatient setting,293.75,84.88,,235,percent of total billed charges,84.88% of total billed charges for outpatient setting,173.04,50,,138.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.56,75,,207.65,percent of total billed charges,75% of total billed charges for outpatient setting,242.26,70,,193.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,12.84,,35.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.86,80,,221.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,12.84,,35.55,percent of total billed charges,12.84% of total billed charges,44.44,12.84,,35.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.95,65,,179.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,35,,96.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,311.47,90,,249.18,percent of total billed charges,90% of total billed charges for outpatient setting,44.44,311.47,
STAPLER CONTOUR RELOAD GREEN / CR40G,69161267,CDM,272,RC,,,Outpatient,,,356,356,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.2,70,,199.36,percent of total billed charges,70% of total billed charges for outpatient setting,302.17,84.88,,241.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,178,50,,142.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267,75,,213.6,percent of total billed charges,75% of total billed charges for outpatient setting,249.2,70,,199.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.71,12.84,,36.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.8,80,,227.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.71,12.84,,36.57,percent of total billed charges,12.84% of total billed charges,45.71,12.84,,36.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,231.4,65,,185.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.6,35,,99.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,320.4,90,,256.32,percent of total billed charges,90% of total billed charges for outpatient setting,45.71,320.4,
STAPLER ECHELON 60X44 PWDRED / PLEE60A,69161849,CDM,272,RC,,,Outpatient,,,1366,1366,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,956.2,70,,764.96,percent of total billed charges,70% of total billed charges for outpatient setting,1159.46,84.88,,927.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,683,50,,546.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1024.5,75,,819.6,percent of total billed charges,75% of total billed charges for outpatient setting,956.2,70,,764.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.39,12.84,,140.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.8,80,,874.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.39,12.84,,140.31,percent of total billed charges,12.84% of total billed charges,175.39,12.84,,140.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,887.9,65,,710.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.1,35,,382.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1229.4,90,,983.52,percent of total billed charges,90% of total billed charges for outpatient setting,175.39,1229.4,
STAPLER EEA XL 25MM / EEAXL25,69161208,CDM,272,RC,,,Outpatient,,,1908.86,1908.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1336.2,70,,1068.96,percent of total billed charges,70% of total billed charges for outpatient setting,1620.24,84.88,,1296.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,954.43,50,,763.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1431.65,75,,1145.32,percent of total billed charges,75% of total billed charges for outpatient setting,1336.2,70,,1068.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.1,12.84,,196.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1527.09,80,,1221.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.1,12.84,,196.08,percent of total billed charges,12.84% of total billed charges,245.1,12.84,,196.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1240.76,65,,992.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.1,35,,534.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1717.97,90,,1374.38,percent of total billed charges,90% of total billed charges for outpatient setting,245.1,1717.97,
STAPLER ENDO 45MM (GUN ONLY) / ATS45,69160462,CDM,272,RC,,,Outpatient,,,716,716,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.2,70,,400.96,percent of total billed charges,70% of total billed charges for outpatient setting,607.74,84.88,,486.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,358,50,,286.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,537,75,,429.6,percent of total billed charges,75% of total billed charges for outpatient setting,501.2,70,,400.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.93,12.84,,73.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.8,80,,458.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.93,12.84,,73.54,percent of total billed charges,12.84% of total billed charges,91.93,12.84,,73.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,465.4,65,,372.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.6,35,,200.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,644.4,90,,515.52,percent of total billed charges,90% of total billed charges for outpatient setting,91.93,644.4,
STAPLER ENDOGIA 45 MED THICK / EGIA45AMT,69161014,CDM,272,RC,,,Outpatient,,,656.3,656.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.41,70,,367.53,percent of total billed charges,70% of total billed charges for outpatient setting,557.07,84.88,,445.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,328.15,50,,262.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.23,75,,393.78,percent of total billed charges,75% of total billed charges for outpatient setting,459.41,70,,367.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.27,12.84,,67.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.04,80,,420.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.27,12.84,,67.42,percent of total billed charges,12.84% of total billed charges,84.27,12.84,,67.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,426.6,65,,341.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.71,35,,183.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,590.67,90,,472.54,percent of total billed charges,90% of total billed charges for outpatient setting,84.27,590.67,
STAPLER ENDOGIA 45 VASC MED / EGIA45AVM,69160999,CDM,272,RC,,,Outpatient,,,609.7,609.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.79,70,,341.43,percent of total billed charges,70% of total billed charges for outpatient setting,517.51,84.88,,414.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,304.85,50,,243.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.28,75,,365.82,percent of total billed charges,75% of total billed charges for outpatient setting,426.79,70,,341.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.29,12.84,,62.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.76,80,,390.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.29,12.84,,62.63,percent of total billed charges,12.84% of total billed charges,78.29,12.84,,62.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,396.31,65,,317.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.4,35,,170.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,548.73,90,,438.98,percent of total billed charges,90% of total billed charges for outpatient setting,78.29,548.73,
STAPLER ENDOGIA 60 MED / EGIA60AMT,69160997,CDM,272,RC,,,Outpatient,,,1163.69,1163.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.58,70,,651.66,percent of total billed charges,70% of total billed charges for outpatient setting,987.74,84.88,,790.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,581.85,50,,465.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,872.77,75,,698.22,percent of total billed charges,75% of total billed charges for outpatient setting,814.58,70,,651.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.42,12.84,,119.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,930.95,80,,744.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.42,12.84,,119.54,percent of total billed charges,12.84% of total billed charges,149.42,12.84,,119.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,756.4,65,,605.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.29,35,,325.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1047.32,90,,837.86,percent of total billed charges,90% of total billed charges for outpatient setting,149.42,1047.32,
STAPLER ENDOGIA 60 VASC MED / EGIA60AVM,69160996,CDM,272,RC,,,Outpatient,,,779.46,779.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.62,70,,436.5,percent of total billed charges,70% of total billed charges for outpatient setting,661.61,84.88,,529.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,389.73,50,,311.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,584.6,75,,467.68,percent of total billed charges,75% of total billed charges for outpatient setting,545.62,70,,436.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.08,12.84,,80.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.57,80,,498.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.08,12.84,,80.06,percent of total billed charges,12.84% of total billed charges,100.08,12.84,,80.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,506.65,65,,405.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.81,35,,218.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,701.51,90,,561.21,percent of total billed charges,90% of total billed charges for outpatient setting,100.08,701.51,
STAPLER ENDOGIA 60MM XTHICK / EGIA60AXT,69161204,CDM,272,RC,,,Outpatient,,,1185.24,1185.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,829.67,70,,663.74,percent of total billed charges,70% of total billed charges for outpatient setting,1006.03,84.88,,804.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,592.62,50,,474.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,888.93,75,,711.14,percent of total billed charges,75% of total billed charges for outpatient setting,829.67,70,,663.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.18,12.84,,121.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.19,80,,758.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.18,12.84,,121.74,percent of total billed charges,12.84% of total billed charges,152.18,12.84,,121.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,770.41,65,,616.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.83,35,,331.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1066.72,90,,853.38,percent of total billed charges,90% of total billed charges for outpatient setting,152.18,1066.72,
STAPLER HANDLE EGIA STND / EGIAUSTND,69160998,CDM,272,RC,,,Outpatient,,,392.58,392.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.81,70,,219.85,percent of total billed charges,70% of total billed charges for outpatient setting,333.22,84.88,,266.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,196.29,50,,157.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.44,75,,235.55,percent of total billed charges,75% of total billed charges for outpatient setting,274.81,70,,219.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.41,12.84,,40.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.06,80,,251.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.41,12.84,,40.33,percent of total billed charges,12.84% of total billed charges,50.41,12.84,,40.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,255.18,65,,204.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.4,35,,109.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,353.32,90,,282.66,percent of total billed charges,90% of total billed charges for outpatient setting,50.41,353.32,
STAPLER HNDL EGIA XL / EGIAUXL,69161095,CDM,272,RC,,,Outpatient,,,615.85,615.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.1,70,,344.88,percent of total billed charges,70% of total billed charges for outpatient setting,522.73,84.88,,418.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,307.93,50,,246.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461.89,75,,369.51,percent of total billed charges,75% of total billed charges for outpatient setting,431.1,70,,344.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.08,12.84,,63.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.68,80,,394.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.08,12.84,,63.26,percent of total billed charges,12.84% of total billed charges,79.08,12.84,,63.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,400.3,65,,320.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.55,35,,172.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,554.27,90,,443.42,percent of total billed charges,90% of total billed charges for outpatient setting,79.08,554.27,
STAPLER INSORB ABSORBABLE SKIN / 2030,69169809,CDM,272,RC,,,Outpatient,,,216.65,216.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.66,70,,121.33,percent of total billed charges,70% of total billed charges for outpatient setting,183.89,84.88,,147.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.33,50,,86.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.49,75,,129.99,percent of total billed charges,75% of total billed charges for outpatient setting,151.66,70,,121.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,12.84,,22.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.32,80,,138.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,12.84,,22.26,percent of total billed charges,12.84% of total billed charges,27.82,12.84,,22.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,140.82,65,,112.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.83,35,,60.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,194.99,90,,155.99,percent of total billed charges,90% of total billed charges for outpatient setting,27.82,194.99,
STAPLER INTRALUMIN 25MM / ECS25A,6152627,CDM,272,RC,,,Outpatient,,,800.31,800.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.22,70,,448.18,percent of total billed charges,70% of total billed charges for outpatient setting,679.3,84.88,,543.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,400.16,50,,320.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,600.23,75,,480.18,percent of total billed charges,75% of total billed charges for outpatient setting,560.22,70,,448.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.76,12.84,,82.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.25,80,,512.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.76,12.84,,82.21,percent of total billed charges,12.84% of total billed charges,102.76,12.84,,82.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,520.2,65,,416.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.11,35,,224.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,720.28,90,,576.22,percent of total billed charges,90% of total billed charges for outpatient setting,102.76,720.28,
STAPLER INTRLM 29MM / ECS29A,6152057,CDM,272,RC,,,Outpatient,,,1295.7,1295.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,906.99,70,,725.59,percent of total billed charges,70% of total billed charges for outpatient setting,1099.79,84.88,,879.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,647.85,50,,518.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,971.78,75,,777.42,percent of total billed charges,75% of total billed charges for outpatient setting,906.99,70,,725.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.37,12.84,,133.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1036.56,80,,829.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.37,12.84,,133.1,percent of total billed charges,12.84% of total billed charges,166.37,12.84,,133.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,842.21,65,,673.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.5,35,,362.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1166.13,90,,932.9,percent of total billed charges,90% of total billed charges for outpatient setting,166.37,1166.13,
STAPLER INTRLMIN 33MM / ECS33A,6152626,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
STAPLER LINEAR RELOAD 55 (GREEN),6150270,CDM,272,RC,,,Outpatient,,,434.06,434.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.84,70,,243.07,percent of total billed charges,70% of total billed charges for outpatient setting,368.43,84.88,,294.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,217.03,50,,173.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.55,75,,260.44,percent of total billed charges,75% of total billed charges for outpatient setting,303.84,70,,243.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.73,12.84,,44.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.25,80,,277.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.73,12.84,,44.58,percent of total billed charges,12.84% of total billed charges,55.73,12.84,,44.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,282.14,65,,225.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.92,35,,121.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,390.65,90,,312.52,percent of total billed charges,90% of total billed charges for outpatient setting,55.73,390.65,
STAPLER MOTOR PACK KIT 381127,69161686,CDM,272,RC,,,Outpatient,,,70.18,70.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,70,,39.3,percent of total billed charges,70% of total billed charges for outpatient setting,59.57,84.88,,47.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.09,50,,28.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.64,75,,42.11,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,70,,39.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,12.84,,7.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.14,80,,44.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,12.84,,7.21,percent of total billed charges,12.84% of total billed charges,9.01,12.84,,7.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.62,65,,36.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.56,35,,19.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.16,90,,50.53,percent of total billed charges,90% of total billed charges for outpatient setting,9.01,63.16,
STAPLER PROTACT 5MM / 174006,6152727,CDM,272,RC,,,Outpatient,,,1189.65,1189.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.76,70,,666.21,percent of total billed charges,70% of total billed charges for outpatient setting,1009.77,84.88,,807.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,594.83,50,,475.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.24,75,,713.79,percent of total billed charges,75% of total billed charges for outpatient setting,832.76,70,,666.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.72,80,,761.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,773.27,65,,618.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.38,35,,333.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1070.69,90,,856.55,percent of total billed charges,90% of total billed charges for outpatient setting,152.75,1070.69,
STAPLER RELOAD 30MM BLUE/XR30B,6152237,CDM,272,RC,,,Outpatient,,,290.43,290.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,70,,162.64,percent of total billed charges,70% of total billed charges for outpatient setting,246.52,84.88,,197.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,145.22,50,,116.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.82,75,,174.26,percent of total billed charges,75% of total billed charges for outpatient setting,203.3,70,,162.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.29,12.84,,29.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.34,80,,185.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.29,12.84,,29.83,percent of total billed charges,12.84% of total billed charges,37.29,12.84,,29.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,188.78,65,,151.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.65,35,,81.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,261.39,90,,209.11,percent of total billed charges,90% of total billed charges for outpatient setting,37.29,261.39,
STAPLER RELOADS 30MM WHITE/XR30V,69159570,CDM,272,RC,,,Outpatient,,,328.41,328.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.89,70,,183.91,percent of total billed charges,70% of total billed charges for outpatient setting,278.75,84.88,,223,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.21,50,,131.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.31,75,,197.05,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,70,,183.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.17,12.84,,33.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.73,80,,210.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.17,12.84,,33.74,percent of total billed charges,12.84% of total billed charges,42.17,12.84,,33.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,213.47,65,,170.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.94,35,,91.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.57,90,,236.46,percent of total billed charges,90% of total billed charges for outpatient setting,42.17,295.57,
STAPLER SKIN 35 REGULAR/PRR35,6152599,CDM,272,RC,,,Outpatient,,,136.34,136.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,70,,76.35,percent of total billed charges,70% of total billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.17,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,70,,76.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.07,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.62,65,,70.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.71,90,,98.17,percent of total billed charges,90% of total billed charges for outpatient setting,17.51,122.71,
STAPLER SKIN 35 WIDE / STAPLER35W,70000268,CDM,272,RC,,,Outpatient,,,52.01,52.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.41,70,,29.13,percent of total billed charges,70% of total billed charges for outpatient setting,44.15,84.88,,35.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.01,50,,20.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.01,75,,31.21,percent of total billed charges,75% of total billed charges for outpatient setting,36.41,70,,29.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,12.84,,5.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.61,80,,33.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,12.84,,5.34,percent of total billed charges,12.84% of total billed charges,6.68,12.84,,5.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.81,65,,27.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.2,35,,14.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.81,90,,37.45,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,46.81,
STAPLER SKIN 35W / PRW35,6150248,CDM,272,RC,,,Outpatient,,,95.16,95.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,70,,53.29,percent of total billed charges,70% of total billed charges for outpatient setting,80.77,84.88,,64.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.58,50,,38.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.37,75,,57.1,percent of total billed charges,75% of total billed charges for outpatient setting,66.61,70,,53.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,12.84,,9.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.13,80,,60.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,12.22,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.85,65,,49.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.31,35,,26.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.64,90,,68.51,percent of total billed charges,90% of total billed charges for outpatient setting,12.22,85.64,
STAR SLEEVE / AR-1606C,69161365,CDM,272,RC,,,Outpatient,,,252,252,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,213.9,84.88,,171.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,126,50,,100.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,75,,151.2,percent of total billed charges,75% of total billed charges for outpatient setting,176.4,70,,141.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,80,,161.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,32.36,12.84,,25.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,163.8,65,,131.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,35,,70.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,226.8,90,,181.44,percent of total billed charges,90% of total billed charges for outpatient setting,32.36,226.8,
STARLIX ( NATEGLINIDINE): 120 MG,3303121,CDM,259,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
STARLIX 120MG TAB,3303017,CDM,259,RC,,,Outpatient,,,8.77,8.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,84.88,,5.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.39,50,,3.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.58,75,,5.26,percent of total billed charges,75% of total billed charges for outpatient setting,6.14,70,,4.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,80,,5.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,1.13,12.84,,0.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.7,65,,4.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,35,,2.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.89,90,,6.31,percent of total billed charges,90% of total billed charges for outpatient setting,1.13,7.89,
STAT TACK FIXTN DEVICE 15/ 50126,69162615,CDM,272,RC,,,Outpatient,,,1535.73,1535.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.01,70,,860.01,percent of total billed charges,70% of total billed charges for outpatient setting,1303.53,84.88,,1042.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,767.87,50,,614.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1151.8,75,,921.44,percent of total billed charges,75% of total billed charges for outpatient setting,1075.01,70,,860.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.19,12.84,,157.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.58,80,,982.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.19,12.84,,157.75,percent of total billed charges,12.84% of total billed charges,197.19,12.84,,157.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,998.22,65,,798.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.51,35,,430.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1382.16,90,,1105.73,percent of total billed charges,90% of total billed charges for outpatient setting,197.19,1382.16,
STEINMAN ACCESS THRD 3.2X9IN / 110003484,70000259,CDM,278,RC,,,Outpatient,,,423.95,423.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.37,60,,203.5,percent of total billed charges,60% of total Billed charges for outpatient setting,359.85,84.88,,287.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,211.98,50,,169.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.96,75,,254.37,percent of total billed charges,75% of total billed charges for outpatient setting,211.98,50,,169.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.16,80,,271.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,54.44,12.84,,43.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,423.95,65,,339.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.38,35,,118.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,254.37,60,,203.5,percent of total billed charges,60% of total billed charges for outpatient setting,54.44,423.95,
STEINMAN PIN THRD 1.8X2.5IN / 406669,69161813,CDM,278,RC,,,Outpatient,,,774,774,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.4,60,,371.52,percent of total billed charges,60% of total Billed charges for outpatient setting,656.97,84.88,,525.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,387,50,,309.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,580.5,75,,464.4,percent of total billed charges,75% of total billed charges for outpatient setting,387,50,,309.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.38,12.84,,79.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.2,80,,495.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.38,12.84,,79.5,percent of total billed charges,12.84% of total billed charges,99.38,12.84,,79.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,774,65,,619.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.9,35,,216.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,464.4,60,,371.52,percent of total billed charges,60% of total billed charges for outpatient setting,99.38,774,
STEINMAN PIN THREAD 1/8X9 / 1617-63-000,6152219,CDM,278,RC,,,Outpatient,,,141.08,141.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.65,60,,67.72,percent of total billed charges,60% of total Billed charges for outpatient setting,119.75,84.88,,95.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.54,50,,56.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.81,75,,84.65,percent of total billed charges,75% of total billed charges for outpatient setting,70.54,50,,56.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,12.84,,14.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.86,80,,90.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,12.84,,14.49,percent of total billed charges,12.84% of total billed charges,18.11,12.84,,14.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.08,65,,112.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.38,35,,39.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.65,60,,67.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.11,141.08,
STEINMAN PIN THREAD 9/64X9 /1617-64-000,6152218,CDM,278,RC,,,Outpatient,,,141.08,141.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.65,60,,67.72,percent of total billed charges,60% of total Billed charges for outpatient setting,119.75,84.88,,95.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.54,50,,56.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.81,75,,84.65,percent of total billed charges,75% of total billed charges for outpatient setting,70.54,50,,56.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,12.84,,14.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.86,80,,90.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,12.84,,14.49,percent of total billed charges,12.84% of total billed charges,18.11,12.84,,14.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.08,65,,112.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.38,35,,39.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.65,60,,67.72,percent of total billed charges,60% of total billed charges for outpatient setting,18.11,141.08,
STEINMANN PIN RVRS SHLDR THRD / 405800,69161568,CDM,278,RC,C1713,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,60,,144,percent of total billed charges,60% of total Billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,300,65,,240,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,180,60,,144,percent of total billed charges,60% of total billed charges for outpatient setting,38.52,300,
STELARA (USTEKINUMAB) LEVEL,220059,CDM,301,RC,80299,HCPCS,Outpatient,,,83.88,75.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,71.2,84.88,,56.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.91,75,,50.33,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,70,,46.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.1,80,,53.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.97,100,,,Fee Schedule,100% of Custom Fee Schedule,75.49,90,,60.39,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,75.49,
STEM 10MM HUM SHOULDER / 12-113560,1623267,CDM,278,RC,C1776,HCPCS,Outpatient,,,6200,6200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3720,60,,2976,percent of total billed charges,60% of total Billed charges for outpatient setting,5262.56,84.88,,4210.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650,75,,3720,percent of total billed charges,75% of total billed charges for outpatient setting,3100,50,,2480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.08,12.84,,636.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960,80,,3968,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.08,12.84,,636.86,percent of total billed charges,12.84% of total billed charges,796.08,12.84,,636.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6510,105,,5208,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,35,,1736,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3720,60,,2976,percent of total billed charges,60% of total billed charges for outpatient setting,796.08,6510,
STEM 10MM HUM SHOULDER / 1307-10-000,217055,CDM,278,RC,C1776,HCPCS,Outpatient,,,6370,6370,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3822,60,,3057.6,percent of total billed charges,60% of total Billed charges for outpatient setting,5406.86,84.88,,4325.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4777.5,75,,3822,percent of total billed charges,75% of total billed charges for outpatient setting,3185,50,,2548,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.91,12.84,,654.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5096,80,,4076.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.91,12.84,,654.33,percent of total billed charges,12.84% of total billed charges,817.91,12.84,,654.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6688.5,105,,5350.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2229.5,35,,1783.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3822,60,,3057.6,percent of total billed charges,60% of total billed charges for outpatient setting,817.91,6688.5,
STEM 10X122MM SHOULDER / 113650,69169260,CDM,278,RC,C1776,HCPCS,Outpatient,,,3640,3640,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,60,,1747.2,percent of total billed charges,60% of total Billed charges for outpatient setting,3089.63,84.88,,2471.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,75,,2184,percent of total billed charges,75% of total billed charges for outpatient setting,1820,50,,1456,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.38,12.84,,373.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2912,80,,2329.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.38,12.84,,373.9,percent of total billed charges,12.84% of total billed charges,467.38,12.84,,373.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3822,105,,3057.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274,35,,1019.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2184,60,,1747.2,percent of total billed charges,60% of total billed charges for outpatient setting,467.38,3822,
STEM 10X140MM FEM TAPERLOC / 51-104100,71000236,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 10X160MM FEM LEGION / 71424043,69161876,CDM,278,RC,C1713,HCPCS,Outpatient,,,2868,2868,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.8,60,,1376.64,percent of total billed charges,60% of total Billed charges for outpatient setting,2434.36,84.88,,1947.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151,75,,1720.8,percent of total billed charges,75% of total billed charges for outpatient setting,1434,50,,1147.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2294.4,80,,1835.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3011.4,105,,2409.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.8,35,,803.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1720.8,60,,1376.64,percent of total billed charges,60% of total billed charges for outpatient setting,368.25,3011.4,
STEM 10X83MM SHOULDER / 113630,69161648,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 11X100MM TRTHLN / 5565-S-011,75000001,CDM,278,RC,C1776,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 11X120MM PRESSFIT / 71424024,69169201,CDM,278,RC,,,Outpatient,,,2188.32,2188.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312.99,60,,1050.39,percent of total billed charges,60% of total Billed charges for outpatient setting,1857.45,84.88,,1485.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,1094.16,50,,875.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1641.24,75,,1312.99,percent of total billed charges,75% of total billed charges for outpatient setting,1094.16,50,,875.33,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.98,12.84,,224.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750.66,80,,1400.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.98,12.84,,224.78,percent of total billed charges,12.84% of total billed charges,280.98,12.84,,224.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2297.74,105,,1838.19,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.91,35,,612.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1312.99,60,,1050.39,percent of total billed charges,60% of total billed charges for outpatient setting,280.98,2297.74,
STEM 11X135MM FEM ECHO / 192411,71000336,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 11X142 FEM TAPERLOC / 51-103110,71000225,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 11X142MM FEM TAPERLOC / 51-104110,71000154,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 11X160MM FEM LEGION / 71424044,69161484,CDM,278,RC,C1713,HCPCS,Outpatient,,,2756.26,2756.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.76,60,,1323.01,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.2,75,,1653.76,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205.01,80,,1764.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.07,105,,2315.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.76,60,,1323.01,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.07,
STEM 11X55MM SHOULDER / 113611,69162896,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 11X83MM SHOULDER MINI / 113631,69161972,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 12X100MM TRTHLN / 5560-S-212,71000466,CDM,278,RC,C1776,HCPCS,Outpatient,,,2330.44,2330.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.26,60,,1118.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1978.08,84.88,,1582.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1747.83,75,,1398.26,percent of total billed charges,75% of total billed charges for outpatient setting,1165.22,50,,932.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.35,80,,1491.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2446.96,105,,1957.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.65,35,,652.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1398.26,60,,1118.61,percent of total billed charges,60% of total billed charges for outpatient setting,299.23,2446.96,
STEM 12X100MM TRTHLN / 5565-S-012,71000591,CDM,278,RC,C1776,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 12X122MM HUM / 113652,389360,CDM,278,RC,C1713,HCPCS,Outpatient,,,9450,9450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,60,,4536,percent of total billed charges,60% of total Billed charges for outpatient setting,8021.16,84.88,,6416.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.5,75,,5670,percent of total billed charges,75% of total billed charges for outpatient setting,4725,50,,3780,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7560,80,,6048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9922.5,105,,7938,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.5,35,,2646,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5670,60,,4536,percent of total billed charges,60% of total billed charges for outpatient setting,1213.38,9922.5,
STEM 12X144 FEM TAPERLOC / 51-103120,71000146,CDM,278,RC,C1713,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 12X144MM FEM TAPERLOC / 51-104120,71000494,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 12X150MM FLUTED TRIATH / 5566-S-012,71000867,CDM,278,RC,C1776,HCPCS,Outpatient,,,2524.16,2524.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.5,60,,1211.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2142.51,84.88,,1714.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1893.12,75,,1514.5,percent of total billed charges,75% of total billed charges for outpatient setting,1262.08,50,,1009.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.33,80,,1615.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2650.37,105,,2120.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,35,,706.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1514.5,60,,1211.6,percent of total billed charges,60% of total billed charges for outpatient setting,324.1,2650.37,
STEM 12X150MM TRTHLN / 5560-S-312,71000838,CDM,278,RC,C1713,HCPCS,Outpatient,,,2330.44,2330.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.26,60,,1118.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1978.08,84.88,,1582.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1747.83,75,,1398.26,percent of total billed charges,75% of total billed charges for outpatient setting,1165.22,50,,932.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.35,80,,1491.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2446.96,105,,1957.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.65,35,,652.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1398.26,60,,1118.61,percent of total billed charges,60% of total billed charges for outpatient setting,299.23,2446.96,
STEM 12X160MM FEM LEGION / 71424045,69161367,CDM,278,RC,C1713,HCPCS,Outpatient,,,2868,2868,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.8,60,,1376.64,percent of total billed charges,60% of total Billed charges for outpatient setting,2434.36,84.88,,1947.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2151,75,,1720.8,percent of total billed charges,75% of total billed charges for outpatient setting,1434,50,,1147.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2294.4,80,,1835.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,368.25,12.84,,294.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3011.4,105,,2409.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.8,35,,803.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1720.8,60,,1376.64,percent of total billed charges,60% of total billed charges for outpatient setting,368.25,3011.4,
STEM 13MM ECHO PROX / 192413,71000253,CDM,278,RC,C1776,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 13MM PRIMARY COMP / 113653,153549,CDM,278,RC,C1713,HCPCS,Outpatient,,,9450,9450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,60,,4536,percent of total billed charges,60% of total Billed charges for outpatient setting,8021.16,84.88,,6416.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.5,75,,5670,percent of total billed charges,75% of total billed charges for outpatient setting,4725,50,,3780,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7560,80,,6048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9922.5,105,,7938,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.5,35,,2646,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5670,60,,4536,percent of total billed charges,60% of total billed charges for outpatient setting,1213.38,9922.5,
STEM 13X100MM TRTHLN / 5565-S-013,71000901,CDM,278,RC,C1776,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
"STEM 13X120MM, PRESSFIT  71424026",69169198,CDM,278,RC,,,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 13X146MM FEM TAPERLOC / 51-103130,71000218,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 13X146MM FEM TAPERLOC / 51-104130,71000149,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 13X160MM FEM LEGION / 71424046,69161481,CDM,278,RC,C1713,HCPCS,Outpatient,,,2246.52,2246.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.91,60,,1078.33,percent of total billed charges,60% of total Billed charges for outpatient setting,1906.85,84.88,,1525.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1684.89,75,,1347.91,percent of total billed charges,75% of total billed charges for outpatient setting,1123.26,50,,898.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.22,80,,1437.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2358.85,105,,1887.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.28,35,,629.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1347.91,60,,1078.33,percent of total billed charges,60% of total billed charges for outpatient setting,288.45,2358.85,
STEM 14X100MM TRTHLN / 5565-S-014,71000514,CDM,278,RC,C1713,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 14X148MM FEM TAPERLOC / 51-103140,71000226,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 14X150 130D ECHO / 192514,71000892,CDM,278,RC,C1776,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 14X150MM FLUTED TRIATH / 5566-S-014,71000952,CDM,278,RC,C1776,HCPCS,Outpatient,,,2524.16,2524.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.5,60,,1211.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2142.51,84.88,,1714.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1893.12,75,,1514.5,percent of total billed charges,75% of total billed charges for outpatient setting,1262.08,50,,1009.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.33,80,,1615.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2650.37,105,,2120.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,35,,706.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1514.5,60,,1211.6,percent of total billed charges,60% of total billed charges for outpatient setting,324.1,2650.37,
STEM 14X160MM FEM LEGION / 71424047,71000772,CDM,278,RC,C1713,HCPCS,Outpatient,,,2246.52,2246.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.91,60,,1078.33,percent of total billed charges,60% of total Billed charges for outpatient setting,1906.85,84.88,,1525.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1684.89,75,,1347.91,percent of total billed charges,75% of total billed charges for outpatient setting,1123.26,50,,898.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.22,80,,1437.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2358.85,105,,1887.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.28,35,,629.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1347.91,60,,1078.33,percent of total billed charges,60% of total billed charges for outpatient setting,288.45,2358.85,
STEM 14X83MM SHOULDER MINI / 113634,69161604,CDM,278,RC,C1713,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 15X100MM TRTHLN / 5560-S-215,71000812,CDM,278,RC,C1776,HCPCS,Outpatient,,,2330.44,2330.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.26,60,,1118.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1978.08,84.88,,1582.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1747.83,75,,1398.26,percent of total billed charges,75% of total billed charges for outpatient setting,1165.22,50,,932.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.35,80,,1491.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2446.96,105,,1957.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.65,35,,652.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1398.26,60,,1118.61,percent of total billed charges,60% of total billed charges for outpatient setting,299.23,2446.96,
STEM 15X100MM TRTHLN / 5565-S-015,71000826,CDM,278,RC,C1713,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 15X150MM FEM TAPERLOC / 51-104150,71000171,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 15X150MM FLUTED TRIATH / 5566-S-015,71000891,CDM,278,RC,C1776,HCPCS,Outpatient,,,2524.16,2524.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.5,60,,1211.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2142.51,84.88,,1714.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1893.12,75,,1514.5,percent of total billed charges,75% of total billed charges for outpatient setting,1262.08,50,,1009.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.33,80,,1615.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2650.37,105,,2120.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,35,,706.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1514.5,60,,1211.6,percent of total billed charges,60% of total billed charges for outpatient setting,324.1,2650.37,
STEM 15X156MM FEM TAPERLOC / 51-103150,71000221,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 16X100MM TRTHLN / 5565-S-016,71000815,CDM,278,RC,C1776,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 16X152MM FEM TAPERLOC / 51-103160,71000241,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 16X152MM FEM TAPERLOC / 51-104160,71000156,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 16X55MM HUMERAL RVRS SYS / 113616,622337,CDM,278,RC,C1713,HCPCS,Outpatient,,,11025,11025,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6615,60,,5292,percent of total billed charges,60% of total Billed charges for outpatient setting,9358.02,84.88,,7486.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8268.75,75,,6615,percent of total billed charges,75% of total billed charges for outpatient setting,5512.5,50,,4410,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.61,12.84,,1132.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820,80,,7056,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.61,12.84,,1132.49,percent of total billed charges,12.84% of total billed charges,1415.61,12.84,,1132.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11576.25,105,,9261,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3858.75,35,,3087,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6615,60,,5292,percent of total billed charges,60% of total billed charges for outpatient setting,1415.61,11576.25,
STEM 16X83MM SHOULDER / 113636,69162705,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 17X100MM TRTHLN / 5565-S-017,71000465,CDM,278,RC,C1776,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 17X140MM FEM TAPERLOC / 51-104170,71000277,CDM,278,RC,C1713,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
STEM 17X150MM FLUTED TRIATH / 5566-S-017,71000487,CDM,278,RC,C1776,HCPCS,Outpatient,,,2524.16,2524.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.5,60,,1211.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2142.51,84.88,,1714.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1893.12,75,,1514.5,percent of total billed charges,75% of total billed charges for outpatient setting,1262.08,50,,1009.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.33,80,,1615.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,324.1,12.84,,259.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2650.37,105,,2120.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.46,35,,706.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1514.5,60,,1211.6,percent of total billed charges,60% of total billed charges for outpatient setting,324.1,2650.37,
STEM 17X154MM FEM TAPERLOC / 51-103170,71000609,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 17X55MM HUMERAL RVRS SYS / 113617,1169339,CDM,278,RC,C1713,HCPCS,Outpatient,,,9450,9450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,60,,4536,percent of total billed charges,60% of total Billed charges for outpatient setting,8021.16,84.88,,6416.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.5,75,,5670,percent of total billed charges,75% of total billed charges for outpatient setting,4725,50,,3780,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7560,80,,6048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9922.5,105,,7938,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.5,35,,2646,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5670,60,,4536,percent of total billed charges,60% of total billed charges for outpatient setting,1213.38,9922.5,
STEM 18X100MM TRTHLN / 5565-S-018,71000479,CDM,278,RC,C1713,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 18X140MM DSTL RECLAIM / 1976-16-140,71000900,CDM,278,RC,C1776,HCPCS,Outpatient,,,8407.36,8407.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5044.42,60,,4035.54,percent of total billed charges,60% of total Billed charges for outpatient setting,7136.17,84.88,,5708.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.52,75,,5044.42,percent of total billed charges,75% of total billed charges for outpatient setting,4203.68,50,,3362.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.51,12.84,,863.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6725.89,80,,5380.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.51,12.84,,863.61,percent of total billed charges,12.84% of total billed charges,1079.51,12.84,,863.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8827.73,105,,7062.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2942.58,35,,2354.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5044.42,60,,4035.54,percent of total billed charges,60% of total billed charges for outpatient setting,1079.51,8827.73,
STEM 18X140MM FEM TAPERLOC / 51-103100,71000109,CDM,278,RC,C1713,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 18X156MM FEM TAPERLOC / 51-103180,71000066,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 18X160MM FEM LEGION / 71424051,71000694,CDM,278,RC,C1776,HCPCS,Outpatient,,,2246.52,2246.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.91,60,,1078.33,percent of total billed charges,60% of total Billed charges for outpatient setting,1906.85,84.88,,1525.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1684.89,75,,1347.91,percent of total billed charges,75% of total billed charges for outpatient setting,1123.26,50,,898.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.22,80,,1437.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2358.85,105,,1887.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.28,35,,629.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1347.91,60,,1078.33,percent of total billed charges,60% of total billed charges for outpatient setting,288.45,2358.85,
STEM 19MM SHOULDER MICRO / 113619,1169341,CDM,278,RC,C1713,HCPCS,Outpatient,,,9450,9450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,60,,4536,percent of total billed charges,60% of total Billed charges for outpatient setting,8021.16,84.88,,6416.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.5,75,,5670,percent of total billed charges,75% of total billed charges for outpatient setting,4725,50,,3780,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7560,80,,6048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9922.5,105,,7938,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.5,35,,2646,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5670,60,,4536,percent of total billed charges,60% of total billed charges for outpatient setting,1213.38,9922.5,
STEM 19X100MM TRTHLN / 5565-S-019,71000837,CDM,278,RC,C1713,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 20MM SHOULDER MICRO / 113620,113620,CDM,278,RC,C1713,HCPCS,Outpatient,,,9450,9450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670,60,,4536,percent of total billed charges,60% of total Billed charges for outpatient setting,8021.16,84.88,,6416.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.5,75,,5670,percent of total billed charges,75% of total billed charges for outpatient setting,4725,50,,3780,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7560,80,,6048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,1213.38,12.84,,970.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9922.5,105,,7938,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.5,35,,2646,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5670,60,,4536,percent of total billed charges,60% of total billed charges for outpatient setting,1213.38,9922.5,
STEM 20X140MM DSTL RECLAIM / 1976-20-140,71000531,CDM,278,RC,C1776,HCPCS,Outpatient,,,8407.36,8407.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5044.42,60,,4035.54,percent of total billed charges,60% of total Billed charges for outpatient setting,7136.17,84.88,,5708.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.52,75,,5044.42,percent of total billed charges,75% of total billed charges for outpatient setting,4203.68,50,,3362.94,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.51,12.84,,863.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6725.89,80,,5380.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.51,12.84,,863.61,percent of total billed charges,12.84% of total billed charges,1079.51,12.84,,863.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8827.73,105,,7062.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2942.58,35,,2354.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5044.42,60,,4035.54,percent of total billed charges,60% of total billed charges for outpatient setting,1079.51,8827.73,
STEM 20X160MM FEM LEGION / 71424053,71000658,CDM,278,RC,C1713,HCPCS,Outpatient,,,2246.52,2246.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.91,60,,1078.33,percent of total billed charges,60% of total Billed charges for outpatient setting,1906.85,84.88,,1525.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1684.89,75,,1347.91,percent of total billed charges,75% of total billed charges for outpatient setting,1123.26,50,,898.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.22,80,,1437.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,288.45,12.84,,230.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2358.85,105,,1887.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.28,35,,629.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1347.91,60,,1078.33,percent of total billed charges,60% of total billed charges for outpatient setting,288.45,2358.85,
STEM 20X160MM TPRLC FEM / 51-104200,71000440,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM 21X100MM TRTHLN / 5565-S-021,71000370,CDM,278,RC,C1713,HCPCS,Outpatient,,,2440.64,2440.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.38,60,,1171.5,percent of total billed charges,60% of total Billed charges for outpatient setting,2071.62,84.88,,1657.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.48,75,,1464.38,percent of total billed charges,75% of total billed charges for outpatient setting,1220.32,50,,976.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.51,80,,1562.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,313.38,12.84,,250.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2562.67,105,,2050.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.22,35,,683.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1464.38,60,,1171.5,percent of total billed charges,60% of total billed charges for outpatient setting,313.38,2562.67,
STEM 25MM EXTENDER TRTHLN / 5571-S-025,71000843,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114.68,2114.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.81,60,,1015.05,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.94,84.88,,1435.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1586.01,75,,1268.81,percent of total billed charges,75% of total billed charges for outpatient setting,1057.34,50,,845.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.74,80,,1353.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2220.41,105,,1776.33,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.14,35,,592.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.81,60,,1015.05,percent of total billed charges,60% of total billed charges for outpatient setting,271.52,2220.41,
STEM 40MM FINNED / 141314,71000388,CDM,278,RC,C1713,HCPCS,Outpatient,,,1200,1200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720,60,,576,percent of total billed charges,60% of total Billed charges for outpatient setting,1018.56,84.88,,814.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,75,,720,percent of total billed charges,75% of total billed charges for outpatient setting,600,50,,480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.08,12.84,,123.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,80,,768,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.08,12.84,,123.26,percent of total billed charges,12.84% of total billed charges,154.08,12.84,,123.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1200,65,,960,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,35,,336,percent of total billed charges,35% of total Billed charges for Outpatient Setting,720,60,,576,percent of total billed charges,60% of total billed charges for outpatient setting,154.08,1200,
STEM 50MM EXTENDER TRTHLN / 5560-S-050,71000813,CDM,278,RC,C1713,HCPCS,Outpatient,,,2114.68,2114.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.81,60,,1015.05,percent of total billed charges,60% of total Billed charges for outpatient setting,1794.94,84.88,,1435.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1586.01,75,,1268.81,percent of total billed charges,75% of total billed charges for outpatient setting,1057.34,50,,845.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.74,80,,1353.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,271.52,12.84,,217.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2220.41,105,,1776.33,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.14,35,,592.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1268.81,60,,1015.05,percent of total billed charges,60% of total billed charges for outpatient setting,271.52,2220.41,
STEM 8X120MM FEM ECHO / 192408,71000291,CDM,278,RC,C1713,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 9X122MM SHOULDER / 113649,726813,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM 9X125MM FEM ECHO / 192109,71000347,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM EXT 14 +75MM / 42-5600-075-14,69169514,CDM,278,RC,C1776,HCPCS,Outpatient,,,5400,5400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3240,60,,2592,percent of total billed charges,60% of total Billed charges for outpatient setting,4583.52,84.88,,3666.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4050,75,,3240,percent of total billed charges,75% of total billed charges for outpatient setting,2700,50,,2160,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320,80,,3456,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,693.36,12.84,,554.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5670,105,,4536,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,35,,1512,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3240,60,,2592,percent of total billed charges,60% of total billed charges for outpatient setting,693.36,5670,
STEM EXT 14X100MM /5988-10-14,69169575,CDM,278,RC,C1776,HCPCS,Outpatient,,,2188,2188,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312.8,60,,1050.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1857.17,84.88,,1485.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1641,75,,1312.8,percent of total billed charges,75% of total billed charges for outpatient setting,1094,50,,875.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.94,12.84,,224.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750.4,80,,1400.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.94,12.84,,224.75,percent of total billed charges,12.84% of total billed charges,280.94,12.84,,224.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2297.4,105,,1837.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.8,35,,612.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1312.8,60,,1050.24,percent of total billed charges,60% of total billed charges for outpatient setting,280.94,2297.4,
STEM EXT 14X30MM / 42-5570-001-14,69169404,CDM,278,RC,C1776,HCPCS,Outpatient,,,2554.13,2554.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.48,60,,1225.98,percent of total billed charges,60% of total Billed charges for outpatient setting,2167.95,84.88,,1734.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.6,75,,1532.48,percent of total billed charges,75% of total billed charges for outpatient setting,1277.07,50,,1021.66,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2043.3,80,,1634.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2681.84,105,,2145.47,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.95,35,,715.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1532.48,60,,1225.98,percent of total billed charges,60% of total billed charges for outpatient setting,327.95,2681.84,
STEM EXT10x100MM /5988-10-10,69169577,CDM,278,RC,C1776,HCPCS,Outpatient,,,2188,2188,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312.8,60,,1050.24,percent of total billed charges,60% of total Billed charges for outpatient setting,1857.17,84.88,,1485.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1641,75,,1312.8,percent of total billed charges,75% of total billed charges for outpatient setting,1094,50,,875.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.94,12.84,,224.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750.4,80,,1400.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.94,12.84,,224.75,percent of total billed charges,12.84% of total billed charges,280.94,12.84,,224.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2297.4,105,,1837.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.8,35,,612.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1312.8,60,,1050.24,percent of total billed charges,60% of total billed charges for outpatient setting,280.94,2297.4,
STEM FEMORAL HIP SZ12 140MM / 192012,69169846,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
STEM KNEE ATTUNE / 1512-14-050,71000846,CDM,278,RC,C1776,HCPCS,Outpatient,,,2075,2075,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245,60,,996,percent of total billed charges,60% of total Billed charges for outpatient setting,1761.26,84.88,,1409.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1556.25,75,,1245,percent of total billed charges,75% of total billed charges for outpatient setting,1037.5,50,,830,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.43,12.84,,213.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1660,80,,1328,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.43,12.84,,213.14,percent of total billed charges,12.84% of total billed charges,266.43,12.84,,213.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2075,65,,1660,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.25,35,,581,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1245,60,,996,percent of total billed charges,60% of total billed charges for outpatient setting,266.43,2075,
STEM RADIAL 2X6MM / 00-8700-006-02,2239758,CDM,278,RC,C1776,HCPCS,Outpatient,,,5880,5880,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3528,60,,2822.4,percent of total billed charges,60% of total Billed charges for outpatient setting,4990.94,84.88,,3992.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4410,75,,3528,percent of total billed charges,75% of total billed charges for outpatient setting,2940,50,,2352,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.99,12.84,,603.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4704,80,,3763.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.99,12.84,,603.99,percent of total billed charges,12.84% of total billed charges,754.99,12.84,,603.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6174,105,,4939.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2058,35,,1646.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3528,60,,2822.4,percent of total billed charges,60% of total billed charges for outpatient setting,754.99,6174,
STEM RADIAL W/SCREW 8X28MM  / 11-210063,69162321,CDM,278,RC,C1776,HCPCS,Outpatient,,,3360,3360,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2016,60,,1612.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2851.97,84.88,,2281.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,75,,2016,percent of total billed charges,75% of total billed charges for outpatient setting,1680,50,,1344,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.42,12.84,,345.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2688,80,,2150.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.42,12.84,,345.14,percent of total billed charges,12.84% of total billed charges,431.42,12.84,,345.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3528,105,,2822.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,35,,940.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2016,60,,1612.8,percent of total billed charges,60% of total billed charges for outpatient setting,431.42,3528,
STEM SHLDR 17X83MM / 113637,69169355,CDM,278,RC,C1776,HCPCS,Outpatient,,,6300,6300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3780,60,,3024,percent of total billed charges,60% of total Billed charges for outpatient setting,5347.44,84.88,,4277.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,75,,3780,percent of total billed charges,75% of total billed charges for outpatient setting,3150,50,,2520,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5040,80,,4032,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,808.92,12.84,,647.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6615,105,,5292,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,35,,1764,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3780,60,,3024,percent of total billed charges,60% of total billed charges for outpatient setting,808.92,6615,
STEM SZ 10 FEMORAL / 3L92500,69169884,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 10 FEMORAL / L971310,71000443,CDM,278,RC,C1713,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 11 CORAIL COLLARLESS / 3L92511,71000575,CDM,278,RC,C1713,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 11 FEMORAL / 3L92501,71000133,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 11 FEMORAL ACTIS / 1010-22-110,71000578,CDM,278,RC,C1713,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 11/14 FEM REV / L98011,69169887,CDM,278,RC,C1776,HCPCS,Outpatient,,,14445,14445,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8667,60,,6933.6,percent of total billed charges,60% of total Billed charges for outpatient setting,12260.92,84.88,,9808.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10833.75,75,,8667,percent of total billed charges,75% of total billed charges for outpatient setting,7222.5,50,,5778,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.74,12.84,,1483.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11556,80,,9244.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.74,12.84,,1483.79,percent of total billed charges,12.84% of total billed charges,1854.74,12.84,,1483.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15167.25,105,,12133.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5055.75,35,,4044.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8667,60,,6933.6,percent of total billed charges,60% of total billed charges for outpatient setting,1854.74,15167.25,
STEM SZ 12 FEMORAL / 3L92502,69169770,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 12 FEMORAL / 3L92504,69169771,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 12 FEMORAL / L971312,71000551,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 12/14 FEM REV / L98012,71000657,CDM,278,RC,C1776,HCPCS,Outpatient,,,14445,14445,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8667,60,,6933.6,percent of total billed charges,60% of total Billed charges for outpatient setting,12260.92,84.88,,9808.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10833.75,75,,8667,percent of total billed charges,75% of total billed charges for outpatient setting,7222.5,50,,5778,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.74,12.84,,1483.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11556,80,,9244.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1854.74,12.84,,1483.79,percent of total billed charges,12.84% of total billed charges,1854.74,12.84,,1483.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15167.25,105,,12133.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5055.75,35,,4044.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8667,60,,6933.6,percent of total billed charges,60% of total billed charges for outpatient setting,1854.74,15167.25,
STEM SZ 12/14 FEMORAL / L971311,71000283,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 13 CORAIL COLLARLESS / 3L92513,71000115,CDM,278,RC,C1713,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 13 FEMORAL / 3L92503,69169752,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 16 FEMORAL / 3L92506,71000915,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 4 140MM FEMORAL / 1570-02-100,71000949,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 4 140MM FEMORAL / 1570-02-120,71000807,CDM,278,RC,C1713,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 5 145MM FEMORAL / 1570-12-110,71000858,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 5 FEMORAL ACTIS / 1010-21-050,71000074,CDM,278,RC,C1713,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 6 150MM FEMORAL / 1570-02-120,71000422,CDM,278,RC,C1713,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 6 150MM FEMORAL / 1570-12-120,71000557,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 6 160MM FEMORAL / 1570-02-150,71000906,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 6 FEMORAL ACTIS / 1010-22-060,71000690,CDM,278,RC,C1713,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 7 155MM FEMORAL / 1570-02-136,71000917,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 7 FEMORAL ACTIS / 1010-21-070,71000177,CDM,278,RC,C1776,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 8 FEMORAL ACTIS / 1010-21-080,71000073,CDM,278,RC,C1713,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 8 FEMORAL ACTIS / 1010-22-080,71000911,CDM,278,RC,C1776,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM SZ 9 FEMORAL / L971309,71000913,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
STEM SZ 9 FEMORAL ACTIS / 1010-22-090,71000849,CDM,278,RC,C1713,HCPCS,Outpatient,,,3410,3410,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2046,60,,1636.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2894.41,84.88,,2315.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2557.5,75,,2046,percent of total billed charges,75% of total billed charges for outpatient setting,1705,50,,1364,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2728,80,,2182.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,437.84,12.84,,350.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3580.5,105,,2864.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.5,35,,954.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2046,60,,1636.8,percent of total billed charges,60% of total billed charges for outpatient setting,437.84,3580.5,
STEM TK 12X50MM/ 5560-S-112,69169802,CDM,278,RC,C1776,HCPCS,Outpatient,,,2330.44,2330.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.26,60,,1118.61,percent of total billed charges,60% of total Billed charges for outpatient setting,1978.08,84.88,,1582.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1747.83,75,,1398.26,percent of total billed charges,75% of total billed charges for outpatient setting,1165.22,50,,932.18,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1864.35,80,,1491.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,299.23,12.84,,239.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2446.96,105,,1957.57,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.65,35,,652.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1398.26,60,,1118.61,percent of total billed charges,60% of total billed charges for outpatient setting,299.23,2446.96,
"STEM, LONG NON-SLOTTED, TOTAL KNEE",69161114,CDM,278,RC,C1776,HCPCS,Outpatient,,,2091.32,2091.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.79,60,,1003.83,percent of total billed charges,60% of total Billed charges for outpatient setting,1775.11,84.88,,1420.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568.49,75,,1254.79,percent of total billed charges,75% of total billed charges for outpatient setting,1045.66,50,,836.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.53,12.84,,214.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1673.06,80,,1338.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.53,12.84,,214.82,percent of total billed charges,12.84% of total billed charges,268.53,12.84,,214.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2091.32,65,,1673.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.96,35,,585.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1254.79,60,,1003.83,percent of total billed charges,60% of total billed charges for outpatient setting,268.53,2091.32,
STEN 4.8FR X 28 PERCUFLEX 145-353,69161597,CDM,278,RC,C2625,HCPCS,Outpatient,,,317.77,317.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.66,60,,152.53,percent of total billed charges,60% of total Billed charges for outpatient setting,269.72,84.88,,215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,75,,190.66,percent of total billed charges,75% of total billed charges for outpatient setting,158.89,50,,127.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,80,,203.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,317.77,65,,254.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.22,35,,88.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.66,60,,152.53,percent of total billed charges,60% of total billed charges for outpatient setting,40.8,317.77,
STENOSTENT 8FR 28CM SILICONE / AJ4W85,69169835,CDM,278,RC,,,Outpatient,,,1355.6,1355.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,813.36,60,,650.69,percent of total billed charges,60% of total Billed charges for outpatient setting,1150.63,84.88,,920.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,677.8,50,,542.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1016.7,75,,813.36,percent of total billed charges,75% of total billed charges for outpatient setting,677.8,50,,542.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.06,12.84,,139.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1084.48,80,,867.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.06,12.84,,139.25,percent of total billed charges,12.84% of total billed charges,174.06,12.84,,139.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1355.6,65,,1084.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.46,35,,379.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,813.36,60,,650.69,percent of total billed charges,60% of total billed charges for outpatient setting,174.06,1355.6,
STENOSTENT 8FRX24CM SILICONE / AJ4W83,69169838,CDM,278,RC,,,Outpatient,,,1303.2,1303.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.92,60,,625.54,percent of total billed charges,60% of total Billed charges for outpatient setting,1106.16,84.88,,884.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,651.6,50,,521.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,977.4,75,,781.92,percent of total billed charges,75% of total billed charges for outpatient setting,651.6,50,,521.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.33,12.84,,133.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1042.56,80,,834.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.33,12.84,,133.86,percent of total billed charges,12.84% of total billed charges,167.33,12.84,,133.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1303.2,65,,1042.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.12,35,,364.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,781.92,60,,625.54,percent of total billed charges,60% of total billed charges for outpatient setting,167.33,1303.2,
STENOSTENT 8FRX26CM SILICONE / AJ4W84,69169832,CDM,278,RC,,,Outpatient,,,1355.6,1355.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,813.36,60,,650.69,percent of total billed charges,60% of total Billed charges for outpatient setting,1150.63,84.88,,920.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,677.8,50,,542.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1016.7,75,,813.36,percent of total billed charges,75% of total billed charges for outpatient setting,677.8,50,,542.24,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.06,12.84,,139.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1084.48,80,,867.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.06,12.84,,139.25,percent of total billed charges,12.84% of total billed charges,174.06,12.84,,139.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1355.6,65,,1084.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.46,35,,379.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,813.36,60,,650.69,percent of total billed charges,60% of total billed charges for outpatient setting,174.06,1355.6,
STENT 4.5FR 24CM SOFCURL / SSC4524,155121,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 4.5FR 26CM SOFCURL / SSC4526,155182,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 4.5FR 28CM SOFCURL / SSC4528,155257,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 4.8FR 22-30 PERCUFLEX / 180-155,69162531,CDM,278,RC,C2625,HCPCS,Outpatient,,,391.72,391.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.03,60,,188.02,percent of total billed charges,60% of total Billed charges for outpatient setting,332.49,84.88,,265.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.79,75,,235.03,percent of total billed charges,75% of total billed charges for outpatient setting,195.86,50,,156.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,80,,250.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,391.72,65,,313.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.1,35,,109.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,235.03,60,,188.02,percent of total billed charges,60% of total billed charges for outpatient setting,50.3,391.72,
STENT 4.8FR 24CM PERCUFLEX / 145-351,69162080,CDM,278,RC,C2625,HCPCS,Outpatient,,,287.52,287.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.51,60,,138.01,percent of total billed charges,60% of total Billed charges for outpatient setting,244.05,84.88,,195.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.64,75,,172.51,percent of total billed charges,75% of total billed charges for outpatient setting,143.76,50,,115.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.92,12.84,,29.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.02,80,,184.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.92,12.84,,29.54,percent of total billed charges,12.84% of total billed charges,36.92,12.84,,29.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,287.52,65,,230.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.63,35,,80.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,172.51,60,,138.01,percent of total billed charges,60% of total billed charges for outpatient setting,36.92,287.52,
STENT 4.8FR 26CM PERCUFLEX / 145-352,69161043,CDM,278,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.14,60,,144.91,percent of total billed charges,60% of total Billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,150.95,50,,120.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.9,65,,241.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.14,60,,144.91,percent of total billed charges,60% of total billed charges for outpatient setting,38.76,301.9,
STENT 6.0FR 24CM SOFCURL / SSC6024,69169836,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 6.0FR 30CM SOFCURL / SSC6030,1600005,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 6FR 20CM PERCUFLEX / 145359,69169244,CDM,278,RC,C2625,HCPCS,Outpatient,,,317.77,317.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.66,60,,152.53,percent of total billed charges,60% of total Billed charges for outpatient setting,269.72,84.88,,215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,75,,190.66,percent of total billed charges,75% of total billed charges for outpatient setting,158.89,50,,127.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,80,,203.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,317.77,65,,254.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.22,35,,88.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.66,60,,152.53,percent of total billed charges,60% of total billed charges for outpatient setting,40.8,317.77,
STENT 6FR 22-30CM PERCUFLEX / 180-156,69162532,CDM,278,RC,C2625,HCPCS,Outpatient,,,391.72,391.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.03,60,,188.02,percent of total billed charges,60% of total Billed charges for outpatient setting,332.49,84.88,,265.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.79,75,,235.03,percent of total billed charges,75% of total billed charges for outpatient setting,195.86,50,,156.69,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.38,80,,250.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,50.3,12.84,,40.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,391.72,65,,313.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.1,35,,109.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,235.03,60,,188.02,percent of total billed charges,60% of total billed charges for outpatient setting,50.3,391.72,
STENT 6FR 24CM PERCUFLEX / 145-361,6150768,CDM,278,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.14,60,,144.91,percent of total billed charges,60% of total Billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,150.95,50,,120.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.9,65,,241.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.14,60,,144.91,percent of total billed charges,60% of total billed charges for outpatient setting,38.76,301.9,
STENT 6FR 26CM PERCUFLEX / 145-362,6150767,CDM,278,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.14,60,,144.91,percent of total billed charges,60% of total Billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,150.95,50,,120.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.9,65,,241.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.14,60,,144.91,percent of total billed charges,60% of total billed charges for outpatient setting,38.76,301.9,
STENT 6FR 26CM SOFCURL / SSC6026,69169612,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 6FR 28CM PERCUFLEX / 145-363,69160985,CDM,278,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.14,60,,144.91,percent of total billed charges,60% of total Billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,150.95,50,,120.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.9,65,,241.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.14,60,,144.91,percent of total billed charges,60% of total billed charges for outpatient setting,38.76,301.9,
STENT 6FR 28CM SOFCURL / SSC6028,69169613,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 6FR 30CM PERCUFLEX / 145-364,69161526,CDM,278,RC,C2625,HCPCS,Outpatient,,,317.77,317.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.66,60,,152.53,percent of total billed charges,60% of total Billed charges for outpatient setting,269.72,84.88,,215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,75,,190.66,percent of total billed charges,75% of total billed charges for outpatient setting,158.89,50,,127.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,80,,203.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,317.77,65,,254.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.22,35,,88.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.66,60,,152.53,percent of total billed charges,60% of total billed charges for outpatient setting,40.8,317.77,
STENT 7.0FR 24CM SOFCURL / SSC7024,1600009,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 7.0FR 26CM SOFCURL / SSC7026,1600010,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 7.0FR 28CM SOFCURL / SSC7028,1600011,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 7.0FR 30CM SOFCURL / SSC7030,1600012,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 7FR 22-30 PERCUFLEX / 180-157,69162533,CDM,278,RC,C2625,HCPCS,Outpatient,,,411.31,411.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.79,60,,197.43,percent of total billed charges,60% of total Billed charges for outpatient setting,349.12,84.88,,279.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.48,75,,246.78,percent of total billed charges,75% of total billed charges for outpatient setting,205.66,50,,164.53,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,12.84,,42.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.05,80,,263.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,12.84,,42.25,percent of total billed charges,12.84% of total billed charges,52.81,12.84,,42.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,411.31,65,,329.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.96,35,,115.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,246.79,60,,197.43,percent of total billed charges,60% of total billed charges for outpatient setting,52.81,411.31,
STENT 7FR 24CM PERCUFLEX PLUS / 175-272,69160361,CDM,272,RC,,,Outpatient,,,432.98,432.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.09,70,,242.47,percent of total billed charges,70% of total billed charges for outpatient setting,367.51,84.88,,294.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.49,50,,173.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.74,75,,259.79,percent of total billed charges,75% of total billed charges for outpatient setting,303.09,70,,242.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.59,12.84,,44.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.38,80,,277.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.59,12.84,,44.47,percent of total billed charges,12.84% of total billed charges,55.59,12.84,,44.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.44,65,,225.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.54,35,,121.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.68,90,,311.74,percent of total billed charges,90% of total billed charges for outpatient setting,55.59,389.68,
STENT 7FR 26CM PERCUFLEX / 145-372,69161025,CDM,278,RC,C2625,HCPCS,Outpatient,,,287.52,287.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.51,60,,138.01,percent of total billed charges,60% of total Billed charges for outpatient setting,244.05,84.88,,195.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.64,75,,172.51,percent of total billed charges,75% of total billed charges for outpatient setting,143.76,50,,115.01,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.92,12.84,,29.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.02,80,,184.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.92,12.84,,29.54,percent of total billed charges,12.84% of total billed charges,36.92,12.84,,29.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,287.52,65,,230.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.63,35,,80.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,172.51,60,,138.01,percent of total billed charges,60% of total billed charges for outpatient setting,36.92,287.52,
STENT 7FR 26CM PERCUFLEX PLUS / 175-273,69160358,CDM,272,RC,C2617,HCPCS,Outpatient,,,432.98,432.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.09,70,,242.47,percent of total billed charges,70% of total billed charges for outpatient setting,367.51,84.88,,294.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.74,75,,259.79,percent of total billed charges,75% of total billed charges for outpatient setting,303.09,70,,242.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.59,12.84,,44.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.38,80,,277.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.59,12.84,,44.47,percent of total billed charges,12.84% of total billed charges,55.59,12.84,,44.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.44,65,,225.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.54,35,,121.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.68,90,,311.74,percent of total billed charges,90% of total billed charges for outpatient setting,55.59,389.68,
STENT 7FR 28CM PERCUFLEX / 145-373,69161527,CDM,272,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.33,70,,169.06,percent of total billed charges,70% of total billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,70,,169.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,196.24,65,,156.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,271.71,90,,217.37,percent of total billed charges,90% of total billed charges for outpatient setting,38.76,271.71,
STENT 7FR 30CM PERCUFLEX / 145-374,69161528,CDM,272,RC,C2625,HCPCS,Outpatient,,,317.77,317.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.44,70,,177.95,percent of total billed charges,70% of total billed charges for outpatient setting,269.72,84.88,,215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,75,,190.66,percent of total billed charges,75% of total billed charges for outpatient setting,222.44,70,,177.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,80,,203.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,206.55,65,,165.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.22,35,,88.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,285.99,90,,228.79,percent of total billed charges,90% of total billed charges for outpatient setting,40.8,285.99,
STENT 7FR X 24 PERCUFLEX 145-371,69161024,CDM,278,RC,C2625,HCPCS,Outpatient,,,301.9,301.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.14,60,,144.91,percent of total billed charges,60% of total Billed charges for outpatient setting,256.25,84.88,,205,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.43,75,,181.14,percent of total billed charges,75% of total billed charges for outpatient setting,150.95,50,,120.76,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.52,80,,193.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,38.76,12.84,,31.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,301.9,65,,241.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,35,,84.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.14,60,,144.91,percent of total billed charges,60% of total billed charges for outpatient setting,38.76,301.9,
STENT 8.0FR 24CM SOFCURL / SSC8524,1600016,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 8.5FR 26CM SOFCURL / SSC8526,1600017,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 8.5FR 28CM SOFCURL / SSC8528,1600018,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 8.5FR 30CM SOFCURL / SSC8530,1600019,CDM,278,RC,C2625,HCPCS,Outpatient,,,369.64,369.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.78,60,,177.42,percent of total billed charges,60% of total Billed charges for outpatient setting,313.75,84.88,,251,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.23,75,,221.78,percent of total billed charges,75% of total billed charges for outpatient setting,184.82,50,,147.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.71,80,,236.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,47.46,12.84,,37.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.64,65,,295.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.37,35,,103.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,221.78,60,,177.42,percent of total billed charges,60% of total billed charges for outpatient setting,47.46,369.64,
STENT 8FR 26CM PERCUFLEX / 145-382,69162523,CDM,278,RC,C2625,HCPCS,Outpatient,,,302.64,302.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.58,60,,145.26,percent of total billed charges,60% of total Billed charges for outpatient setting,256.88,84.88,,205.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.98,75,,181.58,percent of total billed charges,75% of total billed charges for outpatient setting,151.32,50,,121.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,12.84,,31.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.11,80,,193.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,12.84,,31.09,percent of total billed charges,12.84% of total billed charges,38.86,12.84,,31.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.64,65,,242.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.92,35,,84.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.58,60,,145.26,percent of total billed charges,60% of total billed charges for outpatient setting,38.86,302.64,
STENT 8FR 28CM PERCUFLEX / 145-383,69161598,CDM,278,RC,C2625,HCPCS,Outpatient,,,317.77,317.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.66,60,,152.53,percent of total billed charges,60% of total Billed charges for outpatient setting,269.72,84.88,,215.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,75,,190.66,percent of total billed charges,75% of total billed charges for outpatient setting,158.89,50,,127.11,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,80,,203.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,40.8,12.84,,32.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,317.77,65,,254.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.22,35,,88.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,190.66,60,,152.53,percent of total billed charges,60% of total billed charges for outpatient setting,40.8,317.77,
STENT 8FR 30CM PERCUFLEX / 145-384,69161599,CDM,278,RC,C2625,HCPCS,Outpatient,,,302.64,302.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.58,60,,145.26,percent of total billed charges,60% of total Billed charges for outpatient setting,256.88,84.88,,205.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.98,75,,181.58,percent of total billed charges,75% of total billed charges for outpatient setting,151.32,50,,121.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,12.84,,31.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.11,80,,193.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,12.84,,31.09,percent of total billed charges,12.84% of total billed charges,38.86,12.84,,31.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.64,65,,242.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.92,35,,84.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.58,60,,145.26,percent of total billed charges,60% of total billed charges for outpatient setting,38.86,302.64,
STENT GENESIS 5MMX12MM/135CM/PG1250BAX,2250097,CDM,278,RC,,,Outpatient,,,3928.68,3928.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2357.21,60,,1885.77,percent of total billed charges,60% of total Billed charges for outpatient setting,3334.66,84.88,,2667.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,1964.34,50,,1571.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2946.51,75,,2357.21,percent of total billed charges,75% of total billed charges for outpatient setting,1964.34,50,,1571.47,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.44,12.84,,403.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3142.94,80,,2514.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.44,12.84,,403.55,percent of total billed charges,12.84% of total billed charges,504.44,12.84,,403.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4125.11,105,,3300.09,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.04,35,,1100.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2357.21,60,,1885.77,percent of total billed charges,60% of total billed charges for outpatient setting,504.44,4125.11,
STENT HERCULINK 4X12X135/1008013-12,2250305,CDM,278,RC,C1876,HCPCS,Outpatient,,,4720.84,4720.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2832.5,60,,2266,percent of total billed charges,60% of total Billed charges for outpatient setting,4007.05,84.88,,3205.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3540.63,75,,2832.5,percent of total billed charges,75% of total billed charges for outpatient setting,2360.42,50,,1888.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.67,80,,3021.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4956.88,105,,3965.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.29,35,,1321.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2832.5,60,,2266,percent of total billed charges,60% of total billed charges for outpatient setting,606.16,4956.88,
STENT HERCULINK 4X15X135/1008013-15,2250306,CDM,278,RC,C1876,HCPCS,Outpatient,,,4720.84,4720.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2832.5,60,,2266,percent of total billed charges,60% of total Billed charges for outpatient setting,4007.05,84.88,,3205.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3540.63,75,,2832.5,percent of total billed charges,75% of total billed charges for outpatient setting,2360.42,50,,1888.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.67,80,,3021.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4956.88,105,,3965.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.29,35,,1321.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2832.5,60,,2266,percent of total billed charges,60% of total billed charges for outpatient setting,606.16,4956.88,
STENT HERCULINK 4X18X135/1008013-18,2250307,CDM,278,RC,C1876,HCPCS,Outpatient,,,4720.84,4720.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2832.5,60,,2266,percent of total billed charges,60% of total Billed charges for outpatient setting,4007.05,84.88,,3205.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3540.63,75,,2832.5,percent of total billed charges,75% of total billed charges for outpatient setting,2360.42,50,,1888.34,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.67,80,,3021.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,606.16,12.84,,484.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4956.88,105,,3965.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.29,35,,1321.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2832.5,60,,2266,percent of total billed charges,60% of total billed charges for outpatient setting,606.16,4956.88,
STENT PLCMT EA ADD VESSEL,2200760,CDM,481,RC,,,Outpatient,,,13881.87,13881.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9717.31,70,,7773.85,percent of total billed charges,70% of total billed charges for outpatient setting,11782.93,84.88,,9426.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,6940.94,50,,5552.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10411.4,75,,8329.12,percent of total billed charges,75% of total billed charges for outpatient setting,5000,70,,4000,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782.43,12.84,,1425.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11105.5,80,,8884.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782.43,12.84,,1425.94,percent of total billed charges,12.84% of total billed charges,1782.43,12.84,,1425.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.65,35,,3886.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12493.68,90,,9994.94,percent of total billed charges,90% of total billed charges for outpatient setting,1782.43,12493.68,
STENT XCEED 6x100x120/14845-05,69159925,CDM,278,RC,C1876,HCPCS,Outpatient,,,2655,2655,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1593,60,,1274.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2253.56,84.88,,1802.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1991.25,75,,1593,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,50,,1062,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.9,12.84,,272.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2124,80,,1699.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.9,12.84,,272.72,percent of total billed charges,12.84% of total billed charges,340.9,12.84,,272.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2787.75,105,,2230.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.25,35,,743.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1593,60,,1274.4,percent of total billed charges,60% of total billed charges for outpatient setting,340.9,2787.75,
STENT XCEED 6x120x120/14846-05,69159926,CDM,278,RC,C1876,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
STENT XCEED 6x80x120/14844-03,69159167,CDM,278,RC,C1876,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
STENT XCEED 7x100x120/14863-05,69159927,CDM,278,RC,C1876,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
STENT XCEED 7x120x120/14864-05,69159928,CDM,278,RC,C1876,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
STENT XCEED 8x100x120/14880-05,69159930,CDM,278,RC,C1876,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
STENT XCEED 8x120x120/14881-05,69159931,CDM,278,RC,C1876,HCPCS,Outpatient,,,2700,2700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,60,,1296,percent of total billed charges,60% of total Billed charges for outpatient setting,2291.76,84.88,,1833.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2025,75,,1620,percent of total billed charges,75% of total billed charges for outpatient setting,1350,50,,1080,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,80,,1728,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,346.68,12.84,,277.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2835,105,,2268,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,35,,756,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1620,60,,1296,percent of total billed charges,60% of total billed charges for outpatient setting,346.68,2835,
STENT XCEED 8x80x120/14879-03,69159929,CDM,278,RC,C1876,HCPCS,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1320,60,,1056,percent of total billed charges,60% of total Billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2310,105,,1848,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1320,60,,1056,percent of total billed charges,60% of total billed charges for outpatient setting,282.48,2310,
STENT XPERT 3x40x135/82137-01,69159993,CDM,278,RC,C1876,HCPCS,Outpatient,,,3390,3390,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034,60,,1627.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2877.43,84.88,,2301.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2542.5,75,,2034,percent of total billed charges,75% of total billed charges for outpatient setting,1695,50,,1356,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.28,12.84,,348.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2712,80,,2169.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.28,12.84,,348.22,percent of total billed charges,12.84% of total billed charges,435.28,12.84,,348.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3559.5,105,,2847.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.5,35,,949.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2034,60,,1627.2,percent of total billed charges,60% of total billed charges for outpatient setting,435.28,3559.5,
STENT XPERT 4x60x135/82141-01,69160395,CDM,278,RC,C1877,HCPCS,Outpatient,,,3390,3390,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2034,60,,1627.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2877.43,84.88,,2301.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2542.5,75,,2034,percent of total billed charges,75% of total billed charges for outpatient setting,1695,50,,1356,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.28,12.84,,348.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2712,80,,2169.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.28,12.84,,348.22,percent of total billed charges,12.84% of total billed charges,435.28,12.84,,348.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3559.5,105,,2847.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.5,35,,949.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2034,60,,1627.2,percent of total billed charges,60% of total billed charges for outpatient setting,435.28,3559.5,
STEREOTACTIC LOCALIZATION GUIDANCE FOR B,2700045,CDM,320,RC,77031,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.5,50,,75.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.9,100,,,Fee Schedule,100% of Custom Fee Schedule,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,181.9,
STERI STRIP 1/2INX4IN / R1547,6150431,CDM,272,RC,,,Outpatient,,,7.28,7.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,70,,4.08,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,84.88,,4.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.64,50,,2.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.46,75,,4.37,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,70,,4.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,12.84,,0.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.82,80,,4.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.93,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.73,65,,3.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,35,,2.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.55,90,,5.24,percent of total billed charges,90% of total billed charges for outpatient setting,0.93,6.55,
STERI STRIPS 1/4IN 3IN / R1541,7651113,CDM,272,RC,,,Outpatient,,,4.48,4.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,70,,2.51,percent of total billed charges,70% of total billed charges for outpatient setting,3.8,84.88,,3.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.24,50,,1.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.36,75,,2.69,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,70,,2.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,80,,2.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.91,65,,2.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,35,,1.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.03,90,,3.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.03,
STERIBUMP STERILE / 508,71000660,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,161.27,84.88,,129.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,95,50,,76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,75,,114,percent of total billed charges,75% of total billed charges for outpatient setting,133,70,,106.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152,80,,121.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,24.4,12.84,,19.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.5,65,,98.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.5,35,,53.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,171,90,,136.8,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,171,
STERILE WATER INJ SDV : 50ML,3302181,CDM,250,RC,,,Outpatient,,,4.32,4.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,84.88,,2.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.16,50,,1.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.24,75,,2.59,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,70,,2.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,80,,2.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,0.55,12.84,,0.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.81,65,,2.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,35,,1.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.89,90,,3.11,percent of total billed charges,90% of total billed charges for outpatient setting,0.55,3.89,
STERILE WATER INJ SDV 10ML,3302182,CDM,272,RC,A4216,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
STERILE WATER INJ SDV 50ML,3302183,CDM,250,RC,,,Outpatient,,,31.99,31.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.39,70,,17.91,percent of total billed charges,70% of total billed charges for outpatient setting,27.15,84.88,,21.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,16,50,,12.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.99,75,,19.19,percent of total billed charges,75% of total billed charges for outpatient setting,22.39,70,,17.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,12.84,,3.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.59,80,,20.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,12.84,,3.29,percent of total billed charges,12.84% of total billed charges,4.11,12.84,,3.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.79,65,,16.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,35,,8.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.79,90,,23.03,percent of total billed charges,90% of total billed charges for outpatient setting,4.11,28.79,
STERILE WATER INJ SDV: 10ML,3302180,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
STERILE WATER INJ SOLN  2000ML,3309434,CDM,258,RC,,,Outpatient,,,40.88,40.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.62,70,,22.9,percent of total billed charges,70% of total billed charges for outpatient setting,34.7,84.88,,27.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.44,50,,16.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.66,75,,24.53,percent of total billed charges,75% of total billed charges for outpatient setting,28.62,70,,22.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,12.84,,4.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.7,80,,26.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,12.84,,4.2,percent of total billed charges,12.84% of total billed charges,5.25,12.84,,4.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.57,65,,21.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.31,35,,11.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.79,90,,29.43,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,36.79,
STERILE WATER INJ SOLN: 1000ML,3302494,CDM,258,RC,,,Outpatient,,,69.52,69.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.66,70,,38.93,percent of total billed charges,70% of total billed charges for outpatient setting,59.01,84.88,,47.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.76,50,,27.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.14,75,,41.71,percent of total billed charges,75% of total billed charges for outpatient setting,48.66,70,,38.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,12.84,,7.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,80,,44.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,12.84,,7.14,percent of total billed charges,12.84% of total billed charges,8.93,12.84,,7.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.19,65,,36.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.33,35,,19.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.57,90,,50.06,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,62.57,
STERNUM 2 VWS,2400190,CDM,320,RC,71120,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
STERRAD LOCKS SCS01-WHITE,6152603,CDM,272,RC,,,Outpatient,,,1.8,1.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,70,,1.01,percent of total billed charges,70% of total billed charges for outpatient setting,1.53,84.88,,1.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.9,50,,0.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.35,75,,1.08,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,70,,1.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.184,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,80,,1.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,0.23,12.84,,0.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.17,65,,0.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,35,,0.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.62,90,,1.3,percent of total billed charges,90% of total billed charges for outpatient setting,0.23,1.62,
STINGRAFIN : 10ML,3302255,CDM,255,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
STOCKINETTE XL IMP  / 1587,6150015,CDM,270,RC,,,Outpatient,,,25.04,25.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.53,70,,14.02,percent of total billed charges,70% of total billed charges for outpatient setting,21.25,84.88,,17,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.52,50,,10.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.78,75,,15.02,percent of total billed charges,75% of total billed charges for outpatient setting,17.53,70,,14.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,12.84,,2.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,80,,16.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,12.84,,2.58,percent of total billed charges,12.84% of total billed charges,3.22,12.84,,2.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.28,65,,13.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.76,35,,7.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.54,90,,18.03,percent of total billed charges,90% of total billed charges for outpatient setting,3.22,22.54,
STOCKING TED KNEE HIGH-LARGE REG /,69159974,CDM,270,RC,,,Outpatient,,,30.16,30.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.6,84.88,,20.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.08,50,,12.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.62,75,,18.1,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.13,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,3.87,12.84,,3.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.6,65,,15.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,35,,8.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,3.87,27.14,
STOCKING TED KNEE HIGH-MED REG / 7115,69159973,CDM,270,RC,,,Outpatient,,,16.92,16.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,70,,9.47,percent of total billed charges,70% of total billed charges for outpatient setting,14.36,84.88,,11.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.46,50,,6.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.69,75,,10.15,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,70,,9.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,12.84,,1.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,80,,10.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.17,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,2.17,12.84,,1.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11,65,,8.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.92,35,,4.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.23,90,,12.18,percent of total billed charges,90% of total billed charges for outpatient setting,2.17,15.23,
STOCKING TED SMALL/LONG/23640-325,5050214,CDM,270,RC,,,Outpatient,,,64.11,64.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.88,70,,35.9,percent of total billed charges,70% of total billed charges for outpatient setting,54.42,84.88,,43.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.06,50,,25.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.08,75,,38.46,percent of total billed charges,75% of total billed charges for outpatient setting,44.88,70,,35.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,12.84,,6.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.29,80,,41.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,8.23,12.84,,6.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.67,65,,33.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.44,35,,17.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.7,90,,46.16,percent of total billed charges,90% of total billed charges for outpatient setting,8.23,57.7,
STOCKING TED THIGH HIGH-MED REG,6150748,CDM,270,RC,,,Outpatient,,,42.55,42.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.79,70,,23.83,percent of total billed charges,70% of total billed charges for outpatient setting,36.12,84.88,,28.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.28,50,,17.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.91,75,,25.53,percent of total billed charges,75% of total billed charges for outpatient setting,29.79,70,,23.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,12.84,,4.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.04,80,,27.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.46,12.84,,4.37,percent of total billed charges,12.84% of total billed charges,5.46,12.84,,4.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.66,65,,22.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,35,,11.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.3,90,,30.64,percent of total billed charges,90% of total billed charges for outpatient setting,5.46,38.3,
STONE BASKET 3FR 90CM 20MM / 380-112,69161636,CDM,272,RC,,,Outpatient,,,698,698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,592.46,84.88,,473.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,349,50,,279.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,523.5,75,,418.8,percent of total billed charges,75% of total billed charges for outpatient setting,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.4,80,,446.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,453.7,65,,362.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,35,,195.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.2,90,,502.56,percent of total billed charges,90% of total billed charges for outpatient setting,89.62,628.2,
STONE BASKET 4 WIRE FILIFORM / 330-109,69160357,CDM,272,RC,,,Outpatient,,,732.9,732.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.03,70,,410.42,percent of total billed charges,70% of total billed charges for outpatient setting,622.09,84.88,,497.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,366.45,50,,293.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.68,75,,439.74,percent of total billed charges,75% of total billed charges for outpatient setting,513.03,70,,410.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,12.84,,75.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.32,80,,469.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,12.84,,75.28,percent of total billed charges,12.84% of total billed charges,94.1,12.84,,75.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,476.39,65,,381.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.52,35,,205.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,659.61,90,,527.69,percent of total billed charges,90% of total billed charges for outpatient setting,94.1,659.61,
STONE BASKET GEMINI-HELICAL 4 WIRE,6150763,CDM,272,RC,,,Outpatient,,,698,698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,592.46,84.88,,473.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,349,50,,279.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,523.5,75,,418.8,percent of total billed charges,75% of total billed charges for outpatient setting,488.6,70,,390.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.4,80,,446.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,89.62,12.84,,71.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,453.7,65,,362.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,35,,195.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,628.2,90,,502.56,percent of total billed charges,90% of total billed charges for outpatient setting,89.62,628.2,
STONE BASKT 1.9FR 120CM NITINOL / 390105,69162780,CDM,272,RC,,,Outpatient,,,733.8,733.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.66,70,,410.93,percent of total billed charges,70% of total billed charges for outpatient setting,622.85,84.88,,498.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,366.9,50,,293.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,550.35,75,,440.28,percent of total billed charges,75% of total billed charges for outpatient setting,513.66,70,,410.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,12.84,,75.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.04,80,,469.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,12.84,,75.38,percent of total billed charges,12.84% of total billed charges,94.22,12.84,,75.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,476.97,65,,381.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.83,35,,205.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,660.42,90,,528.34,percent of total billed charges,90% of total billed charges for outpatient setting,94.22,660.42,
STONE BSKET 3FR 120CM 16MM / M0063801000,69161635,CDM,272,RC,,,Outpatient,,,696.23,696.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.36,70,,389.89,percent of total billed charges,70% of total billed charges for outpatient setting,590.96,84.88,,472.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,348.12,50,,278.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522.17,75,,417.74,percent of total billed charges,75% of total billed charges for outpatient setting,487.36,70,,389.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.4,12.84,,71.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.98,80,,445.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.4,12.84,,71.52,percent of total billed charges,12.84% of total billed charges,89.4,12.84,,71.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452.55,65,,362.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.68,35,,194.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,626.61,90,,501.29,percent of total billed charges,90% of total billed charges for outpatient setting,89.4,626.61,
STONE BSKT 3FR 120CMx20MM/380-110,69161991,CDM,272,RC,,,Outpatient,,,849.71,849.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.8,70,,475.84,percent of total billed charges,70% of total billed charges for outpatient setting,721.23,84.88,,576.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,424.86,50,,339.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.28,75,,509.82,percent of total billed charges,75% of total billed charges for outpatient setting,594.8,70,,475.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.1,12.84,,87.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,679.77,80,,543.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.1,12.84,,87.28,percent of total billed charges,12.84% of total billed charges,109.1,12.84,,87.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,552.31,65,,441.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.4,35,,237.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,764.74,90,,611.79,percent of total billed charges,90% of total billed charges for outpatient setting,109.1,764.74,
STONE CALCULI  ANALYSIS,220791,CDM,301,RC,82365,HCPCS,Outpatient,,,58.05,52.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,49.27,84.88,,39.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.14,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.54,75,,34.83,percent of total billed charges,75% of total billed charges for outpatient setting,40.64,70,,32.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,80,,37.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.83,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,100,,,Fee Schedule,100% of Custom Fee Schedule,52.25,90,,41.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,52.25,
STONE RETRVL FLEX-CATCH 1.9FR/ NT4F19115,69169834,CDM,272,RC,,,Outpatient,,,795,795,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.5,70,,445.2,percent of total billed charges,70% of total billed charges for outpatient setting,674.8,84.88,,539.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,397.5,50,,318,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.25,75,,477,percent of total billed charges,75% of total billed charges for outpatient setting,556.5,70,,445.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.08,12.84,,81.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636,80,,508.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.08,12.84,,81.66,percent of total billed charges,12.84% of total billed charges,102.08,12.84,,81.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,516.75,65,,413.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.25,35,,222.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,715.5,90,,572.4,percent of total billed charges,90% of total billed charges for outpatient setting,102.08,715.5,
STOOL CHLORIDE,201170,CDM,300,RC,82438,HCPCS,Outpatient,,,22.5,20.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,19.1,84.88,,15.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.88,75,,13.5,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,80,,14.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,20.25,90,,16.2,percent of total billed charges,90% of total billed charges for outpatient setting,5,20.25,
STOOL CHLORIDE,201526,CDM,301,RC,82438,HCPCS,Outpatient,,,22.5,20.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,19.1,84.88,,15.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.88,75,,13.5,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,80,,14.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,20.25,90,,16.2,percent of total billed charges,90% of total billed charges for outpatient setting,5,20.25,
STOOL MAGNESIUM,201180,CDM,300,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
STOOL MAGNESIUM,201527,CDM,301,RC,83735,HCPCS,Outpatient,,,30.15,27.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,25.59,84.88,,20.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,22.61,75,,18.09,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,70,,16.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.12,80,,19.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of Custom Fee Schedule,27.14,90,,21.71,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,27.14,
STOOL OSMOLARITY,200801,CDM,301,RC,84999,HCPCS,Outpatient,,,128.39,115.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.87,70,,71.9,percent of total billed charges,70% of total billed charges for outpatient setting,108.98,84.88,,87.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.2,50,,51.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.29,75,,77.03,percent of total billed charges,75% of total billed charges for outpatient setting,89.87,70,,71.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,12.84,,13.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.71,80,,82.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,12.84,,13.19,percent of total billed charges,12.84% of total billed charges,16.49,12.84,,13.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,64.2,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,100,,,Fee Schedule,100% of Custom Fee Schedule,115.55,90,,92.44,percent of total billed charges,90% of total billed charges for outpatient setting,1.7,115.55,
STOOL PH,200799,CDM,301,RC,83986,HCPCS,Outpatient,,,16.11,14.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,13.67,84.88,,10.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.08,75,,9.66,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,70,,9.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,80,,10.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.78,100,,,Fee Schedule,100% of Custom Fee Schedule,14.5,90,,11.6,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,14.5,
STOOL POTASSIUM,200485,CDM,300,RC,82190,HCPCS,Outpatient,,,71.55,64.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,60.73,84.88,,48.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.66,75,,42.93,percent of total billed charges,75% of total billed charges for outpatient setting,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.24,80,,45.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,100,,,Fee Schedule,100% of Custom Fee Schedule,64.4,90,,51.52,percent of total billed charges,90% of total billed charges for outpatient setting,9.95,64.4,
STOOL SODIUM,201165,CDM,300,RC,82190,HCPCS,Outpatient,,,71.55,64.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,60.73,84.88,,48.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.66,75,,42.93,percent of total billed charges,75% of total billed charges for outpatient setting,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.24,80,,45.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,100,,,Fee Schedule,100% of Custom Fee Schedule,64.4,90,,51.52,percent of total billed charges,90% of total billed charges for outpatient setting,9.95,64.4,
STOOL SODIUM,201524,CDM,301,RC,82190,HCPCS,Outpatient,,,71.55,64.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,60.73,84.88,,48.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.66,75,,42.93,percent of total billed charges,75% of total billed charges for outpatient setting,50.09,70,,40.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.24,80,,45.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.77,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.46,100,,,Fee Schedule,100% of Custom Fee Schedule,64.4,90,,51.52,percent of total billed charges,90% of total billed charges for outpatient setting,9.95,64.4,
STOPCOCK NYLON 4-WAY LL / 2C6204,6150083,CDM,272,RC,,,Outpatient,,,10.89,10.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,9.24,84.88,,7.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.45,50,,4.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.17,75,,6.54,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.71,80,,6.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.08,65,,5.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.81,35,,3.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.8,90,,7.84,percent of total billed charges,90% of total billed charges for outpatient setting,1.4,9.8,
STPL 30MM LINEAR VASCULAR /TX30V,69161282,CDM,272,RC,,,Outpatient,,,522.5,522.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.75,70,,292.6,percent of total billed charges,70% of total billed charges for outpatient setting,443.5,84.88,,354.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.25,50,,209,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.88,75,,313.5,percent of total billed charges,75% of total billed charges for outpatient setting,365.75,70,,292.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.09,12.84,,53.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418,80,,334.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.09,12.84,,53.67,percent of total billed charges,12.84% of total billed charges,67.09,12.84,,53.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,339.63,65,,271.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.88,35,,146.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,470.25,90,,376.2,percent of total billed charges,90% of total billed charges for outpatient setting,67.09,470.25,
STRAIGHT SHOT TUBING XPS / 1895522,69161856,CDM,272,RC,,,Outpatient,,,156.3,156.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.41,70,,87.53,percent of total billed charges,70% of total billed charges for outpatient setting,132.67,84.88,,106.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.15,50,,62.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.23,75,,93.78,percent of total billed charges,75% of total billed charges for outpatient setting,109.41,70,,87.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.07,12.84,,16.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.04,80,,100.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.07,12.84,,16.06,percent of total billed charges,12.84% of total billed charges,20.07,12.84,,16.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.6,65,,81.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,35,,43.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.67,90,,112.54,percent of total billed charges,90% of total billed charges for outpatient setting,20.07,140.67,
STRAP ANKLE DISTRACTION / AR-1710,69162761,CDM,272,RC,,,Outpatient,,,256.2,256.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.34,70,,143.47,percent of total billed charges,70% of total billed charges for outpatient setting,217.46,84.88,,173.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.1,50,,102.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,75,,153.72,percent of total billed charges,75% of total billed charges for outpatient setting,179.34,70,,143.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.96,80,,163.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.53,65,,133.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.67,35,,71.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.58,90,,184.46,percent of total billed charges,90% of total billed charges for outpatient setting,32.9,230.58,
STRAP ANKLE DISTRACTOR / AR-1712,71000705,CDM,272,RC,,,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,212.63,90,,170.1,percent of total billed charges,90% of total billed charges for outpatient setting,30.33,212.63,
STRAP CHIN SHOULDER POSITION,6150640,CDM,270,RC,,,Outpatient,,,85.39,85.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,72.48,84.88,,57.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.7,50,,34.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.04,75,,51.23,percent of total billed charges,75% of total billed charges for outpatient setting,59.77,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.31,80,,54.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,10.96,12.84,,8.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.5,65,,44.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,35,,23.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.85,90,,61.48,percent of total billed charges,90% of total billed charges for outpatient setting,10.96,76.85,
STRAP STIRRUP W/SLIP RING 5IN / 52712,69169120,CDM,272,RC,,,Outpatient,,,22.32,22.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.62,70,,12.5,percent of total billed charges,70% of total billed charges for outpatient setting,18.95,84.88,,15.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.16,50,,8.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.74,75,,13.39,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,70,,12.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.87,12.84,,2.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,80,,14.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.87,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,2.87,12.84,,2.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.51,65,,11.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,35,,6.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.09,90,,16.07,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,20.09,
STRAP STROLL 4X4 / 3448,6150897,CDM,270,RC,,,Outpatient,,,27.2,27.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,23.09,84.88,,18.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.6,50,,10.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.4,75,,16.32,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,70,,15.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,80,,17.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,3.49,12.84,,2.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,65,,14.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,35,,7.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.48,90,,19.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,24.48,
STRAP STROLL 6X6 STL / 23657-564,6150167,CDM,270,RC,,,Outpatient,,,36.56,36.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.59,70,,20.47,percent of total billed charges,70% of total billed charges for outpatient setting,31.03,84.88,,24.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.28,50,,14.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.42,75,,21.94,percent of total billed charges,75% of total billed charges for outpatient setting,25.59,70,,20.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,12.84,,3.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,80,,23.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,12.84,,3.75,percent of total billed charges,12.84% of total billed charges,4.69,12.84,,3.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.76,65,,19.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.8,35,,10.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.9,90,,26.32,percent of total billed charges,90% of total billed charges for outpatient setting,4.69,32.9,
STREP A (STREP PYOGENES) DIR PROBE,200255,CDM,306,RC,87650,HCPCS,Outpatient,,,90.23,81.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,76.59,84.88,,61.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,67.67,75,,54.14,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,70,,50.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.18,80,,57.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,29.27,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.03,100,,,Fee Schedule,100% of Custom Fee Schedule,81.21,90,,64.97,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,81.21,
STREP A AG EIA,220127,CDM,306,RC,87430,HCPCS,Outpatient,,,75.65,68.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.96,70,,42.37,percent of total billed charges,70% of total billed charges for outpatient setting,64.21,84.88,,51.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.38,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.74,75,,45.39,percent of total billed charges,75% of total billed charges for outpatient setting,52.96,70,,42.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.52,80,,48.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.52,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.74,100,,,Fee Schedule,100% of Custom Fee Schedule,68.09,90,,54.47,percent of total billed charges,90% of total billed charges for outpatient setting,16.7,68.09,
STREPTOKINASE (STREPTASE) INJ : 1.5MMU,3302016,CDM,636,RC,J2995,HCPCS,Outpatient,,,1700.09,1700.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.06,70,,952.05,percent of total billed charges,70% of total billed charges for outpatient setting,1443.04,84.88,,1154.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,89.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1275.07,75,,1020.06,percent of total billed charges,75% of total billed charges for outpatient setting,1190.06,70,,952.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.29,12.84,,174.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.07,80,,1088.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.29,12.84,,174.63,percent of total billed charges,12.84% of total billed charges,218.29,12.84,,174.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1105.06,65,,884.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.08,90,,1224.06,percent of total billed charges,90% of total billed charges for outpatient setting,89.06,1530.08,
STREPTOZYME SCRN REFLEX TO TITER,201078,CDM,302,RC,86060,HCPCS,Outpatient,,,32.85,29.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,27.88,84.88,,22.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.53,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.64,75,,19.71,percent of total billed charges,75% of total billed charges for outpatient setting,23,70,,18.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.28,80,,21.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,100% of Custom Fee Schedule,29.57,90,,23.66,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,29.57,
STRESS ECHO,2600035,CDM,480,RC,93350,HCPCS,Outpatient,,,1497.14,1497.14,,692.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,1270.77,84.88,,1016.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1122.86,75,,898.29,percent of total billed charges,75% of total billed charges for outpatient setting,1048,70,,838.4,percent of total billed charges,70% of total billed charges for outpatient setting,736.07,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,192.23,12.84,,153.784,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1197.71,80,,958.17,percent of total billed charges,80% of total billed charges for outpatient setting,606.17,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,192.23,12.84,,153.78,percent of total billed charges,12.84% of total billed charges,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.99,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.27,100,,,Fee Schedule,100% of Custom Fee Schedule,1347.43,90,,1077.94,percent of total billed charges,90% of total billed charges for outpatient setting,192.23,1347.43,
STRESS VWS ANY JNT,2400870,CDM,320,RC,77071,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
STRIATED MUSCLE AB,202157,CDM,300,RC,86255,HCPCS,Outpatient,,,54.23,48.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,46.03,84.88,,36.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.7,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.67,75,,32.54,percent of total billed charges,75% of total billed charges for outpatient setting,37.96,70,,30.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.38,80,,34.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,100,,,Fee Schedule,100% of Custom Fee Schedule,48.81,90,,39.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,48.81,
STRIP FINGER 0.5X18 / 9115-02,6152607,CDM,272,RC,,,Outpatient,,,9.68,9.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.78,70,,5.42,percent of total billed charges,70% of total billed charges for outpatient setting,8.22,84.88,,6.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.84,50,,3.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.26,75,,5.81,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,70,,5.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.74,80,,6.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.29,65,,5.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,35,,2.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.71,90,,6.97,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,8.71,
STRIP FINGER 3/4X18 / 9115-03,6152608,CDM,272,RC,,,Outpatient,,,16.23,16.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,70,,9.09,percent of total billed charges,70% of total billed charges for outpatient setting,13.78,84.88,,11.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.12,50,,6.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.17,75,,9.74,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,70,,9.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.98,80,,10.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,2.08,12.84,,1.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.55,65,,8.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,35,,4.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.61,90,,11.69,percent of total billed charges,90% of total billed charges for outpatient setting,2.08,14.61,
STRONGYLOIDES IGG AB,220834,CDM,302,RC,86682,HCPCS,Outpatient,,,58.55,52.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,49.7,84.88,,39.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.91,75,,35.13,percent of total billed charges,75% of total billed charges for outpatient setting,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.84,80,,37.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.67,100,,,Fee Schedule,100% of Custom Fee Schedule,52.7,90,,42.16,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,52.7,
STRUT TELSCOP MEDIUM 1 / 4933-0-140,70000775,CDM,278,RC,C1713,HCPCS,Outpatient,,,3196,3196,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1917.6,60,,1534.08,percent of total billed charges,60% of total Billed charges for outpatient setting,2712.76,84.88,,2170.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2397,75,,1917.6,percent of total billed charges,75% of total billed charges for outpatient setting,1598,50,,1278.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.37,12.84,,328.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2556.8,80,,2045.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.37,12.84,,328.3,percent of total billed charges,12.84% of total billed charges,410.37,12.84,,328.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3355.8,105,,2684.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1118.6,35,,894.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1917.6,60,,1534.08,percent of total billed charges,60% of total billed charges for outpatient setting,410.37,3355.8,
STS:GLYCERIN: UD CHARGE,3303303,CDM,250,RC,,,Outpatient,,,73.4,73.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.38,70,,41.1,percent of total billed charges,70% of total billed charges for outpatient setting,62.3,84.88,,49.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.7,50,,29.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.05,75,,44.04,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,70,,41.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.42,12.84,,7.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,80,,46.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.42,12.84,,7.54,percent of total billed charges,12.84% of total billed charges,9.42,12.84,,7.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.71,65,,38.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.69,35,,20.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.06,90,,52.85,percent of total billed charges,90% of total billed charges for outpatient setting,9.42,66.06,
STYLET 10FR INTUB / 85864,5050059,CDM,272,RC,,,Outpatient,,,15.12,15.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,70,,8.46,percent of total billed charges,70% of total billed charges for outpatient setting,12.83,84.88,,10.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.56,50,,6.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.34,75,,9.07,percent of total billed charges,75% of total billed charges for outpatient setting,10.58,70,,8.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,80,,9.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.83,65,,7.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.29,35,,4.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.61,90,,10.89,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,13.61,
STYLET GUIDE (Glidescope) 0270-0681,69161689,CDM,272,RC,,,Outpatient,,,189.26,189.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.48,70,,105.98,percent of total billed charges,70% of total billed charges for outpatient setting,160.64,84.88,,128.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.63,50,,75.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.95,75,,113.56,percent of total billed charges,75% of total billed charges for outpatient setting,132.48,70,,105.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,80,,121.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.02,65,,98.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,35,,52.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.33,90,,136.26,percent of total billed charges,90% of total billed charges for outpatient setting,24.3,170.33,
STYLET INTUB 14FR / 251014,5050060,CDM,272,RC,,,Outpatient,,,16.56,16.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.06,84.88,,11.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.42,75,,9.94,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,80,,10.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,35,,4.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
STYLET INTUB 6FR / 85863,5050058,CDM,272,RC,,,Outpatient,,,15.31,15.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.72,70,,8.58,percent of total billed charges,70% of total billed charges for outpatient setting,13,84.88,,10.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.66,50,,6.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,75,,9.18,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,70,,8.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,80,,9.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,1.97,12.84,,1.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.95,65,,7.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.36,35,,4.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.78,90,,11.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.97,13.78,
SUCCINYLCHOLINE (QUELICIN) MDV : 200MG,3302017,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SUCCINYLCHOLINE CL  20MG/ML SYG 10ML,3309858,CDM,636,RC,J0330,HCPCS,Outpatient,,,109.78,109.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.85,70,,61.48,percent of total billed charges,70% of total billed charges for outpatient setting,93.18,84.88,,74.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,82.34,75,,65.87,percent of total billed charges,75% of total billed charges for outpatient setting,76.85,70,,61.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,12.84,,11.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.82,80,,70.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,12.84,,11.28,percent of total billed charges,12.84% of total billed charges,14.1,12.84,,11.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.36,65,,57.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.8,90,,79.04,percent of total billed charges,90% of total billed charges for outpatient setting,1.45,98.8,
SUCCINYLCHOLINE CL  20MG/ML SYR INJ 5ML,3308814,CDM,636,RC,J0330,HCPCS,Outpatient,,,85.4,85.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,72.49,84.88,,57.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,64.05,75,,51.24,percent of total billed charges,75% of total billed charges for outpatient setting,59.78,70,,47.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,80,,54.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.51,65,,44.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.86,90,,61.49,percent of total billed charges,90% of total billed charges for outpatient setting,1.45,76.86,
SUCCINYLCHOLINE(genANECTINE)20mg/ml 10ml,3302018,CDM,636,RC,J0330,HCPCS,Outpatient,,,75.48,75.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.84,70,,42.27,percent of total billed charges,70% of total billed charges for outpatient setting,64.07,84.88,,51.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.61,75,,45.29,percent of total billed charges,75% of total billed charges for outpatient setting,52.84,70,,42.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.69,12.84,,7.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.38,80,,48.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.69,12.84,,7.75,percent of total billed charges,12.84% of total billed charges,9.69,12.84,,7.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,49.06,65,,39.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.93,90,,54.34,percent of total billed charges,90% of total billed charges for outpatient setting,1.45,67.93,
SUCRALFATE (CARAFATE) SUSP 1GM/10ML : UD,3302022,CDM,259,RC,,,Outpatient,,,5.29,5.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.7,70,,2.96,percent of total billed charges,70% of total billed charges for outpatient setting,4.49,84.88,,3.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.65,50,,2.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.97,75,,3.18,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,70,,2.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,80,,3.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.44,65,,2.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,35,,1.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.76,90,,3.81,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.76,
SUCRALFATE (CARAFATE) SUSP 1GM/10ML:10ML,3302020,CDM,259,RC,,,Outpatient,,,105.82,105.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.07,70,,59.26,percent of total billed charges,70% of total billed charges for outpatient setting,89.82,84.88,,71.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.91,50,,42.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.37,75,,63.5,percent of total billed charges,75% of total billed charges for outpatient setting,74.07,70,,59.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.66,80,,67.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,13.59,12.84,,10.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.78,65,,55.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.04,35,,29.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.24,90,,76.19,percent of total billed charges,90% of total billed charges for outpatient setting,13.59,95.24,
SUCRALFATE (CARAFATE) TAB : 1GM,3302019,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SUCRALFATE (CARAFATE) TAB 1GM UD,3302021,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SUCTION CANNISTER 1200CC / 65651-212,6150161,CDM,270,RC,,,Outpatient,,,9.64,9.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,70,,5.4,percent of total billed charges,70% of total billed charges for outpatient setting,8.18,84.88,,6.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.82,50,,3.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.23,75,,5.78,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,70,,5.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,80,,6.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,1.24,12.84,,0.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.27,65,,5.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,35,,2.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.68,90,,6.94,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,8.68,
SUCTION CANNISTER 2000CC // OR220,70000163,CDM,270,RC,,,Outpatient,,,13.14,13.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.2,70,,7.36,percent of total billed charges,70% of total billed charges for outpatient setting,11.15,84.88,,8.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.57,50,,5.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.86,75,,7.89,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,70,,7.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,12.84,,1.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.51,80,,8.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,12.84,,1.35,percent of total billed charges,12.84% of total billed charges,1.69,12.84,,1.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.54,65,,6.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.6,35,,3.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.83,90,,9.46,percent of total billed charges,90% of total billed charges for outpatient setting,1.69,11.83,
SUCTION CANNISTER 3000CC / 65651-430,70000655,CDM,270,RC,,,Outpatient,,,14.85,14.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.4,70,,8.32,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,84.88,,10.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.43,50,,5.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.14,75,,8.91,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,70,,8.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.88,80,,9.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.65,65,,7.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.2,35,,4.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.37,90,,10.7,percent of total billed charges,90% of total billed charges for outpatient setting,1.91,13.37,
SUCTION CANNISTER 850CC / HCS7850,1012203,CDM,272,RC,,,Outpatient,,,14.4,14.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,84.88,,9.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.2,50,,5.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,75,,8.64,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,80,,9.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.36,65,,7.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,35,,4.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.96,90,,10.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,12.96,
SUCTION CATH 18FR W/CONTROL / T62C,5150132,CDM,272,RC,,,Outpatient,,,3.31,3.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,70,,1.86,percent of total billed charges,70% of total billed charges for outpatient setting,2.81,84.88,,2.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.66,50,,1.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.48,75,,1.98,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,70,,1.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,80,,2.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.15,65,,1.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,35,,0.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.98,90,,2.38,percent of total billed charges,90% of total billed charges for outpatient setting,0.43,2.98,
SUCTION CATHETER 10FR / T61C,5050181,CDM,272,RC,,,Outpatient,,,2.53,2.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,70,,1.42,percent of total billed charges,70% of total billed charges for outpatient setting,2.15,84.88,,1.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.27,50,,1.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.9,75,,1.52,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,70,,1.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,80,,1.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,0.32,12.84,,0.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.64,65,,1.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,35,,0.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.28,90,,1.82,percent of total billed charges,90% of total billed charges for outpatient setting,0.32,2.28,
SUCTION CATHETER 12FR / T68C,6152128,CDM,272,RC,,,Outpatient,,,2.19,2.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,70,,1.22,percent of total billed charges,70% of total billed charges for outpatient setting,1.86,84.88,,1.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.1,50,,0.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.64,75,,1.31,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,70,,1.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.28,12.84,,0.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,80,,1.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.28,12.84,,0.22,percent of total billed charges,12.84% of total billed charges,0.28,12.84,,0.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.42,65,,1.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,35,,0.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.97,90,,1.58,percent of total billed charges,90% of total billed charges for outpatient setting,0.28,1.97,
SUCTION CATHETER 14FR / T60C,6150857,CDM,272,RC,,,Outpatient,,,2.65,2.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,70,,1.49,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,84.88,,1.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.33,50,,1.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.99,75,,1.59,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,70,,1.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,80,,1.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,0.34,12.84,,0.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.72,65,,1.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,35,,0.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.39,90,,1.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.34,2.39,
SUCTION CATHETER 8FR W/CONTROL / T64C,5150133,CDM,270,RC,,,Outpatient,,,10.71,10.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,84.88,,7.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.36,50,,4.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,75,,6.42,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,80,,6.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.96,65,,5.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,35,,3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.64,90,,7.71,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.64,
SUCTION CAUTERY 10 FR (Dr. Danna),69160786,CDM,272,RC,,,Outpatient,,,64.2,64.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.94,70,,35.95,percent of total billed charges,70% of total billed charges for outpatient setting,54.49,84.88,,43.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.1,50,,25.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,75,,38.52,percent of total billed charges,75% of total billed charges for outpatient setting,44.94,70,,35.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,12.84,,6.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,80,,41.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.24,12.84,,6.59,percent of total billed charges,12.84% of total billed charges,8.24,12.84,,6.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,41.73,65,,33.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,35,,17.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,57.78,90,,46.22,percent of total billed charges,90% of total billed charges for outpatient setting,8.24,57.78,
SUCTION CAUTERY 10FR / E250510FR,6150628,CDM,272,RC,,,Outpatient,,,57.68,57.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,48.96,84.88,,39.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.84,50,,23.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.26,75,,34.61,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.14,80,,36.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.49,65,,29.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.19,35,,16.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.91,90,,41.53,percent of total billed charges,90% of total billed charges for outpatient setting,7.41,51.91,
SUCTION IRRIGATOR STRYKER / 250-070-500,6150587,CDM,270,RC,,,Outpatient,,,249.8,249.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.86,70,,139.89,percent of total billed charges,70% of total billed charges for outpatient setting,212.03,84.88,,169.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.9,50,,99.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.35,75,,149.88,percent of total billed charges,75% of total billed charges for outpatient setting,174.86,70,,139.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,12.84,,25.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.84,80,,159.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.07,12.84,,25.66,percent of total billed charges,12.84% of total billed charges,32.07,12.84,,25.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.37,65,,129.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.43,35,,69.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,224.82,90,,179.86,percent of total billed charges,90% of total billed charges for outpatient setting,32.07,224.82,
SUCTION IRRIGTR HYDROSURG / 0026880,70000582,CDM,270,RC,,,Outpatient,,,187.91,187.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.54,70,,105.23,percent of total billed charges,70% of total billed charges for outpatient setting,159.5,84.88,,127.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,93.96,50,,75.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.93,75,,112.74,percent of total billed charges,75% of total billed charges for outpatient setting,131.54,70,,105.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.13,12.84,,19.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.33,80,,120.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.13,12.84,,19.3,percent of total billed charges,12.84% of total billed charges,24.13,12.84,,19.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,122.14,65,,97.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.77,35,,52.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,169.12,90,,135.3,percent of total billed charges,90% of total billed charges for outpatient setting,24.13,169.12,
SUCTION RESERVOIR 400CC LG VOL,6150256,CDM,270,RC,,,Outpatient,,,77.98,77.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.59,70,,43.67,percent of total billed charges,70% of total billed charges for outpatient setting,66.19,84.88,,52.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.99,50,,31.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.49,75,,46.79,percent of total billed charges,75% of total billed charges for outpatient setting,54.59,70,,43.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,12.84,,8.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.38,80,,49.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,12.84,,8.01,percent of total billed charges,12.84% of total billed charges,10.01,12.84,,8.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.69,65,,40.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.29,35,,21.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.18,90,,56.14,percent of total billed charges,90% of total billed charges for outpatient setting,10.01,70.18,
SUCTION VALVE / MAJ-209,69160862,CDM,272,RC,,,Outpatient,,,47.6,47.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.32,70,,26.66,percent of total billed charges,70% of total billed charges for outpatient setting,40.4,84.88,,32.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.8,50,,19.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.7,75,,28.56,percent of total billed charges,75% of total billed charges for outpatient setting,33.32,70,,26.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,12.84,,4.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.08,80,,30.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,12.84,,4.89,percent of total billed charges,12.84% of total billed charges,6.11,12.84,,4.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.94,65,,24.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,35,,13.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.84,90,,34.27,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,42.84,
SUCTION YANKAUER W/CONTROL VENT K82,5050136,CDM,270,RC,,,Outpatient,,,3.35,3.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,70,,1.88,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,84.88,,2.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.68,50,,1.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.51,75,,2.01,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,70,,1.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.68,80,,2.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.18,65,,1.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,35,,0.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.02,90,,2.42,percent of total billed charges,90% of total billed charges for outpatient setting,0.43,3.02,
SUFENTANIL (SUFENTA)   0.05/ML1ML,3306938,CDM,636,RC,J3010,HCPCS,Outpatient,,,36.71,36.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,31.16,84.88,,24.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,27.53,75,,22.02,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,70,,20.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,80,,23.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.86,65,,19.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,100,,,Fee Schedule,100% of Custom Fee Schedule,33.04,90,,26.43,percent of total billed charges,90% of total billed charges for outpatient setting,0.79,33.04,
SUGAMMADEX (BRIDION) 100MG/ML  2ML,3308181,CDM,636,RC,J3490,HCPCS,Outpatient,,,484.5,484.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,70,,271.32,percent of total billed charges,70% of total billed charges for outpatient setting,411.24,84.88,,328.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,242.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,363.38,75,,290.7,percent of total billed charges,75% of total billed charges for outpatient setting,339.15,70,,271.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.6,80,,310.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,62.21,12.84,,49.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,314.93,65,,251.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.58,35,,135.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,436.05,90,,348.84,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,436.05,
SULAR ( NISOLDIPINE): 10 MG,3303053,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
SULFACETAMIDE (CETAPRED)OPTH OINT 0.25%:,3302024,CDM,259,RC,,,Outpatient,,,88.7,88.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.09,70,,49.67,percent of total billed charges,70% of total billed charges for outpatient setting,75.29,84.88,,60.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.35,50,,35.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.53,75,,53.22,percent of total billed charges,75% of total billed charges for outpatient setting,62.09,70,,49.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,12.84,,9.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.96,80,,56.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,12.84,,9.11,percent of total billed charges,12.84% of total billed charges,11.39,12.84,,9.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.66,65,,46.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.05,35,,24.84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.83,90,,63.86,percent of total billed charges,90% of total billed charges for outpatient setting,11.39,79.83,
SULFACETAMIDE (ISOPTO)OPTH SOL 0.25%:5ML,3302025,CDM,259,RC,,,Outpatient,,,81.22,81.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.85,70,,45.48,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,84.88,,55.15,percent of total billed charges,84.88% of total billed charges for outpatient setting,40.61,50,,32.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.92,75,,48.74,percent of total billed charges,75% of total billed charges for outpatient setting,56.85,70,,45.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,12.84,,8.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.98,80,,51.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,10.43,12.84,,8.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,52.79,65,,42.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,35,,22.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,73.1,90,,58.48,percent of total billed charges,90% of total billed charges for outpatient setting,10.43,73.1,
SULFACETAMIDE (SULFACET)LOT 10/5% : 25GM,3302026,CDM,259,RC,,,Outpatient,,,123.67,123.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.57,70,,69.26,percent of total billed charges,70% of total billed charges for outpatient setting,104.97,84.88,,83.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.84,50,,49.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.75,75,,74.2,percent of total billed charges,75% of total billed charges for outpatient setting,86.57,70,,69.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,12.84,,12.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,80,,79.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,12.84,,12.7,percent of total billed charges,12.84% of total billed charges,15.88,12.84,,12.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,80.39,65,,64.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.28,35,,34.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,111.3,90,,89.04,percent of total billed charges,90% of total billed charges for outpatient setting,15.88,111.3,
SULFACETAMIDE OPTH SOL 10% : 15ML,3302023,CDM,259,RC,,,Outpatient,,,12.78,12.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.95,70,,7.16,percent of total billed charges,70% of total billed charges for outpatient setting,10.85,84.88,,8.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.39,50,,5.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.59,75,,7.67,percent of total billed charges,75% of total billed charges for outpatient setting,8.95,70,,7.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.22,80,,8.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,1.64,12.84,,1.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.31,65,,6.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,35,,3.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.5,90,,9.2,percent of total billed charges,90% of total billed charges for outpatient setting,1.64,11.5,
SULFACETAMINE (SULFACET-R) LOTION: 25GM,3302027,CDM,259,RC,,,Outpatient,,,137.48,137.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,70,,76.99,percent of total billed charges,70% of total billed charges for outpatient setting,116.69,84.88,,93.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.74,50,,54.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.11,75,,82.49,percent of total billed charges,75% of total billed charges for outpatient setting,96.24,70,,76.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.98,80,,87.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,17.65,12.84,,14.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.36,65,,71.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.12,35,,38.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.73,90,,98.98,percent of total billed charges,90% of total billed charges for outpatient setting,17.65,123.73,
SULFAMETHOXAZOLE DS (BACTRIM) TAB :,3302028,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SULFAMETHOXAZOLE DS (BACTRIM) TAB :,3302029,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SULFAMETHOXAZOLE DS (genBACTRIM DS) TAB,3302030,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
SULFAMETHOXAZOLE SUSP 200-400MG/5ML:20ML,3302033,CDM,259,RC,,,Outpatient,,,5.13,5.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,70,,2.87,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,84.88,,3.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.57,50,,2.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.85,75,,3.08,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,70,,2.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,80,,3.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.33,65,,2.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,35,,1.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.62,90,,3.7,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.62,
SULFAMETHOXAZOLE(BACTRIM)SDV 400-80MG/5M,3302032,CDM,250,RC,,,Outpatient,,,9.51,9.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,70,,5.33,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,84.88,,6.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.76,50,,3.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.13,75,,5.7,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,70,,5.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.61,80,,6.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.18,65,,4.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.33,35,,2.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.56,90,,6.85,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.56,
SULFAMETHOXAZOLE(BACTRIM)SDV 400-80MG/5M,3302031,CDM,250,RC,,,Outpatient,,,11.13,11.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,70,,6.23,percent of total billed charges,70% of total billed charges for outpatient setting,9.45,84.88,,7.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.57,50,,4.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.35,75,,6.68,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,70,,6.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.9,80,,7.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.23,65,,5.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,35,,3.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.02,90,,8.02,percent of total billed charges,90% of total billed charges for outpatient setting,1.43,10.02,
SULFASALAZINE (AZULFIDINE) TAB 500MG,3302034,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
"SULFATE, URINE",201309,CDM,301,RC,84392,HCPCS,Outpatient,,,24.71,22.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.3,70,,13.84,percent of total billed charges,70% of total billed charges for outpatient setting,20.97,84.88,,16.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.53,75,,14.82,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,70,,13.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.77,80,,15.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,100,,,Fee Schedule,100% of Custom Fee Schedule,22.24,90,,17.79,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,22.24,
SULINDAC (CLINORIL) TAB : 150MG,3302036,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
SULINDAC (CLINORIL) TAB : 200MG,3302035,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
SUMATRIPTAN (IMITREX) SDV : 6MG/0.5ML,3302037,CDM,250,RC,,,Outpatient,,,147.08,147.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.96,70,,82.37,percent of total billed charges,70% of total billed charges for outpatient setting,124.84,84.88,,99.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.54,50,,58.83,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.31,75,,88.25,percent of total billed charges,75% of total billed charges for outpatient setting,102.96,70,,82.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.66,80,,94.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,18.89,12.84,,15.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.6,65,,76.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.48,35,,41.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.37,90,,105.9,percent of total billed charges,90% of total billed charges for outpatient setting,18.89,132.37,
SUMATRIPTAN(IMITREX):100 MG TABS,3302939,CDM,250,RC,,,Outpatient,,,79.34,79.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,67.34,84.88,,53.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.67,50,,31.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.51,75,,47.61,percent of total billed charges,75% of total billed charges for outpatient setting,55.54,70,,44.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.47,80,,50.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,10.19,12.84,,8.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.57,65,,41.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.77,35,,22.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.41,90,,57.13,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,71.41,
SUPER TURBOVAC 90 AMBIENT / ASHA4250-01,6153096,CDM,272,RC,,,Outpatient,,,1016.61,1016.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.63,70,,569.3,percent of total billed charges,70% of total billed charges for outpatient setting,862.9,84.88,,690.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,508.31,50,,406.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,762.46,75,,609.97,percent of total billed charges,75% of total billed charges for outpatient setting,711.63,70,,569.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.53,12.84,,104.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,813.29,80,,650.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.53,12.84,,104.42,percent of total billed charges,12.84% of total billed charges,130.53,12.84,,104.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,660.8,65,,528.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.81,35,,284.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,914.95,90,,731.96,percent of total billed charges,90% of total billed charges for outpatient setting,130.53,914.95,
SUPRAPUBIC INTRODUCER SET 18FR / G26666,69160966,CDM,272,RC,,,Outpatient,,,414.12,414.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.88,70,,231.9,percent of total billed charges,70% of total billed charges for outpatient setting,351.51,84.88,,281.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,207.06,50,,165.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.59,75,,248.47,percent of total billed charges,75% of total billed charges for outpatient setting,289.88,70,,231.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.17,12.84,,42.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.3,80,,265.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.17,12.84,,42.54,percent of total billed charges,12.84% of total billed charges,53.17,12.84,,42.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,269.18,65,,215.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.94,35,,115.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,372.71,90,,298.17,percent of total billed charges,90% of total billed charges for outpatient setting,53.17,372.71,
SUPREP BOWEL PREP: 354ML,3304998,CDM,259,RC,,,Outpatient,,,135.73,135.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.01,70,,76.01,percent of total billed charges,70% of total billed charges for outpatient setting,115.21,84.88,,92.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.87,50,,54.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.8,75,,81.44,percent of total billed charges,75% of total billed charges for outpatient setting,95.01,70,,76.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.43,12.84,,13.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.58,80,,86.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.43,12.84,,13.94,percent of total billed charges,12.84% of total billed charges,17.43,12.84,,13.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.22,65,,70.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.51,35,,38.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.16,90,,97.73,percent of total billed charges,90% of total billed charges for outpatient setting,17.43,122.16,
SURG PATH LEVEL 1,900005,CDM,310,RC,88300,HCPCS,Outpatient,,,98.34,88.51,,35.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,83.47,84.88,,66.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.76,75,,59.01,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,37.63,170,,,Fee Schedule,170% of Medicare OPPS rate,47.59,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.74,175,,,Fee Schedule,175% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.67,80,,62.94,percent of total billed charges,80% of total billed charges for outpatient setting,30.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,27.67,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,88.51,90,,70.81,percent of total billed charges,90% of total billed charges for outpatient setting,10.53,88.51,
SURG PATH LEVEL 2,900010,CDM,310,RC,88302,HCPCS,Outpatient,,,98.34,88.51,,35.41,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,83.47,84.88,,66.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.76,75,,59.01,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,70,,55.07,percent of total billed charges,70% of total billed charges for outpatient setting,37.63,170,,,Fee Schedule,170% of Medicare OPPS rate,47.59,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.74,175,,,Fee Schedule,175% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,78.67,80,,62.94,percent of total billed charges,80% of total billed charges for outpatient setting,30.99,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,27.67,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,22.13,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,88.51,90,,70.81,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,88.51,
SURG PATH LEVEL 3,900015,CDM,310,RC,88304,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,178.52,
SURG PATH LEVEL 4,900020,CDM,310,RC,88305,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,178.52,
SURG PATH LEVEL 5,900025,CDM,310,RC,88307,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,73.12,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,1044.92,
SURG PATH LEVEL 6,900030,CDM,310,RC,88309,HCPCS,Outpatient,,,1453.08,1307.77,,939.59,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1017.16,70,,813.73,percent of total billed charges,70% of total billed charges for outpatient setting,1233.37,84.88,,986.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,752.37,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1089.81,75,,871.85,percent of total billed charges,75% of total billed charges for outpatient setting,1017.16,70,,813.73,percent of total billed charges,70% of total billed charges for outpatient setting,998.32,170,,,Fee Schedule,170% of Medicare OPPS rate,1262.58,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1027.68,175,,,Fee Schedule,175% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1162.46,80,,929.97,percent of total billed charges,80% of total billed charges for outpatient setting,822.14,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,734.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,587.24,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.73,100,,,Fee Schedule,100% of Custom Fee Schedule,1307.77,90,,1046.22,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,1307.77,
SURGICAL CLIPPER BLADE / 4406,6150136,CDM,270,RC,,,Outpatient,,,27.92,27.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.54,70,,15.63,percent of total billed charges,70% of total billed charges for outpatient setting,23.7,84.88,,18.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.96,50,,11.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.94,75,,16.75,percent of total billed charges,75% of total billed charges for outpatient setting,19.54,70,,15.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,80,,17.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,3.58,12.84,,2.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.15,65,,14.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,35,,7.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.13,90,,20.1,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,25.13,
SURGICAL PROCEDURE IN ASU/ENDO,5000101,CDM,360,RC,,,Outpatient,,,2840.91,2840.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1988.64,70,,1590.91,percent of total billed charges,70% of total billed charges for outpatient setting,2411.36,84.88,,1929.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1420.46,50,,1136.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2130.68,75,,1704.54,percent of total billed charges,75% of total billed charges for outpatient setting,1988.64,70,,1590.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.77,12.84,,291.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2272.73,80,,1818.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.77,12.84,,291.82,percent of total billed charges,12.84% of total billed charges,364.77,12.84,,291.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.32,35,,795.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2556.82,90,,2045.46,percent of total billed charges,90% of total billed charges for outpatient setting,364.77,2556.82,
SURGICAL SPEARS WECK CELLS / 8065100010,69161869,CDM,272,RC,,,Outpatient,,,14.4,14.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,84.88,,9.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.2,50,,5.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,75,,8.64,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,80,,9.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.36,65,,7.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,35,,4.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.96,90,,10.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,12.96,
SURGICAL SPECIMEN,2400815,CDM,320,RC,76098,HCPCS,Outpatient,,,1545.1,1158.83,,692.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,1311.48,84.88,,1049.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1158.83,75,,927.06,percent of total billed charges,75% of total billed charges for outpatient setting,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,736.08,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,198.39,12.84,,158.712,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1236.08,80,,988.86,percent of total billed charges,80% of total billed charges for outpatient setting,606.18,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,1390.59,90,,1112.47,percent of total billed charges,90% of total billed charges for outpatient setting,128,1390.59,
SURGICAL SPECIMEN RAD EXAM,2400816,CDM,320,RC,76098,HCPCS,Outpatient,,,1545.1,1158.83,,692.78,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,1311.48,84.88,,1049.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,676.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1158.83,75,,927.06,percent of total billed charges,75% of total billed charges for outpatient setting,1081.57,70,,865.26,percent of total billed charges,70% of total billed charges for outpatient setting,736.08,170,,,Fee Schedule,170% of Medicare OPPS rate,930.92,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,198.39,12.84,,158.712,percent of total billed charges,12.84% of total billed charges,757.73,175,,,Fee Schedule,175% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1236.08,80,,988.86,percent of total billed charges,80% of total billed charges for outpatient setting,606.18,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,541.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,198.39,12.84,,158.71,percent of total billed charges,12.84% of total billed charges,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,432.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,378.18,100,,,Fee Schedule,100% of Custom Fee Schedule,1390.59,90,,1112.47,percent of total billed charges,90% of total billed charges for outpatient setting,128,1390.59,
SURGICEL 2X3 / 1953,6150305,CDM,272,RC,,,Outpatient,,,138.96,138.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.27,70,,77.82,percent of total billed charges,70% of total billed charges for outpatient setting,117.95,84.88,,94.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.48,50,,55.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.22,75,,83.38,percent of total billed charges,75% of total billed charges for outpatient setting,97.27,70,,77.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,12.84,,14.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.17,80,,88.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,12.84,,14.27,percent of total billed charges,12.84% of total billed charges,17.84,12.84,,14.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.32,65,,72.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,35,,38.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,125.06,90,,100.05,percent of total billed charges,90% of total billed charges for outpatient setting,17.84,125.06,
SURGICEL 4X8 / 1952,6150304,CDM,272,RC,,,Outpatient,,,168,168,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.6,70,,94.08,percent of total billed charges,70% of total billed charges for outpatient setting,142.6,84.88,,114.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,84,50,,67.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,75,,100.8,percent of total billed charges,75% of total billed charges for outpatient setting,117.6,70,,94.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.57,12.84,,17.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,80,,107.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.57,12.84,,17.26,percent of total billed charges,12.84% of total billed charges,21.57,12.84,,17.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.2,65,,87.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,35,,47.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.2,90,,120.96,percent of total billed charges,90% of total billed charges for outpatient setting,21.57,151.2,
SURGIFLO MATRIX W/O THROMBIN / 2991,70000395,CDM,270,RC,,,Outpatient,,,687.41,687.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.19,70,,384.95,percent of total billed charges,70% of total billed charges for outpatient setting,583.47,84.88,,466.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,343.71,50,,274.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.56,75,,412.45,percent of total billed charges,75% of total billed charges for outpatient setting,481.19,70,,384.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.26,12.84,,70.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.93,80,,439.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.26,12.84,,70.61,percent of total billed charges,12.84% of total billed charges,88.26,12.84,,70.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,446.82,65,,357.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.59,35,,192.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,618.67,90,,494.94,percent of total billed charges,90% of total billed charges for outpatient setting,88.26,618.67,
SURGIFLO W/ THROMBIN / 2994,69161685,CDM,270,RC,J3590,HCPCS,Outpatient,,,629.76,629.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.83,70,,352.66,percent of total billed charges,70% of total billed charges for outpatient setting,534.54,84.88,,427.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,314.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,472.32,75,,377.86,percent of total billed charges,75% of total billed charges for outpatient setting,440.83,70,,352.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,12.84,,64.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.81,80,,403.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,12.84,,64.69,percent of total billed charges,12.84% of total billed charges,80.86,12.84,,64.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,409.34,65,,327.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.42,35,,176.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,566.78,90,,453.42,percent of total billed charges,90% of total billed charges for outpatient setting,80.86,566.78,
SURGIFOAM 8X3CM DRESSING / 1977,6152175,CDM,270,RC,A6209,HCPCS,Outpatient,,,116.88,116.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.82,70,,65.46,percent of total billed charges,70% of total billed charges for outpatient setting,99.21,84.88,,79.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.66,75,,70.13,percent of total billed charges,75% of total billed charges for outpatient setting,81.82,70,,65.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.01,12.84,,12.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.5,80,,74.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.01,12.84,,12.01,percent of total billed charges,12.84% of total billed charges,15.01,12.84,,12.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.97,65,,60.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.19,90,,84.15,percent of total billed charges,90% of total billed charges for outpatient setting,15.01,105.19,
SURGIFOAM SZ 100 AGS / 1974,69161677,CDM,270,RC,,,Outpatient,,,116.88,116.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.82,70,,65.46,percent of total billed charges,70% of total billed charges for outpatient setting,99.21,84.88,,79.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.44,50,,46.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.66,75,,70.13,percent of total billed charges,75% of total billed charges for outpatient setting,81.82,70,,65.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.01,12.84,,12.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.5,80,,74.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.01,12.84,,12.01,percent of total billed charges,12.84% of total billed charges,15.01,12.84,,12.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.97,65,,60.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.91,35,,32.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.19,90,,84.15,percent of total billed charges,90% of total billed charges for outpatient setting,15.01,105.19,
SURGINEEDLE 120MM / 172015,6150031,CDM,272,RC,,,Outpatient,,,241.5,241.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,70,,135.24,percent of total billed charges,70% of total billed charges for outpatient setting,204.99,84.88,,163.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,120.75,50,,96.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.13,75,,144.9,percent of total billed charges,75% of total billed charges for outpatient setting,169.05,70,,135.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.01,12.84,,24.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.2,80,,154.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.01,12.84,,24.81,percent of total billed charges,12.84% of total billed charges,31.01,12.84,,24.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,156.98,65,,125.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.53,35,,67.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,217.35,90,,173.88,percent of total billed charges,90% of total billed charges for outpatient setting,31.01,217.35,
SURGINEEDLE 150MM LONG / 172016,6150032,CDM,270,RC,,,Outpatient,,,77,77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.9,70,,43.12,percent of total billed charges,70% of total billed charges for outpatient setting,65.36,84.88,,52.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.5,50,,30.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,75,,46.2,percent of total billed charges,75% of total billed charges for outpatient setting,53.9,70,,43.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,12.84,,7.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,80,,49.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,12.84,,7.91,percent of total billed charges,12.84% of total billed charges,9.89,12.84,,7.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,50.05,65,,40.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,35,,21.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,69.3,90,,55.44,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,69.3,
SURGINEEDLE120MM  / C2201,70000802,CDM,272,RC,,,Outpatient,,,95.55,95.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.89,70,,53.51,percent of total billed charges,70% of total billed charges for outpatient setting,81.1,84.88,,64.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.78,50,,38.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.66,75,,57.33,percent of total billed charges,75% of total billed charges for outpatient setting,66.89,70,,53.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,12.84,,9.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.44,80,,61.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,12.84,,9.82,percent of total billed charges,12.84% of total billed charges,12.27,12.84,,9.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.11,65,,49.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.44,35,,26.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,86,90,,68.8,percent of total billed charges,90% of total billed charges for outpatient setting,12.27,86,
SUT LASSO 90 CRV QUICKPS / AR-6068-90,69162764,CDM,272,RC,,,Outpatient,,,692.16,692.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,70,,387.61,percent of total billed charges,70% of total billed charges for outpatient setting,587.51,84.88,,470.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,346.08,50,,276.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.12,75,,415.3,percent of total billed charges,75% of total billed charges for outpatient setting,484.51,70,,387.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.87,12.84,,71.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.73,80,,442.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.87,12.84,,71.1,percent of total billed charges,12.84% of total billed charges,88.87,12.84,,71.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,449.9,65,,359.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.26,35,,193.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,622.94,90,,498.35,percent of total billed charges,90% of total billed charges for outpatient setting,88.87,622.94,
SUT LSSO 25 CRV LT QUICKPS / AR-6068-25T,71000526,CDM,272,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,570.39,84.88,,456.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,336,50,,268.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504,75,,403.2,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,80,,430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.8,65,,349.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,35,,188.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,90,,483.84,percent of total billed charges,90% of total billed charges for outpatient setting,86.28,604.8,
SUT LSSO 25 CRV RT QUICKPS / AR-6068-25T,71000629,CDM,272,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,570.39,84.88,,456.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,336,50,,268.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504,75,,403.2,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,80,,430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.8,65,,349.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,35,,188.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,90,,483.84,percent of total billed charges,90% of total billed charges for outpatient setting,86.28,604.8,
SUT LSSO 45 CRV LT QUICKPS / AR-6068-45L,69162720,CDM,272,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,570.39,84.88,,456.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,336,50,,268.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504,75,,403.2,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,80,,430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.8,65,,349.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,35,,188.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,90,,483.84,percent of total billed charges,90% of total billed charges for outpatient setting,86.28,604.8,
SUT LSSO 45 CRV RT QUICKPS / AR-6068-45R,71000610,CDM,272,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,570.39,84.88,,456.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,336,50,,268.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504,75,,403.2,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,70,,376.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,80,,430.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,86.28,12.84,,69.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,436.8,65,,349.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,35,,188.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.8,90,,483.84,percent of total billed charges,90% of total billed charges for outpatient setting,86.28,604.8,
SUT TENSIONER/CUTTER - KNEE / AR-5815,69169729,CDM,272,RC,,,Outpatient,,,735,735,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,623.87,84.88,,499.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,367.5,50,,294,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.25,75,,441,percent of total billed charges,75% of total billed charges for outpatient setting,514.5,70,,411.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,80,,470.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,94.37,12.84,,75.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,477.75,65,,382.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.25,35,,205.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,661.5,90,,529.2,percent of total billed charges,90% of total billed charges for outpatient setting,94.37,661.5,
SUTURE - MULTI PACK,7650452,CDM,272,RC,,,Outpatient,,,193.16,193.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.21,70,,108.17,percent of total billed charges,70% of total billed charges for outpatient setting,163.95,84.88,,131.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,96.58,50,,77.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.87,75,,115.9,percent of total billed charges,75% of total billed charges for outpatient setting,135.21,70,,108.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.8,12.84,,19.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.53,80,,123.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.8,12.84,,19.84,percent of total billed charges,12.84% of total billed charges,24.8,12.84,,19.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,125.55,65,,100.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.61,35,,54.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,173.84,90,,139.07,percent of total billed charges,90% of total billed charges for outpatient setting,24.8,173.84,
SUTURE 0 ETHIBOND CT-2 CR8 / CX27D,6150329,CDM,272,RC,,,Outpatient,,,55.3,55.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.71,70,,30.97,percent of total billed charges,70% of total billed charges for outpatient setting,46.94,84.88,,37.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.65,50,,22.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.48,75,,33.18,percent of total billed charges,75% of total billed charges for outpatient setting,38.71,70,,30.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.1,12.84,,5.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.24,80,,35.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.1,12.84,,5.68,percent of total billed charges,12.84% of total billed charges,7.1,12.84,,5.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35.95,65,,28.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.36,35,,15.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,49.77,90,,39.82,percent of total billed charges,90% of total billed charges for outpatient setting,7.1,49.77,
SUTURE 0 FIBERLINK BLUE / AR-7258,71000622,CDM,272,RC,,,Outpatient,,,273,273,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.1,70,,152.88,percent of total billed charges,70% of total billed charges for outpatient setting,231.72,84.88,,185.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.5,50,,109.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.75,75,,163.8,percent of total billed charges,75% of total billed charges for outpatient setting,191.1,70,,152.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,80,,174.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.45,65,,141.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.55,35,,76.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,245.7,90,,196.56,percent of total billed charges,90% of total billed charges for outpatient setting,35.05,245.7,
SUTURE 0 PDS CT-1 / Z340H,69162667,CDM,272,RC,,,Outpatient,,,16.29,16.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,13.83,84.88,,11.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,50,,6.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.22,75,,9.78,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,70,,9.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,80,,10.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,2.09,12.84,,1.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.59,65,,8.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,35,,4.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.66,90,,11.73,percent of total billed charges,90% of total billed charges for outpatient setting,2.09,14.66,
SUTURE 0 VICRYL CT-2 CR8 / VCP727D,6150298,CDM,272,RC,,,Outpatient,,,66.08,66.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,70,,37.01,percent of total billed charges,70% of total billed charges for outpatient setting,56.09,84.88,,44.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.04,50,,26.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.56,75,,39.65,percent of total billed charges,75% of total billed charges for outpatient setting,46.26,70,,37.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.48,12.84,,6.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.86,80,,42.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.48,12.84,,6.78,percent of total billed charges,12.84% of total billed charges,8.48,12.84,,6.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.95,65,,34.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.13,35,,18.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,59.47,90,,47.58,percent of total billed charges,90% of total billed charges for outpatient setting,8.48,59.47,
SUTURE 2.9MM JUGGERKNOT / 110005096,1342303,CDM,278,RC,,,Outpatient,,,1196.44,1196.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.86,60,,574.29,percent of total billed charges,60% of total Billed charges for outpatient setting,1015.54,84.88,,812.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,598.22,50,,478.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,897.33,75,,717.86,percent of total billed charges,75% of total billed charges for outpatient setting,598.22,50,,478.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.62,12.84,,122.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.15,80,,765.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.62,12.84,,122.9,percent of total billed charges,12.84% of total billed charges,153.62,12.84,,122.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1196.44,65,,957.15,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.75,35,,335,percent of total billed charges,35% of total Billed charges for Outpatient Setting,717.86,60,,574.29,percent of total billed charges,60% of total billed charges for outpatient setting,153.62,1196.44,
SUTURE 4.75MM PK KNTLS SWIVE / AR-2324KP,71000926,CDM,278,RC,C1713,HCPCS,Outpatient,,,1782.37,1782.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.42,60,,855.54,percent of total billed charges,60% of total Billed charges for outpatient setting,1512.88,84.88,,1210.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1336.78,75,,1069.42,percent of total billed charges,75% of total billed charges for outpatient setting,891.19,50,,712.95,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.86,12.84,,183.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.9,80,,1140.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.86,12.84,,183.09,percent of total billed charges,12.84% of total billed charges,228.86,12.84,,183.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1782.37,65,,1425.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,35,,499.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1069.42,60,,855.54,percent of total billed charges,60% of total billed charges for outpatient setting,228.86,1782.37,
SUTURE 4-0 FIBERWIRE / AR-7230-01,69169898,CDM,272,RC,,,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,70,,102.9,percent of total billed charges,70% of total billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,128.63,70,,102.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.44,65,,95.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,165.38,90,,132.3,percent of total billed charges,90% of total billed charges for outpatient setting,23.59,165.38,
SUTURE BOOTS/ 6 per pack,6150658,CDM,272,RC,,,Outpatient,,,102.45,102.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.72,70,,57.38,percent of total billed charges,70% of total billed charges for outpatient setting,86.96,84.88,,69.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,51.23,50,,40.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.84,75,,61.47,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,70,,57.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.96,80,,65.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,13.15,12.84,,10.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.59,65,,53.27,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.86,35,,28.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,92.21,90,,73.77,percent of total billed charges,90% of total billed charges for outpatient setting,13.15,92.21,
SUTURE ENDO RELOAD UNIT / SW110,6150263,CDM,272,RC,,,Outpatient,,,154.71,154.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.3,70,,86.64,percent of total billed charges,70% of total billed charges for outpatient setting,131.32,84.88,,105.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.36,50,,61.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.03,75,,92.82,percent of total billed charges,75% of total billed charges for outpatient setting,108.3,70,,86.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.86,12.84,,15.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.77,80,,99.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.86,12.84,,15.89,percent of total billed charges,12.84% of total billed charges,19.86,12.84,,15.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,100.56,65,,80.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.15,35,,43.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,139.24,90,,111.39,percent of total billed charges,90% of total billed charges for outpatient setting,19.86,139.24,
SUTURE FIBERWIRE  NO 4 W NDL  AR-7230-01,69161814,CDM,272,RC,,,Outpatient,,,130.34,130.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.24,70,,72.99,percent of total billed charges,70% of total billed charges for outpatient setting,110.63,84.88,,88.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,65.17,50,,52.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.76,75,,78.21,percent of total billed charges,75% of total billed charges for outpatient setting,91.24,70,,72.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.74,12.84,,13.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.27,80,,83.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.74,12.84,,13.39,percent of total billed charges,12.84% of total billed charges,16.74,12.84,,13.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.72,65,,67.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.62,35,,36.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,117.31,90,,93.85,percent of total billed charges,90% of total billed charges for outpatient setting,16.74,117.31,
SUTURE FIBERWIRE 2 W/ NEEDLE / AR-7200,69160554,CDM,272,RC,,,Outpatient,,,138.6,138.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.02,70,,77.62,percent of total billed charges,70% of total billed charges for outpatient setting,117.64,84.88,,94.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.3,50,,55.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.95,75,,83.16,percent of total billed charges,75% of total billed charges for outpatient setting,97.02,70,,77.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,80,,88.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,17.8,12.84,,14.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,90.09,65,,72.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.51,35,,38.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.74,90,,99.79,percent of total billed charges,90% of total billed charges for outpatient setting,17.8,124.74,
SUTURE FIBERWIRE 2 W/O NDL / AR-7201,69160526,CDM,272,RC,,,Outpatient,,,183.75,183.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,70,,102.9,percent of total billed charges,70% of total billed charges for outpatient setting,155.97,84.88,,124.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.88,50,,73.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.81,75,,110.25,percent of total billed charges,75% of total billed charges for outpatient setting,128.63,70,,102.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,80,,117.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,23.59,12.84,,18.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.44,65,,95.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.31,35,,51.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,165.38,90,,132.3,percent of total billed charges,90% of total billed charges for outpatient setting,23.59,165.38,
SUTURE FIBERWIRE NO 5 W NDL / AR-7211,69162274,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,178.25,84.88,,142.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,105,50,,84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,75,,126,percent of total billed charges,75% of total billed charges for outpatient setting,147,70,,117.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,80,,134.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,26.96,12.84,,21.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.5,65,,109.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,35,,58.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189,90,,151.2,percent of total billed charges,90% of total billed charges for outpatient setting,26.96,189,
SUTURE GRASPER GREEN 30 DEGREE / 251721,69160210,CDM,272,RC,,,Outpatient,,,1185.32,1185.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,829.72,70,,663.78,percent of total billed charges,70% of total billed charges for outpatient setting,1006.1,84.88,,804.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,592.66,50,,474.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,888.99,75,,711.19,percent of total billed charges,75% of total billed charges for outpatient setting,829.72,70,,663.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.2,12.84,,121.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.26,80,,758.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.2,12.84,,121.76,percent of total billed charges,12.84% of total billed charges,152.2,12.84,,121.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,770.46,65,,616.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.86,35,,331.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1066.79,90,,853.43,percent of total billed charges,90% of total billed charges for outpatient setting,152.2,1066.79,
SUTURE GRASPER PINK 60 DEGREE / 251723,69159616,CDM,272,RC,,,Outpatient,,,1158.51,1158.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810.96,70,,648.77,percent of total billed charges,70% of total billed charges for outpatient setting,983.34,84.88,,786.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,579.26,50,,463.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,868.88,75,,695.1,percent of total billed charges,75% of total billed charges for outpatient setting,810.96,70,,648.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.75,12.84,,119,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.81,80,,741.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.75,12.84,,119,percent of total billed charges,12.84% of total billed charges,148.75,12.84,,119,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,753.03,65,,602.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.48,35,,324.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1042.66,90,,834.13,percent of total billed charges,90% of total billed charges for outpatient setting,148.75,1042.66,
SUTURE LASSO 25 DEG CRV / AR-4068-25TR,71000801,CDM,272,RC,,,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.2,65,,305.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.2,90,,423.36,percent of total billed charges,90% of total billed charges for outpatient setting,75.5,529.2,
SUTURE LASSO 45 DEG CRV LT / AR-4068-45L,69162513,CDM,272,RC,,,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.67,65,,314.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,90,,436.06,percent of total billed charges,90% of total billed charges for outpatient setting,77.76,545.08,
SUTURE LASSO 45 DEG CRV RT / AR-4068-45R,69161713,CDM,272,RC,,,Outpatient,,,588,588,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,499.09,84.88,,399.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,294,50,,235.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441,75,,352.8,percent of total billed charges,75% of total billed charges for outpatient setting,411.6,70,,329.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,80,,376.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,75.5,12.84,,60.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,382.2,65,,305.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,35,,164.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,529.2,90,,423.36,percent of total billed charges,90% of total billed charges for outpatient setting,75.5,529.2,
SUTURE LASSO 45 DEG CUR/ AR-4068-45RH,69162653,CDM,272,RC,,,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.67,65,,314.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,90,,436.06,percent of total billed charges,90% of total billed charges for outpatient setting,77.76,545.08,
SUTURE LASSO 90 DEG RIGHT / AR-4068-90R,69162774,CDM,272,RC,,,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.67,65,,314.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,90,,436.06,percent of total billed charges,90% of total billed charges for outpatient setting,77.76,545.08,
SUTURE LASSO 90 DEG W/LOOP  /AR-4065-90W,69162398,CDM,272,RC,,,Outpatient,,,562.38,562.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,477.35,84.88,,381.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,281.19,50,,224.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.79,75,,337.43,percent of total billed charges,75% of total billed charges for outpatient setting,393.67,70,,314.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.9,80,,359.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,72.21,12.84,,57.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,365.55,65,,292.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,35,,157.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,506.14,90,,404.91,percent of total billed charges,90% of total billed charges for outpatient setting,72.21,506.14,
SUTURE LASSO 90 Degree  AR-4065-90S,69161290,CDM,272,RC,,,Outpatient,,,522.67,522.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.87,70,,292.7,percent of total billed charges,70% of total billed charges for outpatient setting,443.64,84.88,,354.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,261.34,50,,209.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392,75,,313.6,percent of total billed charges,75% of total billed charges for outpatient setting,365.87,70,,292.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.11,12.84,,53.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.14,80,,334.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.11,12.84,,53.69,percent of total billed charges,12.84% of total billed charges,67.11,12.84,,53.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,339.74,65,,271.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.93,35,,146.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,470.4,90,,376.32,percent of total billed charges,90% of total billed charges for outpatient setting,67.11,470.4,
SUTURE LASSO 90 DEGREE STR / AR-4068-90,69162360,CDM,272,RC,,,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.67,65,,314.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,90,,436.06,percent of total billed charges,90% of total billed charges for outpatient setting,77.76,545.08,
SUTURE LASSO SD WIRE LOOP / AR-4068-05SD,69161434,CDM,272,RC,,,Outpatient,,,155.96,155.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.17,70,,87.34,percent of total billed charges,70% of total billed charges for outpatient setting,132.38,84.88,,105.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,77.98,50,,62.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.97,75,,93.58,percent of total billed charges,75% of total billed charges for outpatient setting,109.17,70,,87.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,12.84,,16.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.77,80,,99.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,12.84,,16.02,percent of total billed charges,12.84% of total billed charges,20.03,12.84,,16.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.37,65,,81.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.59,35,,43.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.36,90,,112.29,percent of total billed charges,90% of total billed charges for outpatient setting,20.03,140.36,
SUTURE PASS SUREGRIP / CTSG,69161818,CDM,272,RC,,,Outpatient,,,133.6,133.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.52,70,,74.82,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,84.88,,90.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.8,50,,53.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.2,75,,80.16,percent of total billed charges,75% of total billed charges for outpatient setting,93.52,70,,74.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,12.84,,13.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,80,,85.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,12.84,,13.72,percent of total billed charges,12.84% of total billed charges,17.15,12.84,,13.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.84,65,,69.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.76,35,,37.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.24,90,,96.19,percent of total billed charges,90% of total billed charges for outpatient setting,17.15,120.24,
SUTURE PASSER FIRSTPASS / 22-4038,69162903,CDM,272,RC,,,Outpatient,,,1397.3,1397.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,978.11,70,,782.49,percent of total billed charges,70% of total billed charges for outpatient setting,1186.03,84.88,,948.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,698.65,50,,558.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1047.98,75,,838.38,percent of total billed charges,75% of total billed charges for outpatient setting,978.11,70,,782.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.41,12.84,,143.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1117.84,80,,894.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.41,12.84,,143.53,percent of total billed charges,12.84% of total billed charges,179.41,12.84,,143.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,908.25,65,,726.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.06,35,,391.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1257.57,90,,1006.06,percent of total billed charges,90% of total billed charges for outpatient setting,179.41,1257.57,
SUTURE REMOVAL KIT / DYND70900,5150002,CDM,272,RC,A9270,HCPCS,Outpatient,,,7.47,7.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.23,70,,4.18,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,84.88,,5.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.6,75,,4.48,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,70,,4.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,12.84,,0.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.98,80,,4.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,12.84,,0.77,percent of total billed charges,12.84% of total billed charges,0.96,12.84,,0.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.86,65,,3.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,35,,2.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.72,90,,5.38,percent of total billed charges,90% of total billed charges for outpatient setting,0.96,6.72,
SUTURE RETRIEVER HEWSON / 71111579,6152146,CDM,272,RC,,,Outpatient,,,786.64,786.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.65,70,,440.52,percent of total billed charges,70% of total billed charges for outpatient setting,667.7,84.88,,534.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,393.32,50,,314.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.98,75,,471.98,percent of total billed charges,75% of total billed charges for outpatient setting,550.65,70,,440.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101,12.84,,80.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.31,80,,503.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101,12.84,,80.8,percent of total billed charges,12.84% of total billed charges,101,12.84,,80.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,511.32,65,,409.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.32,35,,220.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,707.98,90,,566.38,percent of total billed charges,90% of total billed charges for outpatient setting,101,707.98,
SUTURE SILK 4-0 PS-2 BLK BRD18,760815,CDM,272,RC,,,Outpatient,,,27.98,27.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,70,,15.67,percent of total billed charges,70% of total billed charges for outpatient setting,23.75,84.88,,19,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.99,50,,11.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.99,75,,16.79,percent of total billed charges,75% of total billed charges for outpatient setting,19.59,70,,15.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,12.84,,2.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.38,80,,17.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.59,12.84,,2.87,percent of total billed charges,12.84% of total billed charges,3.59,12.84,,2.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.19,65,,14.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,35,,7.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.18,90,,20.14,percent of total billed charges,90% of total billed charges for outpatient setting,3.59,25.18,
SUTURE SINGLE PACK OR TIES,7650451,CDM,272,RC,,,Outpatient,,,95.45,95.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.82,70,,53.46,percent of total billed charges,70% of total billed charges for outpatient setting,81.02,84.88,,64.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.73,50,,38.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.59,75,,57.27,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,70,,53.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.26,12.84,,9.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.36,80,,61.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.26,12.84,,9.81,percent of total billed charges,12.84% of total billed charges,12.26,12.84,,9.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.04,65,,49.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.41,35,,26.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.91,90,,68.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.26,85.91,
SUTURE TAPE TIGERLINK 1.3MM/ AR-7535T,69169876,CDM,272,RC,A4649,HCPCS,Outpatient,,,357,357,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,303.02,84.88,,242.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.75,75,,214.2,percent of total billed charges,75% of total billed charges for outpatient setting,249.9,70,,199.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,80,,228.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,45.84,12.84,,36.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,232.05,65,,185.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.95,35,,99.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,321.3,90,,257.04,percent of total billed charges,90% of total billed charges for outpatient setting,45.84,321.3,
SUTURE TIGERWR NO 2 W/ NDL / AR-7205T,69162418,CDM,272,RC,,,Outpatient,,,236.25,236.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,200.53,84.88,,160.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.13,50,,94.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.19,75,,141.75,percent of total billed charges,75% of total billed charges for outpatient setting,165.38,70,,132.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,80,,151.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.56,65,,122.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.69,35,,66.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,212.63,90,,170.1,percent of total billed charges,90% of total billed charges for outpatient setting,30.33,212.63,
SUTURESNARE 90 DEG STRAIGHT / AR-6060-90,69162560,CDM,272,RC,,,Outpatient,,,1189.65,1189.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.76,70,,666.21,percent of total billed charges,70% of total billed charges for outpatient setting,1009.77,84.88,,807.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,594.83,50,,475.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.24,75,,713.79,percent of total billed charges,75% of total billed charges for outpatient setting,832.76,70,,666.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.72,80,,761.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,152.75,12.84,,122.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,773.27,65,,618.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.38,35,,333.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1070.69,90,,856.55,percent of total billed charges,90% of total billed charges for outpatient setting,152.75,1070.69,
SUTURETAPE 1.3MM WHITE/BLUE / AR-7500,69162821,CDM,272,RC,,,Outpatient,,,189.26,189.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.48,70,,105.98,percent of total billed charges,70% of total billed charges for outpatient setting,160.64,84.88,,128.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,94.63,50,,75.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.95,75,,113.56,percent of total billed charges,75% of total billed charges for outpatient setting,132.48,70,,105.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,80,,121.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,24.3,12.84,,19.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,123.02,65,,98.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,35,,52.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,170.33,90,,136.26,percent of total billed charges,90% of total billed charges for outpatient setting,24.3,170.33,
SWAB CULTURE AEROBIC/ANEROBIC / C8552-12,6150706,CDM,272,RC,,,Outpatient,,,3.78,3.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,70,,2.12,percent of total billed charges,70% of total billed charges for outpatient setting,3.21,84.88,,2.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.89,50,,1.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.84,75,,2.27,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,70,,2.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,80,,2.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,0.49,12.84,,0.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.46,65,,1.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,35,,1.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.4,90,,2.72,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,3.4,
SWAB CULTURE LIQ STUART / 220133,69161782,CDM,272,RC,,,Outpatient,,,9.02,9.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.31,70,,5.05,percent of total billed charges,70% of total billed charges for outpatient setting,7.66,84.88,,6.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.51,50,,3.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.77,75,,5.42,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,70,,5.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,12.84,,0.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,80,,5.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,12.84,,0.93,percent of total billed charges,12.84% of total billed charges,1.16,12.84,,0.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.86,65,,4.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.16,35,,2.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.12,90,,6.5,percent of total billed charges,90% of total billed charges for outpatient setting,1.16,8.12,
SWALLOW CURRENT STATUS SLP CH,5100310,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CH,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CI,5100311,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CI,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CJ,5100312,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CJ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CK,5100313,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CK,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CL,5100314,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CL,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CM,5100315,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CM,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW CURRENT STATUS SLP CN,5100316,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,CN,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CH,5100320,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CH,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CI,5100321,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CI,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CJ,5100322,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CJ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CK,5100323,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CK,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CL,5100324,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CL,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CM,5100325,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CM,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW D/C STATUS  CN,5100326,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,CN,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW FUNC W/CINERADIOGRAPHY,2400643,CDM,320,RC,74230,HCPCS,Outpatient,,,316.33,237.25,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,221.43,70,,177.14,percent of total billed charges,70% of total billed charges for outpatient setting,268.5,84.88,,214.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.25,75,,189.8,percent of total billed charges,75% of total billed charges for outpatient setting,221.43,70,,177.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,40.62,12.84,,32.496,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,253.06,80,,202.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,40.62,12.84,,32.5,percent of total billed charges,12.84% of total billed charges,40.62,12.84,,32.5,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,284.7,90,,227.76,percent of total billed charges,90% of total billed charges for outpatient setting,40.62,344.14,
SWALLOW GOAL STATUS SLP CH,5100300,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CH,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CI,5100301,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CI,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CJ,5100302,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CJ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CK,5100303,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CK,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CL,5100304,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CL,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CM,5100305,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CM,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOW GOAL STATUS SLP CN,5100306,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,CN,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.01,50,,0.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,156,
SWALLOWING FUNCTION WITH CINERADIOGRAPHY,2400590,CDM,320,RC,74230,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,121.15,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
SWEEN PERI-WASH II,3304585,CDM,259,RC,,,Outpatient,,,13.62,13.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,84.88,,9.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.81,50,,5.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.22,75,,8.18,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,80,,8.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.85,65,,7.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.77,35,,3.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.26,90,,9.81,percent of total billed charges,90% of total billed charges for outpatient setting,1.75,12.26,
SWIVELOCK 3.5X8.5MM W/ EYE / AR-8978P,71000503,CDM,272,RC,,,Outpatient,,,1785,1785,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.5,70,,999.6,percent of total billed charges,70% of total billed charges for outpatient setting,1515.11,84.88,,1212.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,892.5,50,,714,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1338.75,75,,1071,percent of total billed charges,75% of total billed charges for outpatient setting,1249.5,70,,999.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428,80,,1142.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,229.19,12.84,,183.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1160.25,65,,928.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,35,,499.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1606.5,90,,1285.2,percent of total billed charges,90% of total billed charges for outpatient setting,229.19,1606.5,
SYRINGE FOR HAND CONTROL/14612,8370101,CDM,272,RC,,,Outpatient,,,150.59,150.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.41,70,,84.33,percent of total billed charges,70% of total billed charges for outpatient setting,127.82,84.88,,102.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.3,50,,60.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.94,75,,90.35,percent of total billed charges,75% of total billed charges for outpatient setting,105.41,70,,84.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,12.84,,15.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.47,80,,96.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,12.84,,15.47,percent of total billed charges,12.84% of total billed charges,19.34,12.84,,15.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.88,65,,78.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.71,35,,42.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.53,90,,108.42,percent of total billed charges,90% of total billed charges for outpatient setting,19.34,135.53,
SYSTEM 1.1MM IMPL T-ROPE / AR-8919DS,71000896,CDM,278,RC,C1713,HCPCS,Outpatient,,,3289.12,3289.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1973.47,60,,1578.78,percent of total billed charges,60% of total Billed charges for outpatient setting,2791.81,84.88,,2233.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2466.84,75,,1973.47,percent of total billed charges,75% of total billed charges for outpatient setting,1644.56,50,,1315.65,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2631.3,80,,2105.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,422.32,12.84,,337.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3453.58,105,,2762.86,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1151.19,35,,920.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1973.47,60,,1578.78,percent of total billed charges,60% of total billed charges for outpatient setting,422.32,3453.58,
SYSTEM 10MM ACL FIBERTAG / AR-1288QT-100,71000798,CDM,272,RC,,,Outpatient,,,2047.5,2047.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1433.25,70,,1146.6,percent of total billed charges,70% of total billed charges for outpatient setting,1737.92,84.88,,1390.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,1023.75,50,,819,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1535.63,75,,1228.5,percent of total billed charges,75% of total billed charges for outpatient setting,1433.25,70,,1146.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.9,12.84,,210.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,80,,1310.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.9,12.84,,210.32,percent of total billed charges,12.84% of total billed charges,262.9,12.84,,210.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1330.88,65,,1064.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.63,35,,573.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1842.75,90,,1474.2,percent of total billed charges,90% of total billed charges for outpatient setting,262.9,1842.75,
SYSTEM 2 LAPIPLASTY / SK14,2529187,CDM,278,RC,C1713,HCPCS,Outpatient,,,9120,9120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5472,60,,4377.6,percent of total billed charges,60% of total Billed charges for outpatient setting,7741.06,84.88,,6192.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6840,75,,5472,percent of total billed charges,75% of total billed charges for outpatient setting,4560,50,,3648,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1171.01,12.84,,936.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7296,80,,5836.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1171.01,12.84,,936.81,percent of total billed charges,12.84% of total billed charges,1171.01,12.84,,936.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9576,105,,7660.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3192,35,,2553.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5472,60,,4377.6,percent of total billed charges,60% of total billed charges for outpatient setting,1171.01,9576,
SYSTEM 2ML BULKAMID / 50050,71000918,CDM,278,RC,L8606,HCPCS,Outpatient,,,2300,2300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.24,84.88,,1561.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1725,75,,1380,percent of total billed charges,75% of total billed charges for outpatient setting,1150,50,,920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840,80,,1472,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,295.32,12.84,,236.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415,105,,1932,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380,60,,1104,percent of total billed charges,60% of total billed charges for outpatient setting,295.32,2415,
SYSTEM 4.75X19.1MM SWIVELOCK / AR-1593-P,71000894,CDM,278,RC,C1713,HCPCS,Outpatient,,,2664.37,2664.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.62,60,,1278.9,percent of total billed charges,60% of total Billed charges for outpatient setting,2261.52,84.88,,1809.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1998.28,75,,1598.62,percent of total billed charges,75% of total billed charges for outpatient setting,1332.19,50,,1065.75,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2131.5,80,,1705.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,342.11,12.84,,273.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2797.59,105,,2238.07,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.53,35,,746.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1598.62,60,,1278.9,percent of total billed charges,60% of total billed charges for outpatient setting,342.11,2797.59,
SYSTEM 4X128MM TAPERLOC / 51-100040,71000623,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SYSTEM 65MM RT VANGUARD TI / CP113618,71000386,CDM,278,RC,C1776,HCPCS,Outpatient,,,7600,7600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4560,60,,3648,percent of total billed charges,60% of total Billed charges for outpatient setting,6450.88,84.88,,5160.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5700,75,,4560,percent of total billed charges,75% of total billed charges for outpatient setting,3800,50,,3040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6080,80,,4864,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7980,105,,6384,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,35,,2128,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4560,60,,3648,percent of total billed charges,60% of total billed charges for outpatient setting,975.84,7980,
SYSTEM 6X133MM TAPERLOC / 51-100060,71000232,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SYSTEM 7X134MM TAPERLOC / 51-101070,71000084,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SYSTEM 9X137MM TAPERLOC / 51-103090,71000033,CDM,278,RC,C1713,HCPCS,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SYSTEM CAPIO UPHLD LITE / 68318170,70000148,CDM,278,RC,C1763,HCPCS,Outpatient,,,4257,4257,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2554.2,60,,2043.36,percent of total billed charges,60% of total Billed charges for outpatient setting,3613.34,84.88,,2890.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3192.75,75,,2554.2,percent of total billed charges,75% of total billed charges for outpatient setting,2128.5,50,,1702.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.6,12.84,,437.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3405.6,80,,2724.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.6,12.84,,437.28,percent of total billed charges,12.84% of total billed charges,546.6,12.84,,437.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4469.85,105,,3575.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1489.95,35,,1191.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2554.2,60,,2043.36,percent of total billed charges,60% of total billed charges for outpatient setting,546.6,4469.85,
SYSTEM COMPREHENSIVE SHLDR 15MM / 11635,70000279,CDM,278,RC,C1776,HCPCS,Outpatient,,,3700,3700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220,60,,1776,percent of total billed charges,60% of total Billed charges for outpatient setting,3140.56,84.88,,2512.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2775,75,,2220,percent of total billed charges,75% of total billed charges for outpatient setting,1850,50,,1480,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2960,80,,2368,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,475.08,12.84,,380.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3885,105,,3108,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1295,35,,1036,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2220,60,,1776,percent of total billed charges,60% of total billed charges for outpatient setting,475.08,3885,
SYSTEM ECHO HIP BI METRIC / 192108,71000353,CDM,278,RC,,,Outpatient,,,4000,4000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,60,,1920,percent of total billed charges,60% of total Billed charges for outpatient setting,3395.2,84.88,,2716.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3000,75,,2400,percent of total billed charges,75% of total billed charges for outpatient setting,2000,50,,1600,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200,80,,2560,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,513.6,12.84,,410.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4200,105,,3360,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,35,,1120,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2400,60,,1920,percent of total billed charges,60% of total billed charges for outpatient setting,513.6,4200,
SYSTEM FASTGRAFTER HARVEST / SK27,7304706,CDM,278,RC,C1776,HCPCS,Outpatient,,,3482.5,3482.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2089.5,60,,1671.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2955.95,84.88,,2364.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2611.88,75,,2089.5,percent of total billed charges,75% of total billed charges for outpatient setting,1741.25,50,,1393,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786,80,,2228.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,447.15,12.84,,357.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3656.63,105,,2925.3,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.88,35,,975.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2089.5,60,,1671.6,percent of total billed charges,60% of total billed charges for outpatient setting,447.15,3656.63,
SYSTEM FIBERTAK BUTTON / AR-3680,71000055,CDM,272,RC,,,Outpatient,,,2761.5,2761.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1933.05,70,,1546.44,percent of total billed charges,70% of total billed charges for outpatient setting,2343.96,84.88,,1875.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,1380.75,50,,1104.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2071.13,75,,1656.9,percent of total billed charges,75% of total billed charges for outpatient setting,1933.05,70,,1546.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.58,12.84,,283.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2209.2,80,,1767.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.58,12.84,,283.66,percent of total billed charges,12.84% of total billed charges,354.58,12.84,,283.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1794.98,65,,1435.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.53,35,,773.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2485.35,90,,1988.28,percent of total billed charges,90% of total billed charges for outpatient setting,354.58,2485.35,
SYSTEM FOREFOOT PEEK / AR-1530P-CP,71000500,CDM,278,RC,C1713,HCPCS,Outpatient,,,2929.5,2929.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1757.7,60,,1406.16,percent of total billed charges,60% of total Billed charges for outpatient setting,2486.56,84.88,,1989.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.13,75,,1757.7,percent of total billed charges,75% of total billed charges for outpatient setting,1464.75,50,,1171.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.6,80,,1874.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,376.15,12.84,,300.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3075.98,105,,2460.78,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025.33,35,,820.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1757.7,60,,1406.16,percent of total billed charges,60% of total billed charges for outpatient setting,376.15,3075.98,
SYSTEM ILLUMINATION / 698.605S,69162373,CDM,272,RC,,,Outpatient,,,4960,4960,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3472,70,,2777.6,percent of total billed charges,70% of total billed charges for outpatient setting,4210.05,84.88,,3368.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,2480,50,,1984,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3720,75,,2976,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.86,12.84,,509.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3968,80,,3174.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.86,12.84,,509.49,percent of total billed charges,12.84% of total billed charges,636.86,12.84,,509.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3224,65,,2579.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736,35,,1388.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4464,90,,3571.2,percent of total billed charges,90% of total billed charges for outpatient setting,636.86,4464,
SYSTEM KNOTLESS TENS BTN / AR-2350,71000459,CDM,272,RC,,,Outpatient,,,3215.62,3215.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250.93,70,,1800.74,percent of total billed charges,70% of total billed charges for outpatient setting,2729.42,84.88,,2183.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1607.81,50,,1286.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2411.72,75,,1929.38,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2572.5,80,,2058,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,412.89,12.84,,330.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2090.15,65,,1672.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.47,35,,900.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2894.06,90,,2315.25,percent of total billed charges,90% of total billed charges for outpatient setting,412.89,2894.06,
SYSTEM LAPIPLASTY / SK12,2198592,CDM,278,RC,C1776,HCPCS,Outpatient,,,7600,7600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4560,60,,3648,percent of total billed charges,60% of total Billed charges for outpatient setting,6450.88,84.88,,5160.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5700,75,,4560,percent of total billed charges,75% of total billed charges for outpatient setting,3800,50,,3040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6080,80,,4864,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,975.84,12.84,,780.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7980,105,,6384,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660,35,,2128,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4560,60,,3648,percent of total billed charges,60% of total billed charges for outpatient setting,975.84,7980,
SYSTEM PARS SUTURETAPE / AR-8862DS,71000633,CDM,272,RC,,,Outpatient,,,3139.5,3139.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.65,70,,1758.12,percent of total billed charges,70% of total billed charges for outpatient setting,2664.81,84.88,,2131.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,1569.75,50,,1255.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2354.63,75,,1883.7,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.6,80,,2009.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2040.68,65,,1632.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.83,35,,879.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2825.55,90,,2260.44,percent of total billed charges,90% of total billed charges for outpatient setting,403.11,2825.55,
SYSTEM RELIEVA TRACT / RT1640A,70000816,CDM,272,RC,,,Outpatient,,,2554.13,2554.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1787.89,70,,1430.31,percent of total billed charges,70% of total billed charges for outpatient setting,2167.95,84.88,,1734.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,1277.07,50,,1021.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1915.6,75,,1532.48,percent of total billed charges,75% of total billed charges for outpatient setting,1787.89,70,,1430.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2043.3,80,,1634.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,327.95,12.84,,262.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1660.18,65,,1328.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.95,35,,715.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2298.72,90,,1838.98,percent of total billed charges,90% of total billed charges for outpatient setting,327.95,2298.72,
SYSTEM SCORPION MINI DX / AR-8690DS,71000501,CDM,278,RC,C1713,HCPCS,Outpatient,,,2299.5,2299.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.7,60,,1103.76,percent of total billed charges,60% of total Billed charges for outpatient setting,1951.82,84.88,,1561.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1724.63,75,,1379.7,percent of total billed charges,75% of total billed charges for outpatient setting,1149.75,50,,919.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.26,12.84,,236.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.6,80,,1471.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.26,12.84,,236.21,percent of total billed charges,12.84% of total billed charges,295.26,12.84,,236.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2414.48,105,,1931.58,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.83,35,,643.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1379.7,60,,1103.76,percent of total billed charges,60% of total billed charges for outpatient setting,295.26,2414.48,
SYSTEM STREAMLINE SURGICAL / 10-0066,71000380,CDM,272,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,2037.12,84.88,,1629.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,1200,50,,960,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,75,,1440,percent of total billed charges,75% of total billed charges for outpatient setting,1680,70,,1344,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,80,,1536,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,308.16,12.84,,246.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1560,65,,1248,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,35,,672,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,90,,1728,percent of total billed charges,90% of total billed charges for outpatient setting,308.16,2160,
SYSTEM SZ 11 CORAIL HIP / L20311,71000547,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
SYSTEM SZ 14 CORAIL HIP / L20314,71000924,CDM,278,RC,C1776,HCPCS,Outpatient,,,2810,2810,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686,60,,1348.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2385.13,84.88,,1908.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2107.5,75,,1686,percent of total billed charges,75% of total billed charges for outpatient setting,1405,50,,1124,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2248,80,,1798.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,360.8,12.84,,288.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2950.5,105,,2360.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,35,,786.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1686,60,,1348.8,percent of total billed charges,60% of total billed charges for outpatient setting,360.8,2950.5,
SYSTEM UROLIFT / UL400-4,70000558,CDM,278,RC,L8699,HCPCS,Outpatient,,,3501.36,3501.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2100.82,60,,1680.66,percent of total billed charges,60% of total Billed charges for outpatient setting,2971.95,84.88,,2377.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,1750.68,50,,1400.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2626.02,75,,2100.82,percent of total billed charges,75% of total billed charges for outpatient setting,1750.68,50,,1400.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.57,12.84,,359.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.09,80,,2240.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.57,12.84,,359.66,percent of total billed charges,12.84% of total billed charges,449.57,12.84,,359.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3676.43,105,,2941.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225.48,35,,980.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2100.82,60,,1680.66,percent of total billed charges,60% of total billed charges for outpatient setting,449.57,3676.43,
SYSTEM VISIGI 3D 36FR GASTRCTMY / 5236B,70000593,CDM,272,RC,,,Outpatient,,,831.6,831.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.12,70,,465.7,percent of total billed charges,70% of total billed charges for outpatient setting,705.86,84.88,,564.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,415.8,50,,332.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,623.7,75,,498.96,percent of total billed charges,75% of total billed charges for outpatient setting,582.12,70,,465.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.78,12.84,,85.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.28,80,,532.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.78,12.84,,85.42,percent of total billed charges,12.84% of total billed charges,106.78,12.84,,85.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,540.54,65,,432.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.06,35,,232.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,748.44,90,,598.75,percent of total billed charges,90% of total billed charges for outpatient setting,106.78,748.44,
T CELLS; ABSOLUTE CD4 AND CD8,200272,CDM,302,RC,86360,HCPCS,Outpatient,,,211.41,190.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,179.44,84.88,,143.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,158.56,75,,126.85,percent of total billed charges,75% of total billed charges for outpatient setting,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.13,80,,135.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,68.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.34,100,,,Fee Schedule,100% of Custom Fee Schedule,190.27,90,,152.22,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,190.27,
T CELLS; TOTAL COUNT,200271,CDM,302,RC,86359,HCPCS,Outpatient,,,169.79,152.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,144.12,84.88,,115.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.34,75,,101.87,percent of total billed charges,75% of total billed charges for outpatient setting,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.83,80,,108.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,55.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of Custom Fee Schedule,152.81,90,,122.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,152.81,
T CELLS; TOTAL COUNT,201655,CDM,310,RC,86359,HCPCS,Outpatient,,,169.79,152.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,144.12,84.88,,115.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.34,75,,101.87,percent of total billed charges,75% of total billed charges for outpatient setting,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.83,80,,108.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,55.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of Custom Fee Schedule,152.81,90,,122.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,152.81,
T CELLS; TOTAL COUNT,220145,CDM,302,RC,86359,HCPCS,Outpatient,,,169.79,152.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,144.12,84.88,,115.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.78,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,127.34,75,,101.87,percent of total billed charges,75% of total billed charges for outpatient setting,118.85,70,,95.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.83,80,,108.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,55.08,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of Custom Fee Schedule,152.81,90,,122.25,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,152.81,
T CELLS;ABSOLUTE CD4 & CD8 COUNT,201656,CDM,310,RC,86360,HCPCS,Outpatient,,,211.41,190.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,179.44,84.88,,143.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.68,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,158.56,75,,126.85,percent of total billed charges,75% of total billed charges for outpatient setting,147.99,70,,118.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.13,80,,135.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,68.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.34,100,,,Fee Schedule,100% of Custom Fee Schedule,190.27,90,,152.22,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,190.27,
T L-SPINE SCOLIOSIS,2400225,CDM,320,RC,72081,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,38.23,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
T PALLIDUM,220118,CDM,300,RC,86780,HCPCS,Outpatient,,,59.58,53.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,50.57,84.88,,40.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,44.69,75,,35.75,percent of total billed charges,75% of total billed charges for outpatient setting,41.71,70,,33.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.66,80,,38.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.97,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,100% of Custom Fee Schedule,53.62,90,,42.9,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,53.62,
T3 UPTAKE,200530,CDM,301,RC,84479,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,26.21,
T3 UPTAKE,200715,CDM,300,RC,84479,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,26.21,
T3 UPTAKE,201260,CDM,300,RC,84479,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,26.21,
T3 UPTAKE (TO CPL),222039,CDM,301,RC,84479,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,26.21,
"T3, FREE",220231,CDM,300,RC,84481,HCPCS,Outpatient,,,76.23,68.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,64.7,84.88,,51.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,57.17,75,,45.74,percent of total billed charges,75% of total billed charges for outpatient setting,53.36,70,,42.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,80,,48.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.74,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.71,100,,,Fee Schedule,100% of Custom Fee Schedule,68.61,90,,54.89,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,68.61,
"T3, REVERSE",220233,CDM,300,RC,84482,HCPCS,Outpatient,,,70.92,63.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.64,70,,39.71,percent of total billed charges,70% of total billed charges for outpatient setting,60.2,84.88,,48.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.06,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.19,75,,42.55,percent of total billed charges,75% of total billed charges for outpatient setting,49.64,70,,39.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.74,80,,45.39,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,63.83,90,,51.06,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,63.83,
"T3, TOTAL",220234,CDM,300,RC,84480,HCPCS,Outpatient,,,63.81,57.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,54.16,84.88,,43.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.86,75,,38.29,percent of total billed charges,75% of total billed charges for outpatient setting,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.05,80,,40.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.16,100,,,Fee Schedule,100% of Custom Fee Schedule,57.43,90,,45.94,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,57.43,
T4,200215,CDM,300,RC,84436,HCPCS,Outpatient,,,30.92,27.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,26.24,84.88,,20.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.19,75,,18.55,percent of total billed charges,75% of total billed charges for outpatient setting,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,80,,19.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,100,,,Fee Schedule,100% of Custom Fee Schedule,27.83,90,,22.26,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,27.83,
T4,200536,CDM,301,RC,84436,HCPCS,Outpatient,,,30.92,27.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,26.24,84.88,,20.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.19,75,,18.55,percent of total billed charges,75% of total billed charges for outpatient setting,21.64,70,,17.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.74,80,,19.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,100,,,Fee Schedule,100% of Custom Fee Schedule,27.83,90,,22.26,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,27.83,
T4 (TO CPL),222035,CDM,301,RC,84436,HCPCS,Outpatient,,,62.5,56.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.75,70,,35,percent of total billed charges,70% of total billed charges for outpatient setting,53.05,84.88,,42.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.88,75,,37.5,percent of total billed charges,75% of total billed charges for outpatient setting,43.75,70,,35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,80,,40,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,10.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,100,,,Fee Schedule,100% of Custom Fee Schedule,56.25,90,,45,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,56.25,
T4 FREE,200220,CDM,300,RC,84439,HCPCS,Outpatient,,,40.59,36.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,34.45,84.88,,27.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.44,75,,24.35,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.47,80,,25.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,100,,,Fee Schedule,100% of Custom Fee Schedule,36.53,90,,29.22,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,36.53,
T4 FREE BY EQUILIBRIUM DIALYSIS,200537,CDM,300,RC,84439,HCPCS,Outpatient,,,40.59,36.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,34.45,84.88,,27.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.48,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,30.44,75,,24.35,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,70,,22.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.47,80,,25.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,13.17,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,100,,,Fee Schedule,100% of Custom Fee Schedule,36.53,90,,29.22,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,36.53,
TABLE COVER 44X75 / 8376,6150177,CDM,270,RC,,,Outpatient,,,10.62,10.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,70,,5.94,percent of total billed charges,70% of total billed charges for outpatient setting,9.01,84.88,,7.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.31,50,,4.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.97,75,,6.38,percent of total billed charges,75% of total billed charges for outpatient setting,7.43,70,,5.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,80,,6.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,1.36,12.84,,1.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.9,65,,5.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.72,35,,2.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.56,90,,7.65,percent of total billed charges,90% of total billed charges for outpatient setting,1.36,9.56,
TACKS 2.2MM PLATE THREADED / SN22,7673656,CDM,278,RC,C1713,HCPCS,Outpatient,,,700,700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,60,,336,percent of total billed charges,60% of total Billed charges for outpatient setting,594.16,84.88,,475.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525,75,,420,percent of total billed charges,75% of total billed charges for outpatient setting,350,50,,280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.88,12.84,,71.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560,80,,448,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.88,12.84,,71.9,percent of total billed charges,12.84% of total billed charges,89.88,12.84,,71.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,700,65,,560,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245,35,,196,percent of total billed charges,35% of total Billed charges for Outpatient Setting,420,60,,336,percent of total billed charges,60% of total billed charges for outpatient setting,89.88,700,
TACROLIMUS,220573,CDM,300,RC,80197,HCPCS,Outpatient,,,61.79,55.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.25,70,,34.6,percent of total billed charges,70% of total billed charges for outpatient setting,52.45,84.88,,41.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.34,75,,37.07,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,70,,34.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.43,80,,39.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.04,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.03,100,,,Fee Schedule,100% of Custom Fee Schedule,55.61,90,,44.49,percent of total billed charges,90% of total billed charges for outpatient setting,13.73,55.61,
TALWIN 30MG INJ : 2CC,3302779,CDM,250,RC,,,Outpatient,,,85.47,85.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,70,,47.86,percent of total billed charges,70% of total billed charges for outpatient setting,72.55,84.88,,58.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.74,50,,34.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.1,75,,51.28,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,70,,47.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.38,80,,54.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,10.97,12.84,,8.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,55.56,65,,44.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.91,35,,23.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.92,90,,61.54,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,76.92,
TAMOXIFEN (NOLVADEX) NR TAB : 10MG,3302049,CDM,259,RC,,,Outpatient,,,5.33,5.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,84.88,,3.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.67,50,,2.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4,75,,3.2,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,70,,2.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.26,80,,3.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,0.68,12.84,,0.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.46,65,,2.77,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,35,,1.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.8,90,,3.84,percent of total billed charges,90% of total billed charges for outpatient setting,0.68,4.8,
TAMOXIFEN (NOLVADEX) TAB : 10MG,3302048,CDM,259,RC,,,Outpatient,,,5.46,5.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,84.88,,3.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,50,,2.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.55,65,,2.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.91,90,,3.93,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.91,
TAMSULOSIN (genericFLOMAX) CAP 0.4MG,3302050,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TAP 3.5MM SCREW / 6149.1135,2106100,CDM,272,RC,,,Outpatient,,,1712,1712,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.4,70,,958.72,percent of total billed charges,70% of total billed charges for outpatient setting,1453.15,84.88,,1162.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,856,50,,684.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1284,75,,1027.2,percent of total billed charges,75% of total billed charges for outpatient setting,1198.4,70,,958.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,12.84,,175.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1369.6,80,,1095.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,12.84,,175.86,percent of total billed charges,12.84% of total billed charges,219.82,12.84,,175.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1112.8,65,,890.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.2,35,,479.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1540.8,90,,1232.64,percent of total billed charges,90% of total billed charges for outpatient setting,219.82,1540.8,
TAP 5MM / 2797-02-500,69162948,CDM,272,RC,,,Outpatient,,,1263.19,1263.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.23,70,,707.38,percent of total billed charges,70% of total billed charges for outpatient setting,1072.2,84.88,,857.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,631.6,50,,505.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,947.39,75,,757.91,percent of total billed charges,75% of total billed charges for outpatient setting,884.23,70,,707.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,12.84,,129.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1010.55,80,,808.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.19,12.84,,129.75,percent of total billed charges,12.84% of total billed charges,162.19,12.84,,129.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,821.07,65,,656.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.12,35,,353.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1136.87,90,,909.5,percent of total billed charges,90% of total billed charges for outpatient setting,162.19,1136.87,
TAP 5MM ASNIS CANN / 705361,1167059,CDM,272,RC,,,Outpatient,,,872,872,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.4,70,,488.32,percent of total billed charges,70% of total billed charges for outpatient setting,740.15,84.88,,592.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,436,50,,348.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,654,75,,523.2,percent of total billed charges,75% of total billed charges for outpatient setting,610.4,70,,488.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.96,12.84,,89.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.6,80,,558.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.96,12.84,,89.57,percent of total billed charges,12.84% of total billed charges,111.96,12.84,,89.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,566.8,65,,453.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.2,35,,244.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,784.8,90,,627.84,percent of total billed charges,90% of total billed charges for outpatient setting,111.96,784.8,
TAP BONE CANNULATED 4.5MM / AR-8956C-45T,70000091,CDM,272,RC,,,Outpatient,,,757.05,757.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,642.58,84.88,,514.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,378.53,50,,302.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.79,75,,454.23,percent of total billed charges,75% of total billed charges for outpatient setting,529.94,70,,423.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,80,,484.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,97.21,12.84,,77.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,492.08,65,,393.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.97,35,,211.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,681.35,90,,545.08,percent of total billed charges,90% of total billed charges for outpatient setting,97.21,681.35,
TAP FITTING ASNIS CANN 6.5MM / 702602,70000436,CDM,272,RC,,,Outpatient,,,1899.24,1899.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.47,70,,1063.58,percent of total billed charges,70% of total billed charges for outpatient setting,1612.07,84.88,,1289.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,949.62,50,,759.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1424.43,75,,1139.54,percent of total billed charges,75% of total billed charges for outpatient setting,1329.47,70,,1063.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.86,12.84,,195.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1519.39,80,,1215.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.86,12.84,,195.09,percent of total billed charges,12.84% of total billed charges,243.86,12.84,,195.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1234.51,65,,987.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,664.73,35,,531.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1709.32,90,,1367.46,percent of total billed charges,90% of total billed charges for outpatient setting,243.86,1709.32,
TAPAZOLE (METHIMAZOLE) 5MG:TAB,3302882,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TAS LORDOTIC 12DEG X 13MM / 2312-1113,69161745,CDM,278,RC,,,Outpatient,,,17990,17990,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10794,60,,8635.2,percent of total billed charges,60% of total Billed charges for outpatient setting,15269.91,84.88,,12215.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,8995,50,,7196,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13492.5,75,,10794,percent of total billed charges,75% of total billed charges for outpatient setting,8995,50,,7196,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2309.92,12.84,,1847.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14392,80,,11513.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2309.92,12.84,,1847.94,percent of total billed charges,12.84% of total billed charges,2309.92,12.84,,1847.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18889.5,105,,15111.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.5,35,,5037.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10794,60,,8635.2,percent of total billed charges,60% of total billed charges for outpatient setting,2309.92,18889.5,
TAS SCREW 5.5X30MM  2300-5530,69161746,CDM,278,RC,,,Outpatient,,,1470.41,1470.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.25,60,,705.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1248.08,84.88,,998.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,735.21,50,,588.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1102.81,75,,882.25,percent of total billed charges,75% of total billed charges for outpatient setting,735.21,50,,588.17,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.8,12.84,,151.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.33,80,,941.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.8,12.84,,151.04,percent of total billed charges,12.84% of total billed charges,188.8,12.84,,151.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1470.41,65,,1176.33,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.64,35,,411.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,882.25,60,,705.8,percent of total billed charges,60% of total billed charges for outpatient setting,188.8,1470.41,
TCEMEP UPPER AND LOWER LIMBS,6000651,CDM,740,RC,95939,HCPCS,Outpatient,,,940.86,940.86,XP,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.6,70,,526.88,percent of total billed charges,70% of total billed charges for outpatient setting,798.6,84.88,,638.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,470.43,50,,376.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705.65,75,,564.52,percent of total billed charges,75% of total billed charges for outpatient setting,658.6,70,,526.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.81,12.84,,96.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.69,80,,602.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.81,12.84,,96.65,percent of total billed charges,12.84% of total billed charges,120.81,12.84,,96.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.3,35,,263.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,846.77,90,,677.42,percent of total billed charges,90% of total billed charges for outpatient setting,120.81,846.77,
TEARS RENEWED  15 ML DROP:,3301831,CDM,259,RC,,,Outpatient,,,13.59,13.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,84.88,,9.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.8,50,,5.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.19,75,,8.15,percent of total billed charges,75% of total billed charges for outpatient setting,9.51,70,,7.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.87,80,,8.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.83,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,35,,3.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.23,90,,9.78,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.23,
TED  XXLG LONG THIGH HIGH / 352,69161263,CDM,270,RC,,,Outpatient,,,59.1,59.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.37,70,,33.1,percent of total billed charges,70% of total billed charges for outpatient setting,50.16,84.88,,40.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.55,50,,23.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.33,75,,35.46,percent of total billed charges,75% of total billed charges for outpatient setting,41.37,70,,33.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.28,80,,37.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,7.59,12.84,,6.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.42,65,,30.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.69,35,,16.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.19,90,,42.55,percent of total billed charges,90% of total billed charges for outpatient setting,7.59,53.19,
TED  XXLG REG THIGH HIGH / 351,69161262,CDM,270,RC,,,Outpatient,,,101.33,101.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,70,,56.74,percent of total billed charges,70% of total billed charges for outpatient setting,86.01,84.88,,68.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.67,50,,40.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76,75,,60.8,percent of total billed charges,75% of total billed charges for outpatient setting,70.93,70,,56.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,12.84,,10.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.06,80,,64.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,12.84,,10.41,percent of total billed charges,12.84% of total billed charges,13.01,12.84,,10.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.86,65,,52.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.47,35,,28.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.2,90,,72.96,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,91.2,
TED LG LONG THIGH HIGH / 3856LF,6150735,CDM,270,RC,,,Outpatient,,,39.29,39.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,33.35,84.88,,26.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.65,50,,15.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.47,75,,23.58,percent of total billed charges,75% of total billed charges for outpatient setting,27.5,70,,22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.43,80,,25.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,5.04,12.84,,4.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.54,65,,20.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,35,,11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.36,90,,28.29,percent of total billed charges,90% of total billed charges for outpatient setting,5.04,35.36,
TED LG/REG THIGH HIGH,6150734,CDM,270,RC,,,Outpatient,,,39.44,39.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.61,70,,22.09,percent of total billed charges,70% of total billed charges for outpatient setting,33.48,84.88,,26.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.72,50,,15.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.58,75,,23.66,percent of total billed charges,75% of total billed charges for outpatient setting,27.61,70,,22.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.55,80,,25.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,5.06,12.84,,4.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.64,65,,20.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,35,,11.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.5,90,,28.4,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,35.5,
TED XL LG LONG THIGH HIGH / 642,6150143,CDM,270,RC,,,Outpatient,,,50.26,50.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,42.66,84.88,,34.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.13,50,,20.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.7,75,,30.16,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,70,,28.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.21,80,,32.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,6.45,12.84,,5.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,32.67,65,,26.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.59,35,,14.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.23,90,,36.18,percent of total billed charges,90% of total billed charges for outpatient setting,6.45,45.23,
TED XL REG KNEE HIGH / 4296,69159975,CDM,270,RC,,,Outpatient,,,39.48,39.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.64,70,,22.11,percent of total billed charges,70% of total billed charges for outpatient setting,33.51,84.88,,26.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.74,50,,15.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.61,75,,23.69,percent of total billed charges,75% of total billed charges for outpatient setting,27.64,70,,22.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,80,,25.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,5.07,12.84,,4.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.66,65,,20.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,35,,11.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.53,90,,28.42,percent of total billed charges,90% of total billed charges for outpatient setting,5.07,35.53,
TED XLG / REG THIGH HIGH,7650420,CDM,272,RC,,,Outpatient,,,69.77,69.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.84,70,,39.07,percent of total billed charges,70% of total billed charges for outpatient setting,59.22,84.88,,47.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.89,50,,27.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.33,75,,41.86,percent of total billed charges,75% of total billed charges for outpatient setting,48.84,70,,39.07,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.96,12.84,,7.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.82,80,,44.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.96,12.84,,7.17,percent of total billed charges,12.84% of total billed charges,8.96,12.84,,7.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.35,65,,36.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.42,35,,19.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.79,90,,50.23,percent of total billed charges,90% of total billed charges for outpatient setting,8.96,62.79,
TED XXLG KNEE HIGH / 7470LF,69161245,CDM,270,RC,,,Outpatient,,,29.76,29.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,25.26,84.88,,20.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.88,50,,11.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.32,75,,17.86,percent of total billed charges,75% of total billed charges for outpatient setting,20.83,70,,16.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,12.84,,3.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.81,80,,19.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,3.82,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.34,65,,15.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,35,,8.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.78,90,,21.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.82,26.78,
TEGADERM 2X2.75 W/PAD / 3582,6150412,CDM,272,RC,A6203,HCPCS,Outpatient,,,0.54,0.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,70,,0.3,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,84.88,,0.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.41,75,,0.33,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,70,,0.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,80,,0.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,0.07,12.84,,0.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.35,65,,0.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,90,,0.39,percent of total billed charges,90% of total billed charges for outpatient setting,0.07,0.49,
TEGADERM 3.5X4.25IN / 1635,7650045,CDM,272,RC,A6203,HCPCS,Outpatient,,,10.89,10.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,9.24,84.88,,7.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,75,,6.54,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,70,,6.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.71,80,,6.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,1.4,12.84,,1.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.08,65,,5.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.8,90,,7.84,percent of total billed charges,90% of total billed charges for outpatient setting,1.4,9.8,
TEGADERM 3.5X4IN W/ PAD / 3586,6150413,CDM,272,RC,A6203,HCPCS,Outpatient,,,1.57,1.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,70,,0.88,percent of total billed charges,70% of total billed charges for outpatient setting,1.33,84.88,,1.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,75,,0.94,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,70,,0.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.26,80,,1.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,0.2,12.84,,0.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.02,65,,0.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,90,,1.13,percent of total billed charges,90% of total billed charges for outpatient setting,0.2,1.41,
TEGADERM 3.5X6IN W/ PAD / 3589,6152685,CDM,270,RC,A6203,HCPCS,Outpatient,,,2.34,2.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,70,,1.31,percent of total billed charges,70% of total billed charges for outpatient setting,1.99,84.88,,1.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,75,,1.41,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,70,,1.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,80,,1.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.52,65,,1.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,90,,1.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.3,2.11,
TEGADERM 3.5X8IN W/PAD / 3590,6152686,CDM,270,RC,A6203,HCPCS,Outpatient,,,14.21,14.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,84.88,,9.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,75,,8.53,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,70,,7.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,80,,9.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.24,65,,7.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.79,90,,10.23,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.79,
TEGADERM 4X4.75IN / 1626,5050165,CDM,272,RC,A6203,HCPCS,Outpatient,,,4.24,4.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.97,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,3.6,84.88,,2.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,75,,2.54,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,70,,2.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,80,,2.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.76,65,,2.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,90,,3.06,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.82,
TEGADERM BANDAIDS /MW8516,6150886,CDM,272,RC,,,Outpatient,,,11.64,11.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,70,,6.52,percent of total billed charges,70% of total billed charges for outpatient setting,9.88,84.88,,7.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.82,50,,4.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.73,75,,6.98,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,70,,6.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.31,80,,7.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,1.49,12.84,,1.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.57,65,,6.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,35,,3.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.48,90,,8.38,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,10.48,
TEGASEROD(ZELNORM): 2 MG TAB,3303084,CDM,259,RC,,,Outpatient,,,13.85,13.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.7,70,,7.76,percent of total billed charges,70% of total billed charges for outpatient setting,11.76,84.88,,9.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.93,50,,5.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.39,75,,8.31,percent of total billed charges,75% of total billed charges for outpatient setting,9.7,70,,7.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.424,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.08,80,,8.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.78,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9,65,,7.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.85,35,,3.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.47,90,,9.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.78,12.47,
TEGASEROD(ZELNORM): 6 MG TAB,3302956,CDM,259,RC,,,Outpatient,,,13.6,13.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,84.88,,9.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.8,50,,5.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.2,75,,8.16,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,80,,8.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.84,65,,7.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,35,,3.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.24,90,,9.79,percent of total billed charges,90% of total billed charges for outpatient setting,1.75,12.24,
TELFA 4X3 SMALL / 1050,5150107,CDM,272,RC,,,Outpatient,,,0.79,0.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.55,70,,0.44,percent of total billed charges,70% of total billed charges for outpatient setting,0.67,84.88,,0.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.4,50,,0.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.59,75,,0.47,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,70,,0.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,80,,0.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,0.1,12.84,,0.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.51,65,,0.41,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.28,35,,0.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.71,90,,0.57,percent of total billed charges,90% of total billed charges for outpatient setting,0.1,0.71,
TELFA LARGE 3X8 / 1238,6150461,CDM,272,RC,,,Outpatient,,,1.27,1.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,70,,0.71,percent of total billed charges,70% of total billed charges for outpatient setting,1.08,84.88,,0.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.64,50,,0.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.95,75,,0.76,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,70,,0.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,12.84,,0.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,80,,0.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,12.84,,0.13,percent of total billed charges,12.84% of total billed charges,0.16,12.84,,0.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.83,65,,0.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.44,35,,0.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.14,90,,0.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,1.14,
TEMAZEPAM (genericRESTORIL) 15MG CAP,3302051,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TEMOZOLOMIDE (TEMODAR) CAP: 100 MG,3302052,CDM,259,RC,,,Outpatient,,,404.7,404.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.29,70,,226.63,percent of total billed charges,70% of total billed charges for outpatient setting,343.51,84.88,,274.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,202.35,50,,161.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.53,75,,242.82,percent of total billed charges,75% of total billed charges for outpatient setting,283.29,70,,226.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.96,12.84,,41.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.76,80,,259.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.96,12.84,,41.57,percent of total billed charges,12.84% of total billed charges,51.96,12.84,,41.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,263.06,65,,210.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.65,35,,113.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,364.23,90,,291.38,percent of total billed charges,90% of total billed charges for outpatient setting,51.96,364.23,
TEMPOROMANDIBULAR JOINT,2400110,CDM,320,RC,70332,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,403.66,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
TENDON 3.5 VERSAGRAFT / VRG-351,71000865,CDM,278,RC,C1762,HCPCS,Outpatient,,,2660,2660,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1596,60,,1276.8,percent of total billed charges,60% of total Billed charges for outpatient setting,2257.81,84.88,,1806.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,75,,1596,percent of total billed charges,75% of total billed charges for outpatient setting,1330,50,,1064,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.54,12.84,,273.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2128,80,,1702.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.54,12.84,,273.23,percent of total billed charges,12.84% of total billed charges,341.54,12.84,,273.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2793,105,,2234.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,931,35,,744.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1596,60,,1276.8,percent of total billed charges,60% of total billed charges for outpatient setting,341.54,2793,
TENDON DBL STRAND ANTERIOR TIBILIAS GRFT,69161792,CDM,278,RC,,,Outpatient,,,3900,3900,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2340,60,,1872,percent of total billed charges,60% of total Billed charges for outpatient setting,3310.32,84.88,,2648.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,1950,50,,1560,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2925,75,,2340,percent of total billed charges,75% of total billed charges for outpatient setting,1950,50,,1560,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.76,12.84,,400.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,80,,2496,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.76,12.84,,400.61,percent of total billed charges,12.84% of total billed charges,500.76,12.84,,400.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4095,105,,3276,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,35,,1092,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2340,60,,1872,percent of total billed charges,60% of total billed charges for outpatient setting,500.76,4095,
TENDON SPEEDGRAFT / SPD-001,71000907,CDM,278,RC,C1713,HCPCS,Outpatient,,,4800,4800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,60,,2304,percent of total billed charges,60% of total Billed charges for outpatient setting,4074.24,84.88,,3259.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,75,,2880,percent of total billed charges,75% of total billed charges for outpatient setting,2400,50,,1920,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.32,12.84,,493.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3840,80,,3072,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.32,12.84,,493.06,percent of total billed charges,12.84% of total billed charges,616.32,12.84,,493.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5040,105,,4032,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,35,,1344,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2880,60,,2304,percent of total billed charges,60% of total billed charges for outpatient setting,616.32,5040,
TENECTEPLASE (TNKASE) INJ : 1MG,3302053,CDM,636,RC,J3101,HCPCS,Outpatient,,,19855.75,19855.75,,230.19,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13899.03,70,,11119.22,percent of total billed charges,70% of total billed charges for outpatient setting,16853.56,84.88,,13482.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,148.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,14891.81,75,,11913.45,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,244.57,170,,,Fee Schedule,170% of Medicare OPPS rate,309.32,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,2549.48,12.84,,2039.584,percent of total billed charges,12.84% of total billed charges,251.77,175,,,Fee Schedule,175% of Medicare OPPS rate,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,15884.6,80,,12707.68,percent of total billed charges,80% of total billed charges for outpatient setting,201.41,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,179.83,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,2549.48,12.84,,2039.58,percent of total billed charges,12.84% of total billed charges,2549.48,12.84,,2039.58,percent of total billed charges,12.84% of total billed charges,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12906.24,65,,10324.99,percent of total billed charges,65% of total billed charges for outpatient setting,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,143.87,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,94,100,,,Fee Schedule,100% of Custom Fee Schedule,17870.18,90,,14296.14,percent of total billed charges,90% of total billed charges for outpatient setting,94,17870.18,
TERAZOSIN (HYTRIN) CAP : 1MG,3302056,CDM,259,RC,,,Outpatient,,,4.92,4.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,84.88,,3.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.46,50,,1.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.69,75,,2.95,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,80,,3.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.2,65,,2.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.43,90,,3.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.63,4.43,
TERAZOSIN (HYTRIN) CAP : 1MG,3302055,CDM,259,RC,,,Outpatient,,,5.87,5.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.11,70,,3.29,percent of total billed charges,70% of total billed charges for outpatient setting,4.98,84.88,,3.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.94,50,,2.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.4,75,,3.52,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,70,,3.29,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,80,,3.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,0.75,12.84,,0.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.82,65,,3.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.05,35,,1.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.28,90,,4.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.75,5.28,
TERAZOSIN (HYTRIN) CAP : 2MG,3302057,CDM,259,RC,,,Outpatient,,,4.92,4.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,84.88,,3.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.46,50,,1.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.69,75,,2.95,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,80,,3.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.2,65,,2.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.43,90,,3.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.63,4.43,
TERAZOSIN (HYTRIN) CAP : 5MG,3302054,CDM,259,RC,,,Outpatient,,,5.12,5.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,84.88,,3.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.56,50,,2.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.84,75,,3.07,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,80,,3.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,0.66,12.84,,0.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.33,65,,2.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,35,,1.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.61,90,,3.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.66,4.61,
TERAZOSIN (HYTRIN) CAP : 5MG UD,3302058,CDM,259,RC,,,Outpatient,,,4.92,4.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,84.88,,3.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.46,50,,1.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.69,75,,2.95,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,70,,2.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,80,,3.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.63,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.2,65,,2.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,35,,1.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.43,90,,3.54,percent of total billed charges,90% of total billed charges for outpatient setting,0.63,4.43,
TERBUTALINE(BRETHINE):1 MG/ML,3302773,CDM,250,RC,,,Outpatient,,,152.58,152.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.81,70,,85.45,percent of total billed charges,70% of total billed charges for outpatient setting,129.51,84.88,,103.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,76.29,50,,61.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.44,75,,91.55,percent of total billed charges,75% of total billed charges for outpatient setting,106.81,70,,85.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,12.84,,15.672,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.06,80,,97.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,12.84,,15.67,percent of total billed charges,12.84% of total billed charges,19.59,12.84,,15.67,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,99.18,65,,79.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.4,35,,42.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.32,90,,109.86,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,137.32,
TERCONAZOLE  (TERCONAZOLE-3)W/APL,3303320,CDM,259,RC,,,Outpatient,,,46.5,46.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,70,,26.04,percent of total billed charges,70% of total billed charges for outpatient setting,39.47,84.88,,31.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,50,,18.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,75,,27.9,percent of total billed charges,75% of total billed charges for outpatient setting,32.55,70,,26.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,80,,29.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,5.97,12.84,,4.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.23,65,,24.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.28,35,,13.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,41.85,
TESSALON PERLES CAP: 100MG,3303339,CDM,259,RC,,,Outpatient,,,10.32,10.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,8.76,84.88,,7.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.16,50,,4.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.74,75,,6.19,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,80,,6.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.71,65,,5.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,35,,2.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.29,90,,7.43,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,9.29,
TESSALON PERLES: 200MG,3302928,CDM,259,RC,,,Outpatient,,,10.32,10.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,8.76,84.88,,7.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.16,50,,4.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.74,75,,6.19,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,80,,6.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.71,65,,5.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,35,,2.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.29,90,,7.43,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,9.29,
TEST GASTRIC EMPTYING BREATH / GEBT,71000254,CDM,272,RC,,,Outpatient,,,2187.5,2187.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.25,70,,1225,percent of total billed charges,70% of total billed charges for outpatient setting,1856.75,84.88,,1485.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,1093.75,50,,875,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1640.63,75,,1312.5,percent of total billed charges,75% of total billed charges for outpatient setting,1531.25,70,,1225,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.88,12.84,,224.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,80,,1400,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.88,12.84,,224.7,percent of total billed charges,12.84% of total billed charges,280.88,12.84,,224.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1421.88,65,,1137.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.63,35,,612.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1968.75,90,,1575,percent of total billed charges,90% of total billed charges for outpatient setting,280.88,1968.75,
"TESTOSTERONE, TOTAL FEMALE OR CHILD",220298,CDM,300,RC,84403,HCPCS,Outpatient,,,116.15,104.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,84.88,,78.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,87.11,75,,69.69,percent of total billed charges,75% of total billed charges for outpatient setting,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.92,80,,74.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,100% of Custom Fee Schedule,104.54,90,,83.63,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,104.54,
"TESTOSTERONE,FREE,FEMALE OR CHILD",220299,CDM,301,RC,84402,HCPCS,Outpatient,,,114.62,103.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.23,70,,64.18,percent of total billed charges,70% of total billed charges for outpatient setting,97.29,84.88,,77.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.97,75,,68.78,percent of total billed charges,75% of total billed charges for outpatient setting,80.23,70,,64.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.7,80,,73.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,100,,,Fee Schedule,100% of Custom Fee Schedule,103.16,90,,82.53,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,103.16,
"TESTOSTERONE,MALE",220297,CDM,300,RC,84403,HCPCS,Outpatient,,,116.15,104.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,84.88,,78.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,87.11,75,,69.69,percent of total billed charges,75% of total billed charges for outpatient setting,81.31,70,,65.05,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.92,80,,74.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,100% of Custom Fee Schedule,104.54,90,,83.63,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,104.54,
"TESTOSTERONE,TOTAL/FREE AND WEAKLY BOUND",220289,CDM,300,RC,84410,HCPCS,Outpatient,,,230.76,207.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.53,70,,129.22,percent of total billed charges,70% of total billed charges for outpatient setting,195.87,84.88,,156.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,88.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,173.07,75,,138.46,percent of total billed charges,75% of total billed charges for outpatient setting,161.53,70,,129.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.61,80,,147.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,72.55,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.67,100,,,Fee Schedule,100% of Custom Fee Schedule,207.68,90,,166.14,percent of total billed charges,90% of total billed charges for outpatient setting,51.28,207.68,
"TESTOSTERONE,TOTAL/FREE MALE",220751,CDM,301,RC,84402,HCPCS,Outpatient,,,114.62,103.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.23,70,,64.18,percent of total billed charges,70% of total billed charges for outpatient setting,97.29,84.88,,77.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.74,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,85.97,75,,68.78,percent of total billed charges,75% of total billed charges for outpatient setting,80.23,70,,64.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.7,80,,73.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,37.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,100,,,Fee Schedule,100% of Custom Fee Schedule,103.16,90,,82.53,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,103.16,
TETANUS ANTITOXOID ANTIBODIES,220874,CDM,302,RC,86317,HCPCS,Outpatient,,,67.46,60.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,57.26,84.88,,45.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.6,75,,40.48,percent of total billed charges,75% of total billed charges for outpatient setting,47.22,70,,37.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.97,80,,43.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.89,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.43,100,,,Fee Schedule,100% of Custom Fee Schedule,60.71,90,,48.57,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,60.71,
TETANUS DT ADULT 0.5ML SINGLE DOSE,3303324,CDM,636,RC,90714,HCPCS,Outpatient,,,55.86,55.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,47.41,84.88,,37.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,41.9,75,,33.52,percent of total billed charges,75% of total billed charges for outpatient setting,39.1,70,,31.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.17,12.84,,5.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.69,80,,35.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.17,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,7.17,12.84,,5.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.31,65,,29.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,100% of Custom Fee Schedule,50.27,90,,40.22,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,50.27,
TETANUS DT ADULT MDV :5ML,3302059,CDM,250,RC,90714,HCPCS,Outpatient,,,282.05,282.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.44,70,,157.95,percent of total billed charges,70% of total billed charges for outpatient setting,239.4,84.88,,191.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,211.54,75,,169.23,percent of total billed charges,75% of total billed charges for outpatient setting,197.44,70,,157.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.22,12.84,,28.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.64,80,,180.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.22,12.84,,28.98,percent of total billed charges,12.84% of total billed charges,36.22,12.84,,28.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,183.33,65,,146.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,100% of Custom Fee Schedule,253.85,90,,203.08,percent of total billed charges,90% of total billed charges for outpatient setting,26.37,253.85,
TETANUS TOXOID MDV :5ML,3302060,CDM,250,RC,90703,HCPCS,Outpatient,,,95.28,95.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.7,70,,53.36,percent of total billed charges,70% of total billed charges for outpatient setting,80.87,84.88,,64.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.64,50,,38.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.46,75,,57.17,percent of total billed charges,75% of total billed charges for outpatient setting,66.7,70,,53.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.23,12.84,,9.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.22,80,,60.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.23,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,12.23,12.84,,9.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.93,65,,49.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.35,35,,26.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,85.75,90,,68.6,percent of total billed charges,90% of total billed charges for outpatient setting,12.23,85.75,
TETRACAINE (PONOTAINE)OPTH SOL 0.5%:1ML,3302063,CDM,259,RC,,,Outpatient,,,14.15,14.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,84.88,,9.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.08,50,,5.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.61,75,,8.49,percent of total billed charges,75% of total billed charges for outpatient setting,9.91,70,,7.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,80,,9.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.82,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.2,65,,7.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,35,,3.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.74,90,,10.19,percent of total billed charges,90% of total billed charges for outpatient setting,1.82,12.74,
TETRACAINE (PONTOCAINE) OPTH SOL 2%:30ML,3302061,CDM,259,RC,,,Outpatient,,,41.08,41.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.76,70,,23.01,percent of total billed charges,70% of total billed charges for outpatient setting,34.87,84.88,,27.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.54,50,,16.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.81,75,,24.65,percent of total billed charges,75% of total billed charges for outpatient setting,28.76,70,,23.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.27,12.84,,4.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.86,80,,26.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.27,12.84,,4.22,percent of total billed charges,12.84% of total billed charges,5.27,12.84,,4.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.7,65,,21.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.38,35,,11.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.97,90,,29.58,percent of total billed charges,90% of total billed charges for outpatient setting,5.27,36.97,
TETRACAINE (PONTOCAINE)OPTH 0.5%:2ML,3302062,CDM,259,RC,,,Outpatient,,,14.27,14.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,84.88,,9.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.14,50,,5.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.7,75,,8.56,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,80,,9.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,1.83,12.84,,1.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.28,65,,7.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.99,35,,3.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.84,90,,10.27,percent of total billed charges,90% of total billed charges for outpatient setting,1.83,12.84,
TETRACAINE (TETRAVISC) 0.5% 0.6ML,3312975,CDM,259,RC,,,Outpatient,,,59.46,59.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.62,70,,33.3,percent of total billed charges,70% of total billed charges for outpatient setting,50.47,84.88,,40.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.73,50,,23.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,75,,35.68,percent of total billed charges,75% of total billed charges for outpatient setting,41.62,70,,33.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,12.84,,6.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.57,80,,38.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,12.84,,6.1,percent of total billed charges,12.84% of total billed charges,7.63,12.84,,6.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.65,65,,30.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.81,35,,16.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.51,90,,42.81,percent of total billed charges,90% of total billed charges for outpatient setting,7.63,53.51,
TETRACAINE LOLLIPOP:0.5%,3303282,CDM,259,RC,,,Outpatient,,,31.23,31.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,70,,17.49,percent of total billed charges,70% of total billed charges for outpatient setting,26.51,84.88,,21.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.62,50,,12.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.42,75,,18.74,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,70,,17.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,12.84,,3.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,80,,19.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,12.84,,3.21,percent of total billed charges,12.84% of total billed charges,4.01,12.84,,3.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.3,65,,16.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.93,35,,8.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.11,90,,22.49,percent of total billed charges,90% of total billed charges for outpatient setting,4.01,28.11,
TETRACAINE OPHTH 0.5% 4ML(TETRAVISC GEN),3303189,CDM,259,RC,,,Outpatient,,,69.87,69.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.91,70,,39.13,percent of total billed charges,70% of total billed charges for outpatient setting,59.31,84.88,,47.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,34.94,50,,27.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,75,,41.92,percent of total billed charges,75% of total billed charges for outpatient setting,48.91,70,,39.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,12.84,,7.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.9,80,,44.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,12.84,,7.18,percent of total billed charges,12.84% of total billed charges,8.97,12.84,,7.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.42,65,,36.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,35,,19.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,62.88,90,,50.3,percent of total billed charges,90% of total billed charges for outpatient setting,8.97,62.88,
TETRACYC/BIS SS/METRONID (HELIDAC):PAC,3303217,CDM,259,RC,,,Outpatient,,,957.93,957.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.55,70,,536.44,percent of total billed charges,70% of total billed charges for outpatient setting,813.09,84.88,,650.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,478.97,50,,383.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,718.45,75,,574.76,percent of total billed charges,75% of total billed charges for outpatient setting,670.55,70,,536.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,12.84,,98.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.34,80,,613.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,12.84,,98.4,percent of total billed charges,12.84% of total billed charges,123,12.84,,98.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,622.65,65,,498.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.28,35,,268.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,862.14,90,,689.71,percent of total billed charges,90% of total billed charges for outpatient setting,123,862.14,
TETRACYCLINE (SUMYCIN) CAP : 250MG,3302064,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TETRACYCLINE (SUMYCIN) CAP : 250MG UD,3302065,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TETRACYCLINE: 250 MG,3309629,CDM,259,RC,,,Outpatient,,,42.57,42.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.8,70,,23.84,percent of total billed charges,70% of total billed charges for outpatient setting,36.13,84.88,,28.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.29,50,,17.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.93,75,,25.54,percent of total billed charges,75% of total billed charges for outpatient setting,29.8,70,,23.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.06,80,,27.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,5.47,12.84,,4.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.67,65,,22.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.9,35,,11.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.31,90,,30.65,percent of total billed charges,90% of total billed charges for outpatient setting,5.47,38.31,
TETRACYCLINE: 500 MG,3303159,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
TETRAHYDROZOLINE 0.05% (VISINE): 15ML,3303025,CDM,259,RC,,,Outpatient,,,13.69,13.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,11.62,84.88,,9.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.85,50,,5.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.27,75,,8.22,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,70,,7.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.95,80,,8.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.9,65,,7.12,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.79,35,,3.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.32,90,,9.86,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.32,
TEVETEN HCT: 600 MG/12.5 MG,3302999,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
"THALLIUM,URINE",201648,CDM,301,RC,81000,HCPCS,Outpatient,,,18.09,16.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,70,,10.13,percent of total billed charges,70% of total billed charges for outpatient setting,15.35,84.88,,12.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,13.57,75,,10.86,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,70,,10.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.47,80,,11.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,100% of Custom Fee Schedule,16.28,90,,13.02,percent of total billed charges,90% of total billed charges for outpatient setting,3.94,16.28,
THAW BLOOD UNIT,1000285,CDM,390,RC,86931,HCPCS,Outpatient,,,217.39,217.39,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,152.17,70,,121.74,percent of total billed charges,70% of total billed charges for outpatient setting,184.52,84.88,,147.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,163.04,75,,130.43,percent of total billed charges,75% of total billed charges for outpatient setting,152.17,70,,121.74,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,27.91,12.84,,22.328,percent of total billed charges,12.84% of total billed charges,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.91,80,,139.13,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,27.91,12.84,,22.33,percent of total billed charges,12.84% of total billed charges,27.91,12.84,,22.33,percent of total billed charges,12.84% of total billed charges,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,141.3,65,,113.04,percent of total billed charges,65% of total billed charges for outpatient setting,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,71.92,100,,,Fee Schedule,100% of Custom Fee Schedule,195.65,90,,156.52,percent of total billed charges,90% of total billed charges for outpatient setting,27.91,561.12,
THEOPHYLLINE,200865,CDM,300,RC,80198,HCPCS,Outpatient,,,63.63,57.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,54.01,84.88,,43.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.72,75,,38.18,percent of total billed charges,75% of total billed charges for outpatient setting,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.9,80,,40.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.83,100,,,Fee Schedule,100% of Custom Fee Schedule,57.27,90,,45.82,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,57.27,
THEOPHYLLINE,220037,CDM,300,RC,80198,HCPCS,Outpatient,,,63.63,57.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,54.01,84.88,,43.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.72,75,,38.18,percent of total billed charges,75% of total billed charges for outpatient setting,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.9,80,,40.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.83,100,,,Fee Schedule,100% of Custom Fee Schedule,57.27,90,,45.82,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,57.27,
THEOPHYLLINE (ELIXOPHYLIN)ELX 80MG/15ML:,3302066,CDM,259,RC,,,Outpatient,,,17.55,17.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,84.88,,11.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.78,50,,7.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.16,75,,10.53,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,70,,9.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.04,80,,11.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,2.25,12.84,,1.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.41,65,,9.13,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,35,,4.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.8,90,,12.64,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,15.8,
THEOPHYLLINE (THEO-DUR)  TAB : 300MG UD,3302071,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
THEOPHYLLINE (THEO-DUR) TAB : 100MG UD,3304000,CDM,259,RC,,,Outpatient,,,12.99,12.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,11.03,84.88,,8.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.5,50,,5.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.74,75,,7.79,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.39,80,,8.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.44,65,,6.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,35,,3.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.69,90,,9.35,percent of total billed charges,90% of total billed charges for outpatient setting,1.67,11.69,
THEOPHYLLINE (THEO-DUR) TAB : 200MG,3302067,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
THEOPHYLLINE (THEO-DUR) TAB : 200MG UD,3302069,CDM,259,RC,,,Outpatient,,,12.99,12.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,11.03,84.88,,8.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.5,50,,5.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.74,75,,7.79,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,70,,7.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.39,80,,8.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,1.67,12.84,,1.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.44,65,,6.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,35,,3.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.69,90,,9.35,percent of total billed charges,90% of total billed charges for outpatient setting,1.67,11.69,
THEOPHYLLINE (THEO-DUR) TAB : 300MG UD,3302068,CDM,259,RC,,,Outpatient,,,12.47,12.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,10.58,84.88,,8.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.24,50,,4.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.35,75,,7.48,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,70,,6.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.98,80,,7.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,1.6,12.84,,1.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.11,65,,6.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.36,35,,3.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.22,90,,8.98,percent of total billed charges,90% of total billed charges for outpatient setting,1.6,11.22,
THEOPHYLLINE (UNIPHYL) TAB : 400MG,3302070,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
THEOPHYLLINE QUANT,201270,CDM,300,RC,80198,HCPCS,Outpatient,,,63.63,57.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,54.01,84.88,,43.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.28,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.72,75,,38.18,percent of total billed charges,75% of total billed charges for outpatient setting,44.54,70,,35.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.9,80,,40.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.66,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.83,100,,,Fee Schedule,100% of Custom Fee Schedule,57.27,90,,45.82,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,57.27,
THERAPEUTIC ENEMA CONTRAST OR AIR,2400655,CDM,320,RC,74283,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
THERMACHOICE CATHETER (SINGLE),69159937,CDM,272,RC,,,Outpatient,,,10491.12,10491.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7343.78,70,,5875.02,percent of total billed charges,70% of total billed charges for outpatient setting,8904.86,84.88,,7123.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,5245.56,50,,4196.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7868.34,75,,6294.67,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.06,12.84,,1077.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8392.9,80,,6714.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.06,12.84,,1077.65,percent of total billed charges,12.84% of total billed charges,1347.06,12.84,,1077.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6819.23,65,,5455.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3671.89,35,,2937.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9442.01,90,,7553.61,percent of total billed charges,90% of total billed charges for outpatient setting,1347.06,9442.01,
THERMAPLINT LG DENVER,6150725,CDM,270,RC,,,Outpatient,,,168.71,168.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.1,70,,94.48,percent of total billed charges,70% of total billed charges for outpatient setting,143.2,84.88,,114.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.36,50,,67.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.53,75,,101.22,percent of total billed charges,75% of total billed charges for outpatient setting,118.1,70,,94.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.66,12.84,,17.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.97,80,,107.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.66,12.84,,17.33,percent of total billed charges,12.84% of total billed charges,21.66,12.84,,17.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,109.66,65,,87.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.05,35,,47.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,151.84,90,,121.47,percent of total billed charges,90% of total billed charges for outpatient setting,21.66,151.84,
THERMAPLINT SM/MED DENVER / 10-4021-05KS,6150724,CDM,270,RC,,,Outpatient,,,232.2,232.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.54,70,,130.03,percent of total billed charges,70% of total billed charges for outpatient setting,197.09,84.88,,157.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,116.1,50,,92.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,75,,139.32,percent of total billed charges,75% of total billed charges for outpatient setting,162.54,70,,130.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.81,12.84,,23.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.76,80,,148.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.81,12.84,,23.85,percent of total billed charges,12.84% of total billed charges,29.81,12.84,,23.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.93,65,,120.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.27,35,,65.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,208.98,90,,167.18,percent of total billed charges,90% of total billed charges for outpatient setting,29.81,208.98,
THIAMINE (B-1) 100MG TAB,3303172,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
THIAMINE 100MG/ML: INJ.,3302931,CDM,636,RC,J3411,HCPCS,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.79,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,100,,,Fee Schedule,100% of Custom Fee Schedule,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
THIOPENTAL (PENTOTHAL) INJ : 500MG,3302073,CDM,250,RC,,,Outpatient,,,42.35,42.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.65,70,,23.72,percent of total billed charges,70% of total billed charges for outpatient setting,35.95,84.88,,28.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.18,50,,16.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.76,75,,25.41,percent of total billed charges,75% of total billed charges for outpatient setting,29.65,70,,23.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.44,12.84,,4.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,80,,27.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.44,12.84,,4.35,percent of total billed charges,12.84% of total billed charges,5.44,12.84,,4.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.53,65,,22.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,35,,11.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,38.12,90,,30.5,percent of total billed charges,90% of total billed charges for outpatient setting,5.44,38.12,
THIORIDAZINE (MELLARIL) TAB : 10MG,3302074,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
THIORIDAZINE (MELLARIL) TAB : 25MG,3302075,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
THIOTHIXENE (NAVANE) CAP : 1MG UD,3302076,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
THIOTHIXENE(NAVANE) : 10 MG,3302846,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
THREE IN ONE OPHTH DROP 0.5 ML DROPPER,3309610,CDM,250,RC,,,Outpatient,,,58.8,58.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.16,70,,32.93,percent of total billed charges,70% of total billed charges for outpatient setting,49.91,84.88,,39.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.4,50,,23.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.1,75,,35.28,percent of total billed charges,75% of total billed charges for outpatient setting,41.16,70,,32.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,80,,37.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,7.55,12.84,,6.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.22,65,,30.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.58,35,,16.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.92,90,,42.34,percent of total billed charges,90% of total billed charges for outpatient setting,7.55,52.92,
THROMBIN  THROMBIN JMI)5000 IU  VIAL,3302606,CDM,250,RC,,,Outpatient,,,236.2,236.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.34,70,,132.27,percent of total billed charges,70% of total billed charges for outpatient setting,200.49,84.88,,160.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.1,50,,94.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.15,75,,141.72,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,70,,132.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.96,80,,151.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,30.33,12.84,,24.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,153.53,65,,122.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.67,35,,66.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,212.58,90,,170.06,percent of total billed charges,90% of total billed charges for outpatient setting,30.33,212.58,
THROMBIN (RECOTHROM) 5000 UNIT  VIAL,3310132,CDM,250,RC,,,Outpatient,,,226.96,226.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.87,70,,127.1,percent of total billed charges,70% of total billed charges for outpatient setting,192.64,84.88,,154.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.48,50,,90.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.22,75,,136.18,percent of total billed charges,75% of total billed charges for outpatient setting,158.87,70,,127.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.14,12.84,,23.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,80,,145.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.14,12.84,,23.31,percent of total billed charges,12.84% of total billed charges,29.14,12.84,,23.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.52,65,,118.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.44,35,,63.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.26,90,,163.41,percent of total billed charges,90% of total billed charges for outpatient setting,29.14,204.26,
THROMBIN (THROMBIN-JMI) SDV 10000U :,3302077,CDM,250,RC,,,Outpatient,,,291.12,291.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.78,70,,163.02,percent of total billed charges,70% of total billed charges for outpatient setting,247.1,84.88,,197.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,145.56,50,,116.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.34,75,,174.67,percent of total billed charges,75% of total billed charges for outpatient setting,203.78,70,,163.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.9,80,,186.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,37.38,12.84,,29.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,189.23,65,,151.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.89,35,,81.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,262.01,90,,209.61,percent of total billed charges,90% of total billed charges for outpatient setting,37.38,262.01,
THROMBIN BOVINEGELATIN  FLOSEAL,3373782,CDM,250,RC,,,Outpatient,,,817.58,817.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.31,70,,457.85,percent of total billed charges,70% of total billed charges for outpatient setting,693.96,84.88,,555.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,408.79,50,,327.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.19,75,,490.55,percent of total billed charges,75% of total billed charges for outpatient setting,572.31,70,,457.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,12.84,,83.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.06,80,,523.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.98,12.84,,83.98,percent of total billed charges,12.84% of total billed charges,104.98,12.84,,83.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,531.43,65,,425.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.15,35,,228.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,735.82,90,,588.66,percent of total billed charges,90% of total billed charges for outpatient setting,104.98,735.82,
THROMBIN TIME; PLASMA,200713,CDM,305,RC,85670,HCPCS,Outpatient,,,25.97,23.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.18,70,,14.54,percent of total billed charges,70% of total billed charges for outpatient setting,22.04,84.88,,17.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.48,75,,15.58,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,70,,14.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.78,80,,16.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.44,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,100,,,Fee Schedule,100% of Custom Fee Schedule,23.37,90,,18.7,percent of total billed charges,90% of total billed charges for outpatient setting,5.77,23.37,
THROMBOPLASTIN TIME;SUBSTITUTION,200716,CDM,305,RC,85732,HCPCS,Outpatient,,,29.12,26.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,24.72,84.88,,19.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.84,75,,17.47,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,70,,16.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.3,80,,18.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,100,,,Fee Schedule,100% of Custom Fee Schedule,26.21,90,,20.97,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,26.21,
THYROGLOBULIN AB AND THYROGLOBULIN,220912,CDM,302,RC,86800,HCPCS,Outpatient,,,71.6,64.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,60.77,84.88,,48.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.7,75,,42.96,percent of total billed charges,75% of total billed charges for outpatient setting,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,80,,45.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,100,,,Fee Schedule,100% of Custom Fee Schedule,64.44,90,,51.55,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,64.44,
THYROGLOBULIN BY LCMS,221911,CDM,302,RC,86800,HCPCS,Outpatient,,,71.6,64.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,60.77,84.88,,48.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.32,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,53.7,75,,42.96,percent of total billed charges,75% of total billed charges for outpatient setting,50.12,70,,40.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,80,,45.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,100,,,Fee Schedule,100% of Custom Fee Schedule,64.44,90,,51.55,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,64.44,
THYROGLOBULIN COMPREHENSIVE,220826,CDM,301,RC,84432,HCPCS,Outpatient,,,72.27,65.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.59,70,,40.47,percent of total billed charges,70% of total billed charges for outpatient setting,61.34,84.88,,49.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.58,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.2,75,,43.36,percent of total billed charges,75% of total billed charges for outpatient setting,50.59,70,,40.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.82,80,,46.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.45,100,,,Fee Schedule,100% of Custom Fee Schedule,65.04,90,,52.03,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,65.04,
THYROID PEROXIDASE ANTIBODY,220354,CDM,302,RC,86376,HCPCS,Outpatient,,,65.48,58.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,70,,36.67,percent of total billed charges,70% of total billed charges for outpatient setting,55.58,84.88,,44.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.98,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,49.11,75,,39.29,percent of total billed charges,75% of total billed charges for outpatient setting,45.84,70,,36.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.38,80,,41.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.25,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.59,100,,,Fee Schedule,100% of Custom Fee Schedule,58.93,90,,47.14,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,58.93,
THYROID STIMULATING IMMUNOGLOBULIN,220638,CDM,301,RC,84445,HCPCS,Outpatient,,,228.87,205.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.21,70,,128.17,percent of total billed charges,70% of total billed charges for outpatient setting,194.26,84.88,,155.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,87.31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,171.65,75,,137.32,percent of total billed charges,75% of total billed charges for outpatient setting,160.21,70,,128.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.1,80,,146.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,74.24,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.9,100,,,Fee Schedule,100% of Custom Fee Schedule,205.98,90,,164.78,percent of total billed charges,90% of total billed charges for outpatient setting,22.43,205.98,
THYROID TAB 30MG,3302078,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
THYROID TAB 60MG,3304757,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TIAGABINE 4MG TABS (GABATRIL),3304725,CDM,259,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,70,,11.76,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,84.88,,14.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.5,50,,8.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,75,,12.6,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,70,,11.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,12.84,,2.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,80,,13.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,12.84,,2.16,percent of total billed charges,12.84% of total billed charges,2.7,12.84,,2.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.65,65,,10.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,35,,5.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.9,90,,15.12,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,18.9,
TIAZAC 240MG: CAP,3302900,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TIB/FIB 2 VWS BIL,2400412,CDM,320,RC,73590,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
TIB/FIB 2 VWS LEFT,2400411,CDM,320,RC,73590,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TIB/FIB 2 VWS RIGHT,2400410,CDM,320,RC,73590,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TIBIA  SZ 3 LEFT STEMD/ 5980-37-01,69169578,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA  SZ C LEFT STEMD/ 42-5320-064-01,69169563,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA  SZ C RIGHT STEMD/42-5320-064-02,69169632,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA  SZ D LEFT STEMD / 42-5320-067-01,69169472,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA 14MM 6-9 RT PRSNA / 42-5226-007-14,71000145,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIA 16MM 12GH R PRSNA / 42-5226-010-16,71000245,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIA COMP SZ 8G LEFT /42-5320-079-01,69169225,CDM,272,RC,,,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1791.56,65,,1433.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2480.63,90,,1984.5,percent of total billed charges,90% of total billed charges for outpatient setting,353.9,2480.63,
TIBIA COMP SZ E LEFT/42-5320-071-01,69169470,CDM,278,RC,,,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA COMP SZ E RIGHT/42-5320-071-02,69169415,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA COMP SZ F LEFT/42-5320-075-01,69169484,CDM,278,RC,,,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA COMP SZ F RIGHT/42-5320-075-02,69169369,CDM,278,RC,,,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIA COMP SZ G RIGHT /42-5320-079-02,69169582,CDM,272,RC,,,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1791.56,65,,1433.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2480.63,90,,1984.5,percent of total billed charges,90% of total billed charges for outpatient setting,353.9,2480.63,
TIBIA COMP SZ H LEFT /42-5320-083-01,69169682,CDM,272,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1791.56,65,,1433.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2480.63,90,,1984.5,percent of total billed charges,90% of total billed charges for outpatient setting,353.9,2480.63,
TIBIA COMP SZ H RIGHT /42-5320-083-02,69169513,CDM,272,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1929.38,70,,1543.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1791.56,65,,1433.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2480.63,90,,1984.5,percent of total billed charges,90% of total billed charges for outpatient setting,353.9,2480.63,
TIBIA SZ D RIGHT STEMD / 42-5320-067-02,69169435,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756.25,2756.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.75,60,,1323,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.51,84.88,,1871.61,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.19,75,,1653.75,percent of total billed charges,75% of total billed charges for outpatient setting,1378.13,50,,1102.5,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,80,,1764,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,353.9,12.84,,283.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2894.06,105,,2315.25,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.69,35,,771.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.75,60,,1323,percent of total billed charges,60% of total billed charges for outpatient setting,353.9,2894.06,
TIBIAL   SZ C RT MED OXF PRT KNE 154723,69169292,CDM,278,RC,C1776,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
TIBIAL  INSERT SZ 6  CR/ 5530-G-609-E,69169766,CDM,278,RC,C1776,HCPCS,Outpatient,,,2268,2268,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.8,60,,1088.64,percent of total billed charges,60% of total Billed charges for outpatient setting,1925.08,84.88,,1540.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1701,75,,1360.8,percent of total billed charges,75% of total billed charges for outpatient setting,1134,50,,907.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1814.4,80,,1451.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,291.21,12.84,,232.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2381.4,105,,1905.12,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.8,35,,635.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1360.8,60,,1088.64,percent of total billed charges,60% of total billed charges for outpatient setting,291.21,2381.4,
TIBIAL  INSERT SZ 6  CR/ 5530-G-610-E,69169741,CDM,278,RC,C1776,HCPCS,Outpatient,,,3568.43,3568.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2141.06,60,,1712.85,percent of total billed charges,60% of total Billed charges for outpatient setting,3028.88,84.88,,2423.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2676.32,75,,2141.06,percent of total billed charges,75% of total billed charges for outpatient setting,1784.22,50,,1427.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.19,12.84,,366.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2854.74,80,,2283.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.19,12.84,,366.55,percent of total billed charges,12.84% of total billed charges,458.19,12.84,,366.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3746.85,105,,2997.48,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248.95,35,,999.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2141.06,60,,1712.85,percent of total billed charges,60% of total billed charges for outpatient setting,458.19,3746.85,
TIBIAL  INSERT SZ 7    CR/ 5530-G-710-E,69169763,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
TIBIAL  SZ D  LFT MED OXF PRT KNE 154724,69162280,CDM,278,RC,C1776,HCPCS,Outpatient,,,2762,2762,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1657.2,60,,1325.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2344.39,84.88,,1875.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2071.5,75,,1657.2,percent of total billed charges,75% of total billed charges for outpatient setting,1381,50,,1104.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.64,12.84,,283.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2209.6,80,,1767.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.64,12.84,,283.71,percent of total billed charges,12.84% of total billed charges,354.64,12.84,,283.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2900.1,105,,2320.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.7,35,,773.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1657.2,60,,1325.76,percent of total billed charges,60% of total billed charges for outpatient setting,354.64,2900.1,
TIBIAL  SZ D  RIGHT MED OXF KNEE 154725,69162943,CDM,278,RC,C1776,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
TIBIAL  TRAY SZ 3 / 1294-35-130,69169650,CDM,278,RC,C1776,HCPCS,Outpatient,,,8541,8541,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5124.6,60,,4099.68,percent of total billed charges,60% of total Billed charges for outpatient setting,7249.6,84.88,,5799.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6405.75,75,,5124.6,percent of total billed charges,75% of total billed charges for outpatient setting,4270.5,50,,3416.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.66,12.84,,877.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6832.8,80,,5466.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.66,12.84,,877.33,percent of total billed charges,12.84% of total billed charges,1096.66,12.84,,877.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8968.05,105,,7174.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2989.35,35,,2391.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5124.6,60,,4099.68,percent of total billed charges,60% of total billed charges for outpatient setting,1096.66,8968.05,
TIBIAL BASE 2 LEFT / 71420162,69161720,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIAL BASE 3 LT / 71420164,69161291,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIAL BASE 3 RIGHT / 71420182,69161175,CDM,278,RC,C1776,HCPCS,Outpatient,,,2887.45,2887.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1732.47,60,,1385.98,percent of total billed charges,60% of total Billed charges for outpatient setting,2450.87,84.88,,1960.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2165.59,75,,1732.47,percent of total billed charges,75% of total billed charges for outpatient setting,1443.73,50,,1154.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.75,12.84,,296.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2309.96,80,,1847.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.75,12.84,,296.6,percent of total billed charges,12.84% of total billed charges,370.75,12.84,,296.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3031.82,105,,2425.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1010.61,35,,808.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1732.47,60,,1385.98,percent of total billed charges,60% of total billed charges for outpatient setting,370.75,3031.82,
TIBIAL BASE 7 LEFT / 71420172,69161211,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIAL BASE GNS 4 RT / 71420184,69161112,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL BASE, 1 LEFT  71420160",69162096,CDM,278,RC,C1776,HCPCS,Outpatient,,,3042.9,3042.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1825.74,60,,1460.59,percent of total billed charges,60% of total Billed charges for outpatient setting,2582.81,84.88,,2066.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2282.18,75,,1825.74,percent of total billed charges,75% of total billed charges for outpatient setting,1521.45,50,,1217.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.71,12.84,,312.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.32,80,,1947.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.71,12.84,,312.57,percent of total billed charges,12.84% of total billed charges,390.71,12.84,,312.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3195.05,105,,2556.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.02,35,,852.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1825.74,60,,1460.59,percent of total billed charges,60% of total billed charges for outpatient setting,390.71,3195.05,
"TIBIAL BASE, 2 RIGHT  71420182",69161585,CDM,278,RC,C1776,HCPCS,Outpatient,,,3480.36,3480.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2088.22,60,,1670.58,percent of total billed charges,60% of total Billed charges for outpatient setting,2954.13,84.88,,2363.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2610.27,75,,2088.22,percent of total billed charges,75% of total billed charges for outpatient setting,1740.18,50,,1392.14,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.88,12.84,,357.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2784.29,80,,2227.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.88,12.84,,357.5,percent of total billed charges,12.84% of total billed charges,446.88,12.84,,357.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3654.38,105,,2923.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.13,35,,974.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2088.22,60,,1670.58,percent of total billed charges,60% of total billed charges for outpatient setting,446.88,3654.38,
"TIBIAL BASE, 5 RIGHT  71420186",69161105,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL BASE, 5 RIGHT  71420186",69161116,CDM,278,RC,C1776,HCPCS,Outpatient,,,2530,2530,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518,60,,1214.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2147.46,84.88,,1717.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1897.5,75,,1518,percent of total billed charges,75% of total billed charges for outpatient setting,1265,50,,1012,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2024,80,,1619.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2656.5,105,,2125.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.5,35,,708.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1518,60,,1214.4,percent of total billed charges,60% of total billed charges for outpatient setting,324.85,2656.5,
"TIBIAL BASE, 6 LEFT  71420170",69161126,CDM,278,RC,C1776,HCPCS,Outpatient,,,2656.5,2656.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1593.9,60,,1275.12,percent of total billed charges,60% of total Billed charges for outpatient setting,2254.84,84.88,,1803.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1992.38,75,,1593.9,percent of total billed charges,75% of total billed charges for outpatient setting,1328.25,50,,1062.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.09,12.84,,272.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2125.2,80,,1700.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.09,12.84,,272.87,percent of total billed charges,12.84% of total billed charges,341.09,12.84,,272.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2789.33,105,,2231.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.78,35,,743.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1593.9,60,,1275.12,percent of total billed charges,60% of total billed charges for outpatient setting,341.09,2789.33,
"TIBIAL BASE, 6 RIGHT  71420188",69161121,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL BASE, 7 LEFT Revision 71424007",69161483,CDM,278,RC,C1776,HCPCS,Outpatient,,,5985,5985,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3591,60,,2872.8,percent of total billed charges,60% of total Billed charges for outpatient setting,5080.07,84.88,,4064.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4488.75,75,,3591,percent of total billed charges,75% of total billed charges for outpatient setting,2992.5,50,,2394,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.47,12.84,,614.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4788,80,,3830.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.47,12.84,,614.78,percent of total billed charges,12.84% of total billed charges,768.47,12.84,,614.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6284.25,105,,5027.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2094.75,35,,1675.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3591,60,,2872.8,percent of total billed charges,60% of total billed charges for outpatient setting,768.47,6284.25,
"TIBIAL BASE, 7 RIGHT  71420190",69161092,CDM,278,RC,C1776,HCPCS,Outpatient,,,2530,2530,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518,60,,1214.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2147.46,84.88,,1717.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1897.5,75,,1518,percent of total billed charges,75% of total billed charges for outpatient setting,1265,50,,1012,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2024,80,,1619.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2656.5,105,,2125.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.5,35,,708.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1518,60,,1214.4,percent of total billed charges,60% of total billed charges for outpatient setting,324.85,2656.5,
"TIBIAL BASE, 8 LEFT  71420174",69161129,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL BASE, 9 LEFT  71931923",69161545,CDM,278,RC,C1776,HCPCS,Outpatient,,,7000,7000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,60,,3360,percent of total billed charges,60% of total Billed charges for outpatient setting,5941.6,84.88,,4753.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250,75,,4200,percent of total billed charges,75% of total billed charges for outpatient setting,3500,50,,2800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,80,,4480,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,898.8,12.84,,719.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7350,105,,5880,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,35,,1960,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4200,60,,3360,percent of total billed charges,60% of total billed charges for outpatient setting,898.8,7350,
"TIBIAL BASE,4 LEFT  71420166",69161144,CDM,278,RC,C1776,HCPCS,Outpatient,,,2656.5,2656.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1593.9,60,,1275.12,percent of total billed charges,60% of total Billed charges for outpatient setting,2254.84,84.88,,1803.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1992.38,75,,1593.9,percent of total billed charges,75% of total billed charges for outpatient setting,1328.25,50,,1062.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.09,12.84,,272.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2125.2,80,,1700.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.09,12.84,,272.87,percent of total billed charges,12.84% of total billed charges,341.09,12.84,,272.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2789.33,105,,2231.46,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.78,35,,743.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1593.9,60,,1275.12,percent of total billed charges,60% of total billed charges for outpatient setting,341.09,2789.33,
"TIBIAL BASE,5 LEFT  71420168",69161101,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL BASEPLATE SZ 1, RIGHT  71424011",69169199,CDM,278,RC,,,Outpatient,,,4721.96,4721.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2833.18,60,,2266.54,percent of total billed charges,60% of total Billed charges for outpatient setting,4008,84.88,,3206.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,2360.98,50,,1888.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3541.47,75,,2833.18,percent of total billed charges,75% of total billed charges for outpatient setting,2360.98,50,,1888.78,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3777.57,80,,3022.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,606.3,12.84,,485.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4958.06,105,,3966.45,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.69,35,,1322.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2833.18,60,,2266.54,percent of total billed charges,60% of total billed charges for outpatient setting,606.3,4958.06,
"TIBIAL BASEPLATE SZ 4, RIGHT  71424014",69161370,CDM,278,RC,,,Outpatient,,,5700,5700,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3420,60,,2736,percent of total billed charges,60% of total Billed charges for outpatient setting,4838.16,84.88,,3870.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,2850,50,,2280,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4275,75,,3420,percent of total billed charges,75% of total billed charges for outpatient setting,2850,50,,2280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.88,12.84,,585.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4560,80,,3648,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.88,12.84,,585.5,percent of total billed charges,12.84% of total billed charges,731.88,12.84,,585.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5985,105,,4788,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,35,,1596,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3420,60,,2736,percent of total billed charges,60% of total billed charges for outpatient setting,731.88,5985,
"TIBIAL BASEPLATE SZ 8, RIGHT  71420191",69161284,CDM,278,RC,,,Outpatient,,,2530,2530,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518,60,,1214.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2147.46,84.88,,1717.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,1265,50,,1012,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1897.5,75,,1518,percent of total billed charges,75% of total billed charges for outpatient setting,1265,50,,1012,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2024,80,,1619.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,324.85,12.84,,259.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2656.5,105,,2125.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.5,35,,708.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1518,60,,1214.4,percent of total billed charges,60% of total billed charges for outpatient setting,324.85,2656.5,
TIBIAL COMP SZ 3 / 5536-B-300,69169891,CDM,278,RC,C1776,HCPCS,Outpatient,,,2160,2160,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,60,,1036.8,percent of total billed charges,60% of total Billed charges for outpatient setting,1833.41,84.88,,1466.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,75,,1296,percent of total billed charges,75% of total billed charges for outpatient setting,1080,50,,864,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,80,,1382.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,277.34,12.84,,221.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2268,105,,1814.4,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,35,,604.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1296,60,,1036.8,percent of total billed charges,60% of total billed charges for outpatient setting,277.34,2268,
TIBIAL COMP SZ 6 / 5536-B-600,69169740,CDM,278,RC,C1776,HCPCS,Outpatient,,,2756,2756,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.6,60,,1322.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2339.29,84.88,,1871.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067,75,,1653.6,percent of total billed charges,75% of total billed charges for outpatient setting,1378,50,,1102.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.87,12.84,,283.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2204.8,80,,1763.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.87,12.84,,283.1,percent of total billed charges,12.84% of total billed charges,353.87,12.84,,283.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2893.8,105,,2315.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.6,35,,771.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1653.6,60,,1322.88,percent of total billed charges,60% of total billed charges for outpatient setting,353.87,2893.8,
"TIBIAL INSERT 3, 10MM / 96-2031",69169649,CDM,278,RC,C1776,HCPCS,Outpatient,,,3164,3164,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1898.4,60,,1518.72,percent of total billed charges,60% of total Billed charges for outpatient setting,2685.6,84.88,,2148.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2373,75,,1898.4,percent of total billed charges,75% of total billed charges for outpatient setting,1582,50,,1265.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.26,12.84,,325.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2531.2,80,,2024.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.26,12.84,,325.01,percent of total billed charges,12.84% of total billed charges,406.26,12.84,,325.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3322.2,105,,2657.76,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1107.4,35,,885.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1898.4,60,,1518.72,percent of total billed charges,60% of total billed charges for outpatient setting,406.26,3322.2,
"TIBIAL INSERT PLI 2.5, 10MM",69162112,CDM,278,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
"TIBIAL INSERT PLI 3,10MM / 1581-03-110",69162544,CDM,278,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
"TIBIAL INSERT PLI 3,12.5MM",69161988,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,60,,960,percent of total billed charges,60% of total Billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2000,65,,1600,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1200,60,,960,percent of total billed charges,60% of total billed charges for outpatient setting,256.8,2000,
TIBIAL INSERT PLI 5 10MM // 1581-05-110,70000008,CDM,278,RC,C1776,HCPCS,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
TIBIAL TRAY MEDIAL LT OXFORD UNI/154720,69162913,CDM,278,RC,C1776,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
TIBIAL TRAY MEDIAL RT OXFORD UNI/154719,69169114,CDM,278,RC,C1776,HCPCS,Outpatient,,,3000,3000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,60,,1440,percent of total billed charges,60% of total Billed charges for outpatient setting,2546.4,84.88,,2037.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250,75,,1800,percent of total billed charges,75% of total billed charges for outpatient setting,1500,50,,1200,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,80,,1920,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,385.2,12.84,,308.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3150,105,,2520,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,35,,840,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,60,,1440,percent of total billed charges,60% of total billed charges for outpatient setting,385.2,3150,
TIBIAL TRAY SZ 2.5 SIGMA,69162110,CDM,278,RC,C1776,HCPCS,Outpatient,,,2600,2600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,60,,1248,percent of total billed charges,60% of total Billed charges for outpatient setting,2206.88,84.88,,1765.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950,75,,1560,percent of total billed charges,75% of total billed charges for outpatient setting,1300,50,,1040,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2080,80,,1664,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,333.84,12.84,,267.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2730,105,,2184,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910,35,,728,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1560,60,,1248,percent of total billed charges,60% of total billed charges for outpatient setting,333.84,2730,
TIBIAL TRAY SZ 3 SIGMA /96-7507,69161986,CDM,278,RC,C1776,HCPCS,Outpatient,,,3338,3338,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.8,60,,1602.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2833.29,84.88,,2266.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2503.5,75,,2002.8,percent of total billed charges,75% of total billed charges for outpatient setting,1669,50,,1335.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2670.4,80,,2136.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3504.9,105,,2803.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.3,35,,934.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2002.8,60,,1602.24,percent of total billed charges,60% of total billed charges for outpatient setting,428.6,3504.9,
TIBIAL TRAY SZ 5 SIGMA /96-7509,70000006,CDM,278,RC,C1776,HCPCS,Outpatient,,,3338,3338,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.8,60,,1602.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2833.29,84.88,,2266.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2503.5,75,,2002.8,percent of total billed charges,75% of total billed charges for outpatient setting,1669,50,,1335.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2670.4,80,,2136.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,428.6,12.84,,342.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3504.9,105,,2803.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.3,35,,934.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2002.8,60,,1602.24,percent of total billed charges,60% of total billed charges for outpatient setting,428.6,3504.9,
TIBIAL WEDGE SZ 1-2 /10MM  71423057,69169195,CDM,278,RC,C1776,HCPCS,Outpatient,,,2708.24,2708.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624.94,60,,1299.95,percent of total billed charges,60% of total Billed charges for outpatient setting,2298.75,84.88,,1839,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2031.18,75,,1624.94,percent of total billed charges,75% of total billed charges for outpatient setting,1354.12,50,,1083.3,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.74,12.84,,278.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2166.59,80,,1733.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.74,12.84,,278.19,percent of total billed charges,12.84% of total billed charges,347.74,12.84,,278.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2843.65,105,,2274.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.88,35,,758.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1624.94,60,,1299.95,percent of total billed charges,60% of total billed charges for outpatient setting,347.74,2843.65,
TIBIAL WEDGE SZ 5-6 /10MM  71423059,69161874,CDM,278,RC,C1776,HCPCS,Outpatient,,,3456,3456,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2073.6,60,,1658.88,percent of total billed charges,60% of total Billed charges for outpatient setting,2933.45,84.88,,2346.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2592,75,,2073.6,percent of total billed charges,75% of total billed charges for outpatient setting,1728,50,,1382.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.75,12.84,,355,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2764.8,80,,2211.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.75,12.84,,355,percent of total billed charges,12.84% of total billed charges,443.75,12.84,,355,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3628.8,105,,2903.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.6,35,,967.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2073.6,60,,1658.88,percent of total billed charges,60% of total billed charges for outpatient setting,443.75,3628.8,
TIBIAL-WEDGE 5mm SZ 5-6 L-Lat  71421147,69161513,CDM,278,RC,C1776,HCPCS,Outpatient,,,3087,3087,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1852.2,60,,1481.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2620.25,84.88,,2096.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,75,,1852.2,percent of total billed charges,75% of total billed charges for outpatient setting,1543.5,50,,1234.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2469.6,80,,1975.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3241.35,105,,2593.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.45,35,,864.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1852.2,60,,1481.76,percent of total billed charges,60% of total billed charges for outpatient setting,396.37,3241.35,
TIBIAL-WEDGE 5mm SZ 5-6 RT-Lat 71421143,69161512,CDM,278,RC,C1776,HCPCS,Outpatient,,,3087,3087,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1852.2,60,,1481.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2620.25,84.88,,2096.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.25,75,,1852.2,percent of total billed charges,75% of total billed charges for outpatient setting,1543.5,50,,1234.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2469.6,80,,1975.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,396.37,12.84,,317.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3241.35,105,,2593.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.45,35,,864.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1852.2,60,,1481.76,percent of total billed charges,60% of total billed charges for outpatient setting,396.37,3241.35,
TICARCILLIN (TIMENTIN) INJ 3.1GM :10VL,3302079,CDM,250,RC,,,Outpatient,,,456.72,456.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.7,70,,255.76,percent of total billed charges,70% of total billed charges for outpatient setting,387.66,84.88,,310.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,228.36,50,,182.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342.54,75,,274.03,percent of total billed charges,75% of total billed charges for outpatient setting,319.7,70,,255.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.64,12.84,,46.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.38,80,,292.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.64,12.84,,46.91,percent of total billed charges,12.84% of total billed charges,58.64,12.84,,46.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,296.87,65,,237.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.85,35,,127.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,411.05,90,,328.84,percent of total billed charges,90% of total billed charges for outpatient setting,58.64,411.05,
TICLOPIDINE (TICLID) TAB : 250MG,3302080,CDM,259,RC,,,Outpatient,,,7.41,7.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,70,,4.15,percent of total billed charges,70% of total billed charges for outpatient setting,6.29,84.88,,5.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.71,50,,2.97,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.56,75,,4.45,percent of total billed charges,75% of total billed charges for outpatient setting,5.19,70,,4.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.93,80,,4.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,0.95,12.84,,0.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.82,65,,3.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,35,,2.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.67,90,,5.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.95,6.67,
TIGERLINK SUTURE /WHITE / AR-7235T,69162242,CDM,272,RC,,,Outpatient,,,237.93,237.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,201.95,84.88,,161.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,118.97,50,,95.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.45,75,,142.76,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,70,,133.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.34,80,,152.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,30.55,12.84,,24.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,154.65,65,,123.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.28,35,,66.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,214.14,90,,171.31,percent of total billed charges,90% of total billed charges for outpatient setting,30.55,214.14,
TIGERLOOP/ AR-7234T /WHITE,69161670,CDM,278,RC,,,Outpatient,,,250.64,250.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.38,60,,120.3,percent of total billed charges,60% of total Billed charges for outpatient setting,212.74,84.88,,170.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.98,75,,150.38,percent of total billed charges,75% of total billed charges for outpatient setting,125.32,50,,100.26,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.51,80,,160.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,32.18,12.84,,25.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,250.64,65,,200.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.72,35,,70.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,150.38,60,,120.3,percent of total billed charges,60% of total billed charges for outpatient setting,32.18,250.64,
TIGERTAPE 2MM / AR-7237-7T,69162334,CDM,272,RC,,,Outpatient,,,243.34,243.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.34,70,,136.27,percent of total billed charges,70% of total billed charges for outpatient setting,206.55,84.88,,165.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,121.67,50,,97.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.51,75,,146.01,percent of total billed charges,75% of total billed charges for outpatient setting,170.34,70,,136.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.67,80,,155.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,31.24,12.84,,24.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,158.17,65,,126.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.17,35,,68.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,219.01,90,,175.21,percent of total billed charges,90% of total billed charges for outpatient setting,31.24,219.01,
"TIGHTROPE ABS,BUTTON 8X12MM/ AR-1588TB",69161926,CDM,278,RC,,,Outpatient,,,618.62,618.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.17,60,,296.94,percent of total billed charges,60% of total Billed charges for outpatient setting,525.08,84.88,,420.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.97,75,,371.18,percent of total billed charges,75% of total billed charges for outpatient setting,309.31,50,,247.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.9,80,,395.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,79.43,12.84,,63.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.52,35,,173.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,371.17,60,,296.94,percent of total billed charges,60% of total billed charges for outpatient setting,79.43,618.62,
"TIGHTROPE ABS,IMPLANT OPEN/ AR-1588TN-1",69161927,CDM,278,RC,,,Outpatient,,,839.24,839.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.54,60,,402.83,percent of total billed charges,60% of total Billed charges for outpatient setting,712.35,84.88,,569.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,419.62,50,,335.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,629.43,75,,503.54,percent of total billed charges,75% of total billed charges for outpatient setting,419.62,50,,335.7,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,12.84,,86.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.39,80,,537.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,12.84,,86.21,percent of total billed charges,12.84% of total billed charges,107.76,12.84,,86.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,839.24,65,,671.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.73,35,,234.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,503.54,60,,402.83,percent of total billed charges,60% of total billed charges for outpatient setting,107.76,839.24,
TIMOLOL (TIMOPTIC XE)OPTH SOL 0.5%:5ML,3302084,CDM,259,RC,,,Outpatient,,,82.67,82.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.87,70,,46.3,percent of total billed charges,70% of total billed charges for outpatient setting,70.17,84.88,,56.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.34,50,,33.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62,75,,49.6,percent of total billed charges,75% of total billed charges for outpatient setting,57.87,70,,46.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.14,80,,52.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,10.61,12.84,,8.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,53.74,65,,42.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,35,,23.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,74.4,90,,59.52,percent of total billed charges,90% of total billed charges for outpatient setting,10.61,74.4,
TIMOLOL (TIMOPTIC) OPTH SOL 0.25% : 5ML,3302082,CDM,259,RC,,,Outpatient,,,14.07,14.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,11.94,84.88,,9.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.04,50,,5.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.55,75,,8.44,percent of total billed charges,75% of total billed charges for outpatient setting,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,80,,9.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.15,65,,7.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,35,,3.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.66,90,,10.13,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.66,
TIMOLOL (TIMOPTIC) OPTH SOL 0.25% : 5ML,3302081,CDM,259,RC,,,Outpatient,,,40.44,40.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,70,,22.65,percent of total billed charges,70% of total billed charges for outpatient setting,34.33,84.88,,27.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.22,50,,16.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.33,75,,24.26,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,70,,22.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,12.84,,4.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.35,80,,25.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.19,12.84,,4.15,percent of total billed charges,12.84% of total billed charges,5.19,12.84,,4.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.29,65,,21.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,35,,11.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.4,90,,29.12,percent of total billed charges,90% of total billed charges for outpatient setting,5.19,36.4,
TIMOLOL (TIMOPTIC) OPTH SOL 0.5%  5ML,3302083,CDM,259,RC,,,Outpatient,,,40.83,40.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,34.66,84.88,,27.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.42,50,,16.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.62,75,,24.5,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,70,,22.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.66,80,,26.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,5.24,12.84,,4.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.54,65,,21.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.29,35,,11.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.75,90,,29.4,percent of total billed charges,90% of total billed charges for outpatient setting,5.24,36.75,
TIP COVER ACCESSORY CRV SCIS / 400180,69161326,CDM,272,RC,,,Outpatient,,,126,126,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,70,,70.56,percent of total billed charges,70% of total billed charges for outpatient setting,106.95,84.88,,85.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,63,50,,50.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,75,,75.6,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,70,,70.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,80,,80.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,16.18,12.84,,12.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.9,65,,65.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,35,,35.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,113.4,90,,90.72,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,113.4,
TIP GREEN ENDOCUFF / ARV120,1973640,CDM,272,RC,,,Outpatient,,,144,144,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,70,,80.64,percent of total billed charges,70% of total billed charges for outpatient setting,122.23,84.88,,97.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,72,50,,57.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,75,,86.4,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,70,,80.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,12.84,,14.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,80,,92.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,12.84,,14.79,percent of total billed charges,12.84% of total billed charges,18.49,12.84,,14.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,93.6,65,,74.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,35,,40.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,129.6,90,,103.68,percent of total billed charges,90% of total billed charges for outpatient setting,18.49,129.6,
TIP I/A POLYMER 45 DEGREE / 8065751511,69169184,CDM,272,RC,,,Outpatient,,,67.06,67.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.94,70,,37.55,percent of total billed charges,70% of total billed charges for outpatient setting,56.92,84.88,,45.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.53,50,,26.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.3,75,,40.24,percent of total billed charges,75% of total billed charges for outpatient setting,46.94,70,,37.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.61,12.84,,6.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.65,80,,42.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.61,12.84,,6.89,percent of total billed charges,12.84% of total billed charges,8.61,12.84,,6.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.59,65,,34.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.47,35,,18.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.35,90,,48.28,percent of total billed charges,90% of total billed charges for outpatient setting,8.61,60.35,
TIP I/A STRAIGHT PLMER 0.3MM/ 8065751510,69169875,CDM,272,RC,,,Outpatient,,,67.06,67.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.94,70,,37.55,percent of total billed charges,70% of total billed charges for outpatient setting,56.92,84.88,,45.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,33.53,50,,26.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.3,75,,40.24,percent of total billed charges,75% of total billed charges for outpatient setting,46.94,70,,37.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.61,12.84,,6.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.65,80,,42.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.61,12.84,,6.89,percent of total billed charges,12.84% of total billed charges,8.61,12.84,,6.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.59,65,,34.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.47,35,,18.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,60.35,90,,48.28,percent of total billed charges,90% of total billed charges for outpatient setting,8.61,60.35,
TIP PURPLE ENDOCUFF / ARV130,1973641,CDM,272,RC,,,Outpatient,,,138.24,138.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.77,70,,77.42,percent of total billed charges,70% of total billed charges for outpatient setting,117.34,84.88,,93.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,69.12,50,,55.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.68,75,,82.94,percent of total billed charges,75% of total billed charges for outpatient setting,96.77,70,,77.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.59,80,,88.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.86,65,,71.89,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.38,35,,38.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,124.42,90,,99.54,percent of total billed charges,90% of total billed charges for outpatient setting,17.75,124.42,
TIP RADIAL SPRAY HI CAP / 00515018200,71000017,CDM,272,RC,,,Outpatient,,,137.7,137.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.39,70,,77.11,percent of total billed charges,70% of total billed charges for outpatient setting,116.88,84.88,,93.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.85,50,,55.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.28,75,,82.62,percent of total billed charges,75% of total billed charges for outpatient setting,96.39,70,,77.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,12.84,,14.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.16,80,,88.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,17.68,12.84,,14.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.51,65,,71.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.2,35,,38.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,123.93,90,,99.14,percent of total billed charges,90% of total billed charges for outpatient setting,17.68,123.93,
TIROFIBAN (AGGRASTAT) 0.25mg PRMIX:250,3302086,CDM,636,RC,J3246,HCPCS,Outpatient,,,1311.48,1311.48,,5.74,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,918.04,70,,734.43,percent of total billed charges,70% of total billed charges for outpatient setting,1113.18,84.88,,890.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.03,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,983.61,75,,786.89,percent of total billed charges,75% of total billed charges for outpatient setting,918.04,70,,734.43,percent of total billed charges,70% of total billed charges for outpatient setting,6.1,170,,,Fee Schedule,170% of Medicare OPPS rate,7.71,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,168.39,12.84,,134.712,percent of total billed charges,12.84% of total billed charges,6.28,175,,,Fee Schedule,175% of Medicare OPPS rate,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1049.18,80,,839.34,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,4.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,168.39,12.84,,134.71,percent of total billed charges,12.84% of total billed charges,168.39,12.84,,134.71,percent of total billed charges,12.84% of total billed charges,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,852.46,65,,681.97,percent of total billed charges,65% of total billed charges for outpatient setting,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3.59,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,10.68,100,,,Fee Schedule,100% of Custom Fee Schedule,1180.33,90,,944.26,percent of total billed charges,90% of total billed charges for outpatient setting,3.59,1180.33,
TIROFIBAN (AGGRASTAT) 250MCG/ML SDV:50ML,3302085,CDM,250,RC,,,Outpatient,,,1311.48,1311.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.04,70,,734.43,percent of total billed charges,70% of total billed charges for outpatient setting,1113.18,84.88,,890.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,655.74,50,,524.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,983.61,75,,786.89,percent of total billed charges,75% of total billed charges for outpatient setting,918.04,70,,734.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.39,12.84,,134.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1049.18,80,,839.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.39,12.84,,134.71,percent of total billed charges,12.84% of total billed charges,168.39,12.84,,134.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,852.46,65,,681.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.02,35,,367.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1180.33,90,,944.26,percent of total billed charges,90% of total billed charges for outpatient setting,168.39,1180.33,
TISSEEL FIBRIN SEALANT 4ML / 1506079,69161722,CDM,278,RC,,,Outpatient,,,667.25,667.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.35,60,,320.28,percent of total billed charges,60% of total Billed charges for outpatient setting,566.36,84.88,,453.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,333.63,50,,266.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,500.44,75,,400.35,percent of total billed charges,75% of total billed charges for outpatient setting,333.63,50,,266.9,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.67,12.84,,68.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,533.8,80,,427.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.67,12.84,,68.54,percent of total billed charges,12.84% of total billed charges,85.67,12.84,,68.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,667.25,65,,533.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.54,35,,186.83,percent of total billed charges,35% of total Billed charges for Outpatient Setting,400.35,60,,320.28,percent of total billed charges,60% of total billed charges for outpatient setting,85.67,667.25,
TISSUE 20CM TIBIALIS TENDON / 430335,69161668,CDM,278,RC,C1763,HCPCS,Outpatient,,,4300,4300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2580,60,,2064,percent of total billed charges,60% of total Billed charges for outpatient setting,3649.84,84.88,,2919.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3225,75,,2580,percent of total billed charges,75% of total billed charges for outpatient setting,2150,50,,1720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440,80,,2752,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,552.12,12.84,,441.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4515,105,,3612,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505,35,,1204,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2580,60,,2064,percent of total billed charges,60% of total billed charges for outpatient setting,552.12,4515,
TISSUE 22CM TIBIALIS TENDON / 430343,7156754,CDM,278,RC,C1763,HCPCS,Outpatient,,,3200,3200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1920,60,,1536,percent of total billed charges,60% of total Billed charges for outpatient setting,2716.16,84.88,,2172.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400,75,,1920,percent of total billed charges,75% of total billed charges for outpatient setting,1600,50,,1280,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.88,12.84,,328.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2560,80,,2048,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.88,12.84,,328.7,percent of total billed charges,12.84% of total billed charges,410.88,12.84,,328.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3360,105,,2688,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,35,,896,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1920,60,,1536,percent of total billed charges,60% of total billed charges for outpatient setting,410.88,3360,
TISSUE CULTURE BONE MARROW BLOOD CELLS,201058,CDM,300,RC,88237,HCPCS,Outpatient,,,646.88,582.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.82,70,,362.26,percent of total billed charges,70% of total billed charges for outpatient setting,549.07,84.88,,439.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.87,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,485.16,75,,388.13,percent of total billed charges,75% of total billed charges for outpatient setting,452.82,70,,362.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.5,80,,414,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,184.41,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.19,100,,,Fee Schedule,100% of Custom Fee Schedule,582.19,90,,465.75,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,582.19,
"TISSUE CULTURE, SKIN/SOLID BIOPSY",201034,CDM,300,RC,88233,HCPCS,Outpatient,,,633.29,569.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.3,70,,354.64,percent of total billed charges,70% of total billed charges for outpatient setting,537.54,84.88,,430.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,241.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,474.97,75,,379.98,percent of total billed charges,75% of total billed charges for outpatient setting,443.3,70,,354.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.63,80,,405.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,205.48,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.19,100,,,Fee Schedule,100% of Custom Fee Schedule,569.96,90,,455.97,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,569.96,
TISSUE EXPANDER 400CC/ 133FV-12-T,69161845,CDM,278,RC,,,Outpatient,,,3190,3190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914,60,,1531.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2707.67,84.88,,2166.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2392.5,75,,1914,percent of total billed charges,75% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552,80,,2041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3349.5,105,,2679.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.5,35,,893.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1914,60,,1531.2,percent of total billed charges,60% of total billed charges for outpatient setting,409.6,3349.5,
TISSUE EXPANDER 500CC/ 133FV-13-T,69161617,CDM,278,RC,,,Outpatient,,,3190,3190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914,60,,1531.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2707.67,84.88,,2166.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2392.5,75,,1914,percent of total billed charges,75% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552,80,,2041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3349.5,105,,2679.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.5,35,,893.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1914,60,,1531.2,percent of total billed charges,60% of total billed charges for outpatient setting,409.6,3349.5,
TISSUE EXPANDER 500CC/ 133MV-T,69161752,CDM,278,RC,,,Outpatient,,,3190,3190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914,60,,1531.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2707.67,84.88,,2166.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2392.5,75,,1914,percent of total billed charges,75% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552,80,,2041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3349.5,105,,2679.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.5,35,,893.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1914,60,,1531.2,percent of total billed charges,60% of total billed charges for outpatient setting,409.6,3349.5,
TISSUE EXPANDER 600CC/ 133FV-14-T,69161618,CDM,278,RC,,,Outpatient,,,3190,3190,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914,60,,1531.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2707.67,84.88,,2166.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2392.5,75,,1914,percent of total billed charges,75% of total billed charges for outpatient setting,1595,50,,1276,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552,80,,2041.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,409.6,12.84,,327.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3349.5,105,,2679.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.5,35,,893.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1914,60,,1531.2,percent of total billed charges,60% of total billed charges for outpatient setting,409.6,3349.5,
TISSUE EXPANDER 600CC/ 133MV-15-T,69162152,CDM,278,RC,,,Outpatient,,,2920,2920,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752,60,,1401.6,percent of total billed charges,60% of total Billed charges for outpatient setting,2478.5,84.88,,1982.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,1460,50,,1168,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2190,75,,1752,percent of total billed charges,75% of total billed charges for outpatient setting,1460,50,,1168,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.93,12.84,,299.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2336,80,,1868.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.93,12.84,,299.94,percent of total billed charges,12.84% of total billed charges,374.93,12.84,,299.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3066,105,,2452.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022,35,,817.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1752,60,,1401.6,percent of total billed charges,60% of total billed charges for outpatient setting,374.93,3066,
"TISSUE IN SITU HYBRIDIZATION,INTERP",900038,CDM,310,RC,88365,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,179.66,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,535.12,
TISSUE TIBIALIS TENDON DIA 9-10 /430336,69169871,CDM,278,RC,C1763,HCPCS,Outpatient,,,3400,3400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2040,60,,1632,percent of total billed charges,60% of total Billed charges for outpatient setting,2885.92,84.88,,2308.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2550,75,,2040,percent of total billed charges,75% of total billed charges for outpatient setting,1700,50,,1360,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2720,80,,2176,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,436.56,12.84,,349.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3570,105,,2856,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190,35,,952,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2040,60,,1632,percent of total billed charges,60% of total billed charges for outpatient setting,436.56,3570,
TISSUE TRANSGLUTAMINASE AB IGG,220187,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
TISSUE TRANSGLUTAMINASE IGA,220185,CDM,301,RC,83516,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.8,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of Custom Fee Schedule,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,46.7,
"TISSUE TRANSGLUTAMINASE, EA Ig CLASS",201096,CDM,302,RC,86364,HCPCS,Outpatient,,,51.89,46.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,84.88,,35.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.04,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.92,75,,31.14,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,70,,29.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,80,,33.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.16,35,,14.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.7,90,,37.36,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,46.7,
TIZANIDINE (genericZANAFLEX) 4 MG TAB,3303118,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TIZANIDINE 2 MG: TAB,3303114,CDM,259,RC,,,Outpatient,,,14.07,14.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,11.94,84.88,,9.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.04,50,,5.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.55,75,,8.44,percent of total billed charges,75% of total billed charges for outpatient setting,9.85,70,,7.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.26,80,,9.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.15,65,,7.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,35,,3.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.66,90,,10.13,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.66,
TMJ BILAT OPEN & CLOSED,2400105,CDM,320,RC,70330,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TMJ UNILAT OPEN & CLOSED,2400100,CDM,320,RC,70328,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TOBRAMYCIN (NEBCIN) MDV 40MG/ML  2ML,3302090,CDM,636,RC,J3260,HCPCS,Outpatient,,,3.07,3.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.41,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.3,75,,1.84,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,70,,1.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,100,,,Fee Schedule,100% of Custom Fee Schedule,2.76,90,,2.21,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,3.87,
TOBRAMYCIN (NEBCIN) MDV 40MG/ML : 2ML,3302089,CDM,250,RC,,,Outpatient,,,10.32,10.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,8.76,84.88,,7.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.16,50,,4.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.74,75,,6.19,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,70,,5.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.26,80,,6.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,1.33,12.84,,1.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.71,65,,5.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,35,,2.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.29,90,,7.43,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,9.29,
TOBRAMYCIN (TOBRADEX)OPTH OINT 1% :3.5GM,3302092,CDM,259,RC,,,Outpatient,,,148.45,148.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.92,70,,83.14,percent of total billed charges,70% of total billed charges for outpatient setting,126,84.88,,100.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.23,50,,59.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.34,75,,89.07,percent of total billed charges,75% of total billed charges for outpatient setting,103.92,70,,83.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.06,12.84,,15.248,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.76,80,,95.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.06,12.84,,15.25,percent of total billed charges,12.84% of total billed charges,19.06,12.84,,15.25,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.49,65,,77.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.96,35,,41.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.61,90,,106.89,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,133.61,
TOBRAMYCIN (TOBRADEX)OPTH SOL 0.3% 2.5ML,3302091,CDM,259,RC,,,Outpatient,,,217.82,217.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.47,70,,121.98,percent of total billed charges,70% of total billed charges for outpatient setting,184.89,84.88,,147.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,108.91,50,,87.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.37,75,,130.7,percent of total billed charges,75% of total billed charges for outpatient setting,152.47,70,,121.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,12.84,,22.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.26,80,,139.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,12.84,,22.38,percent of total billed charges,12.84% of total billed charges,27.97,12.84,,22.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.58,65,,113.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.24,35,,60.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.04,90,,156.83,percent of total billed charges,90% of total billed charges for outpatient setting,27.97,196.04,
TOBRAMYCIN (TOBREX) OINT 1% : 3.5GM,3302088,CDM,259,RC,,,Outpatient,,,199.07,199.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.35,70,,111.48,percent of total billed charges,70% of total billed charges for outpatient setting,168.97,84.88,,135.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,99.54,50,,79.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.3,75,,119.44,percent of total billed charges,75% of total billed charges for outpatient setting,139.35,70,,111.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,12.84,,20.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.26,80,,127.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,12.84,,20.45,percent of total billed charges,12.84% of total billed charges,25.56,12.84,,20.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,129.4,65,,103.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.67,35,,55.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,179.16,90,,143.33,percent of total billed charges,90% of total billed charges for outpatient setting,25.56,179.16,
TOBRAMYCIN (TOBREX) OPTH SOL 0.3% :5ML,3302087,CDM,259,RC,,,Outpatient,,,45.37,45.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.76,70,,25.41,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,84.88,,30.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.69,50,,18.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.03,75,,27.22,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,70,,25.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.3,80,,29.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,5.83,12.84,,4.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,29.49,65,,23.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.88,35,,12.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,40.83,90,,32.66,percent of total billed charges,90% of total billed charges for outpatient setting,5.83,40.83,
TOBRAMYCIN PEAK,220039,CDM,300,RC,80200,HCPCS,Outpatient,,,72.59,65.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,61.61,84.88,,49.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.44,75,,43.55,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.07,80,,46.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,65.33,90,,52.26,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,65.33,
TOBRAMYCIN POWDER: 1.2 G VIAL,3303038,CDM,250,RC,,,Outpatient,,,541,541,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.7,70,,302.96,percent of total billed charges,70% of total billed charges for outpatient setting,459.2,84.88,,367.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,270.5,50,,216.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.75,75,,324.6,percent of total billed charges,75% of total billed charges for outpatient setting,378.7,70,,302.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.46,12.84,,55.568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.8,80,,346.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.46,12.84,,55.57,percent of total billed charges,12.84% of total billed charges,69.46,12.84,,55.57,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,351.65,65,,281.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.35,35,,151.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,486.9,90,,389.52,percent of total billed charges,90% of total billed charges for outpatient setting,69.46,486.9,
TOBRAMYCIN TROUGH,220041,CDM,300,RC,80200,HCPCS,Outpatient,,,72.59,65.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,61.61,84.88,,49.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,27.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,54.44,75,,43.55,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,70,,40.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.07,80,,46.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.07,100,,,Fee Schedule,100% of Custom Fee Schedule,65.33,90,,52.26,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,65.33,
TOE(S) 2+ VWS LEFT,2400451,CDM,320,RC,73660,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TOE(S) 2+ VWS RIGHT,2400450,CDM,320,RC,73660,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
TOLAZAMIDE (TOLINASE) TAB: 250MG,3302093,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TOLBUTAMIDE (ORINASE) TAB:500 MG,3302094,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TOLTERODINE (DETROL) 1 MG TAB :,3302096,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TOLTERODINE (DETROL) TAB:1 MG,3302095,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TOLTERODINE (genericDETROL) 2MG TAB,3302097,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TOLTERODINE(DETROL LA):4 MG,3302769,CDM,259,RC,,,Outpatient,,,14.11,14.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.88,70,,7.9,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,84.88,,9.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.06,50,,5.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,75,,8.46,percent of total billed charges,75% of total billed charges for outpatient setting,9.88,70,,7.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.448,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.29,80,,9.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,1.81,12.84,,1.45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.17,65,,7.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,35,,3.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.7,90,,10.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.81,12.7,
TOOL 28CM TUNNELING / SC-4252,71000615,CDM,272,RC,,,Outpatient,,,300,300,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,70,,168,percent of total billed charges,70% of total billed charges for outpatient setting,254.64,84.88,,203.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,150,50,,120,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,75,,180,percent of total billed charges,75% of total billed charges for outpatient setting,210,70,,168,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,80,,192,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,38.52,12.84,,30.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,195,65,,156,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,35,,84,percent of total billed charges,35% of total Billed charges for Outpatient Setting,270,90,,216,percent of total billed charges,90% of total billed charges for outpatient setting,38.52,270,
TOOL PINCH ON ACCESS / 6056,70000490,CDM,275,RC,C1779,HCPCS,Outpatient,,,152.62,152.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.83,70,,85.46,percent of total billed charges,70% of total billed charges for outpatient setting,129.54,84.88,,103.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.47,75,,91.58,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,50,,61.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.1,80,,97.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,19.6,12.84,,15.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.62,65,,122.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.42,35,,42.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,137.36,90,,109.89,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,152.62,
TOOL SAFFRON FIXATION / 520340,7100314,CDM,272,RC,,,Outpatient,,,2240,2240,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568,70,,1254.4,percent of total billed charges,70% of total billed charges for outpatient setting,1901.31,84.88,,1521.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1120,50,,896,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1680,75,,1344,percent of total billed charges,75% of total billed charges for outpatient setting,1568,70,,1254.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792,80,,1433.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,287.62,12.84,,230.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1456,65,,1164.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784,35,,627.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2016,90,,1612.8,percent of total billed charges,90% of total billed charges for outpatient setting,287.62,2016,
TOOL TUNNELING 35CM / SC-4254,70000138,CDM,272,RC,,,Outpatient,,,648.9,648.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,550.79,84.88,,440.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.45,50,,259.56,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.68,75,,389.34,percent of total billed charges,75% of total billed charges for outpatient setting,454.23,70,,363.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.12,80,,415.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,83.32,12.84,,66.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,421.79,65,,337.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,35,,181.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,584.01,90,,467.21,percent of total billed charges,90% of total billed charges for outpatient setting,83.32,584.01,
TOOTH PROTECTOR DISP / 9-3041-03,6150961,CDM,271,RC,,,Outpatient,,,15.75,15.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,13.37,84.88,,10.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.88,50,,6.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.81,75,,9.45,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,70,,8.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.616,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,80,,10.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,2.02,12.84,,1.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.24,65,,8.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,35,,4.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.18,90,,11.34,percent of total billed charges,90% of total billed charges for outpatient setting,2.02,14.18,
TOPIRAMATE,220042,CDM,301,RC,80201,HCPCS,Outpatient,,,53.64,48.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.55,70,,30.04,percent of total billed charges,70% of total billed charges for outpatient setting,45.53,84.88,,36.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.47,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,40.23,75,,32.18,percent of total billed charges,75% of total billed charges for outpatient setting,37.55,70,,30.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,80,,34.33,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,17.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.62,100,,,Fee Schedule,100% of Custom Fee Schedule,48.28,90,,38.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.92,48.28,
TOPIRAMATE (TOPAMAX) TAB:25 MG,3302098,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TOPROL XL 100MG: TAB,3302899,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TOPROL XL 25MG (METOPROLOL EXT RELEASE),3302705,CDM,259,RC,,,Outpatient,,,5.06,5.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,70,,2.83,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,84.88,,3.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.53,50,,2.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.8,75,,3.04,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,70,,2.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,80,,3.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.29,65,,2.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,35,,1.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.55,90,,3.64,percent of total billed charges,90% of total billed charges for outpatient setting,0.65,4.55,
TORSEMIDE (DEMADEX) 10MG: TAB,3303180,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TORSEMIDE (genericDEMADEX) 20MG TAB,3302901,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TORSEMIDE(DEMADEX):20MG INJ.,3302895,CDM,250,RC,,,Outpatient,,,25.6,25.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.92,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,84.88,,17.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.8,50,,10.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.2,75,,15.36,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,70,,14.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.48,80,,16.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,3.29,12.84,,2.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.64,65,,13.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.96,35,,7.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.04,90,,18.43,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,23.04,
TORSEMIDE(DEMADEX)10MG/ML INJ.:5ML AMP,3302950,CDM,636,RC,J3265,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.6,70,,38.08,percent of total billed charges,70% of total billed charges for outpatient setting,57.72,84.88,,46.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.21,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,51,75,,40.8,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,70,,38.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,12.84,,6.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,80,,43.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.73,12.84,,6.98,percent of total billed charges,12.84% of total billed charges,8.73,12.84,,6.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,44.2,65,,35.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,90,,48.96,percent of total billed charges,90% of total billed charges for outpatient setting,3.21,61.2,
TOTAL BILI,200660,CDM,300,RC,82247,HCPCS,Outpatient,,,22.59,20.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,20.33,
TOTAL BILIRUBIN,200540,CDM,300,RC,82247,HCPCS,Outpatient,,,22.59,20.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,84.88,,15.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.94,75,,13.55,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,70,,12.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.07,80,,14.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.33,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,100% of Custom Fee Schedule,20.33,90,,16.26,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,20.33,
TOTAL CARBON DIOXIDE BLD,201285,CDM,300,RC,82374,HCPCS,Outpatient,,,21.96,19.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,84.88,,14.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,16.47,75,,13.18,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,70,,12.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.57,80,,14.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.14,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.27,100,,,Fee Schedule,100% of Custom Fee Schedule,19.76,90,,15.81,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,19.76,
TOTAL METATARSAL,69162133,CDM,278,RC,,,Outpatient,,,6650,6650,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3990,60,,3192,percent of total billed charges,60% of total Billed charges for outpatient setting,5644.52,84.88,,4515.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4987.5,75,,3990,percent of total billed charges,75% of total billed charges for outpatient setting,3325,50,,2660,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5320,80,,4256,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,853.86,12.84,,683.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6982.5,105,,5586,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.5,35,,1862,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3990,60,,3192,percent of total billed charges,60% of total billed charges for outpatient setting,853.86,6982.5,
TOTAL PROTEIN,200545,CDM,300,RC,84155,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
TOTAL PROXIMAL PHALANX,69162132,CDM,278,RC,,,Outpatient,,,5876,5876,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3525.6,60,,2820.48,percent of total billed charges,60% of total Billed charges for outpatient setting,4987.55,84.88,,3990.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,2938,50,,2350.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4407,75,,3525.6,percent of total billed charges,75% of total billed charges for outpatient setting,2938,50,,2350.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.48,12.84,,603.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4700.8,80,,3760.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.48,12.84,,603.58,percent of total billed charges,12.84% of total billed charges,754.48,12.84,,603.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6169.8,105,,4935.84,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2056.6,35,,1645.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3525.6,60,,2820.48,percent of total billed charges,60% of total billed charges for outpatient setting,754.48,6169.8,
TOURNIQUET CUFFS 12IN / 607070102R,6150631,CDM,272,RC,,,Outpatient,,,74.75,74.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.33,70,,41.86,percent of total billed charges,70% of total billed charges for outpatient setting,63.45,84.88,,50.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.38,50,,29.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.06,75,,44.85,percent of total billed charges,75% of total billed charges for outpatient setting,52.33,70,,41.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.8,80,,47.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.59,65,,38.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,35,,20.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.28,90,,53.82,percent of total billed charges,90% of total billed charges for outpatient setting,9.6,67.28,
TOURNIQUET CUFFS 18IN / 60-7070-103,6150632,CDM,272,RC,,,Outpatient,,,79.56,79.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.69,70,,44.55,percent of total billed charges,70% of total billed charges for outpatient setting,67.53,84.88,,54.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.78,50,,31.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.67,75,,47.74,percent of total billed charges,75% of total billed charges for outpatient setting,55.69,70,,44.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.22,12.84,,8.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.65,80,,50.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.22,12.84,,8.18,percent of total billed charges,12.84% of total billed charges,10.22,12.84,,8.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,51.71,65,,41.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,35,,22.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,71.6,90,,57.28,percent of total billed charges,90% of total billed charges for outpatient setting,10.22,71.6,
TOURNIQUET CUFFS 24IN / 60-7070-104,6150633,CDM,272,RC,,,Outpatient,,,92.82,92.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.97,70,,51.98,percent of total billed charges,70% of total billed charges for outpatient setting,78.79,84.88,,63.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.41,50,,37.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.62,75,,55.7,percent of total billed charges,75% of total billed charges for outpatient setting,64.97,70,,51.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,12.84,,9.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.26,80,,59.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,12.84,,9.54,percent of total billed charges,12.84% of total billed charges,11.92,12.84,,9.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.33,65,,48.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.49,35,,25.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.54,90,,66.83,percent of total billed charges,90% of total billed charges for outpatient setting,11.92,83.54,
TOURNIQUET CUFFS 30IN / 60-7070-105,6150634,CDM,272,RC,,,Outpatient,,,91,91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,77.24,84.88,,61.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.5,50,,36.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.25,75,,54.6,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,80,,58.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.15,65,,47.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,35,,25.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,81.9,
TOURNIQUET CUFFS 34IN / 60-7070-106,6150635,CDM,272,RC,,,Outpatient,,,91,91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,77.24,84.88,,61.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.5,50,,36.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.25,75,,54.6,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,80,,58.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.15,65,,47.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,35,,25.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,81.9,
TOURNIQUET CUFFS 42IN / 60-7070-107,6150636,CDM,272,RC,,,Outpatient,,,91,91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,77.24,84.88,,61.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.5,50,,36.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.25,75,,54.6,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,80,,58.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.15,65,,47.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,35,,25.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,81.9,
TOURNIQUET CUFFS 9IN / 60-7070-101,6150630,CDM,272,RC,,,Outpatient,,,201.83,201.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.28,70,,113.02,percent of total billed charges,70% of total billed charges for outpatient setting,171.31,84.88,,137.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,100.92,50,,80.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.37,75,,121.1,percent of total billed charges,75% of total billed charges for outpatient setting,141.28,70,,113.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.91,12.84,,20.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.46,80,,129.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.91,12.84,,20.73,percent of total billed charges,12.84% of total billed charges,25.91,12.84,,20.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.19,65,,104.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.64,35,,56.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,181.65,90,,145.32,percent of total billed charges,90% of total billed charges for outpatient setting,25.91,181.65,
TOWEL 17X27IN STERILE CLOTH / MDT2168204,6150060,CDM,270,RC,,,Outpatient,,,13.95,13.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,11.84,84.88,,9.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.98,50,,5.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.46,75,,8.37,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,70,,7.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.16,80,,8.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,1.79,12.84,,1.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.07,65,,7.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.88,35,,3.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.56,90,,10.05,percent of total billed charges,90% of total billed charges for outpatient setting,1.79,12.56,
TOWEL OR HI-SORB STR BLUE 6PK,761970,CDM,272,RC,,,Outpatient,,,126.83,126.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.78,70,,71.02,percent of total billed charges,70% of total billed charges for outpatient setting,107.65,84.88,,86.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.42,50,,50.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.12,75,,76.1,percent of total billed charges,75% of total billed charges for outpatient setting,88.78,70,,71.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.28,12.84,,13.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.46,80,,81.17,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.28,12.84,,13.02,percent of total billed charges,12.84% of total billed charges,16.28,12.84,,13.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.44,65,,65.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.39,35,,35.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.15,90,,91.32,percent of total billed charges,90% of total billed charges for outpatient setting,16.28,114.15,
TOXOCARA AB IGG,200149,CDM,302,RC,86682,HCPCS,Outpatient,,,58.55,52.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,49.7,84.88,,39.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.91,75,,35.13,percent of total billed charges,75% of total billed charges for outpatient setting,40.99,70,,32.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.84,80,,37.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.67,100,,,Fee Schedule,100% of Custom Fee Schedule,52.7,90,,42.16,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,52.7,
"TOXOPLASMA ABS, IGG",220070,CDM,302,RC,86777,HCPCS,Outpatient,,,64.76,58.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,54.97,84.88,,43.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.71,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.57,75,,38.86,percent of total billed charges,75% of total billed charges for outpatient setting,45.33,70,,36.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,80,,41.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,100,,,Fee Schedule,100% of Custom Fee Schedule,58.28,90,,46.62,percent of total billed charges,90% of total billed charges for outpatient setting,13.81,58.28,
"TOXOPLASMA ABS, IGM",220074,CDM,302,RC,86778,HCPCS,Outpatient,,,64.85,58.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.4,70,,36.32,percent of total billed charges,70% of total billed charges for outpatient setting,55.04,84.88,,44.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.73,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,48.64,75,,38.91,percent of total billed charges,75% of total billed charges for outpatient setting,45.4,70,,36.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.88,80,,41.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,21.03,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.31,100,,,Fee Schedule,100% of Custom Fee Schedule,58.37,90,,46.7,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,58.37,
TPMT ACTIVITY,220910,CDM,301,RC,82657,HCPCS,Outpatient,,,99.77,89.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.84,70,,55.87,percent of total billed charges,70% of total billed charges for outpatient setting,84.68,84.88,,67.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,31,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,74.83,75,,59.86,percent of total billed charges,75% of total billed charges for outpatient setting,69.84,70,,55.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.82,80,,63.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.24,100,,,Fee Schedule,100% of Custom Fee Schedule,89.79,90,,71.83,percent of total billed charges,90% of total billed charges for outpatient setting,22.17,89.79,
TPN EXTENSION W/1.2 MCR FILTER:,3303148,CDM,259,RC,,,Outpatient,,,23.72,23.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.6,70,,13.28,percent of total billed charges,70% of total billed charges for outpatient setting,20.13,84.88,,16.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.86,50,,9.49,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.79,75,,14.23,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,70,,13.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.98,80,,15.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,3.05,12.84,,2.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,65,,12.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,35,,6.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,21.35,90,,17.08,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,21.35,
TRACE METALS  MDV : 10ML,3302099,CDM,250,RC,,,Outpatient,,,33.73,33.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,70,,18.89,percent of total billed charges,70% of total billed charges for outpatient setting,28.63,84.88,,22.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.87,50,,13.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.3,75,,20.24,percent of total billed charges,75% of total billed charges for outpatient setting,23.61,70,,18.89,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,12.84,,3.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,80,,21.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,4.33,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.92,65,,17.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.81,35,,9.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.36,90,,24.29,percent of total billed charges,90% of total billed charges for outpatient setting,4.33,30.36,
TRACH TUBE ORAL RAE UNCUFFED 3.5,6150782,CDM,272,RC,,,Outpatient,,,31.96,31.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.37,70,,17.9,percent of total billed charges,70% of total billed charges for outpatient setting,27.13,84.88,,21.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.98,50,,12.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.97,75,,19.18,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,70,,17.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.57,80,,20.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.77,65,,16.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.19,35,,8.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.76,90,,23.01,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,28.76,
TRAMADOL (genericULTRAM) 50MG TAB,3302100,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TRAMADOL (ULTRAM) TAB : 100MG UD,3302103,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TRANDOLAPRIL/VERAPAMIL (TARKA):4-240MG,3303153,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
TRANEXAMIC ACID (TXA) 650MG TAB,3314318,CDM,259,RC,,,Outpatient,,,29.82,29.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.87,70,,16.7,percent of total billed charges,70% of total billed charges for outpatient setting,25.31,84.88,,20.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.91,50,,11.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.37,75,,17.9,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,70,,16.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,12.84,,3.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.86,80,,19.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,3.83,12.84,,3.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.38,65,,15.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,35,,8.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,26.84,90,,21.47,percent of total billed charges,90% of total billed charges for outpatient setting,3.83,26.84,
TRANEXAMIC ACID 100MG/ML 10ML,3307180,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
TRANS OBTURATOR KIT / 68504110,69159301,CDM,278,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
TRANSCERVICAL CATHETERIZATION OF FALLOPI,2400810,CDM,320,RC,74742,HCPCS,Outpatient,,,189,141.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,160.42,84.88,,128.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,75,,113.4,percent of total billed charges,75% of total billed charges for outpatient setting,132.3,70,,105.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,80,,120.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,24.27,12.84,,19.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,136.08,percent of total billed charges,90% of total billed charges for outpatient setting,24.27,170.1,
TRANSCORTIN,201665,CDM,301,RC,84449,HCPCS,Outpatient,,,81,72.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,70,,45.36,percent of total billed charges,70% of total billed charges for outpatient setting,68.75,84.88,,55,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.75,75,,48.6,percent of total billed charges,75% of total billed charges for outpatient setting,56.7,70,,45.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,80,,51.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.12,100,,,Fee Schedule,100% of Custom Fee Schedule,72.9,90,,58.32,percent of total billed charges,90% of total billed charges for outpatient setting,18,72.9,
TRANSCRANIAL DOPPLER INTRACRANIAL ARTER,2600043,CDM,921,RC,93886,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
TRANSDUCER KIT DISP / 42632-05,6152266,CDM,272,RC,,,Outpatient,,,84.56,84.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.19,70,,47.35,percent of total billed charges,70% of total billed charges for outpatient setting,71.77,84.88,,57.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,42.28,50,,33.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.42,75,,50.74,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,70,,47.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,12.84,,8.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.65,80,,54.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,12.84,,8.69,percent of total billed charges,12.84% of total billed charges,10.86,12.84,,8.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.96,65,,43.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,35,,23.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,76.1,90,,60.88,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,76.1,
TRANSFER SET/350-8400,6153119,CDM,272,RC,,,Outpatient,,,110.78,110.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.55,70,,62.04,percent of total billed charges,70% of total billed charges for outpatient setting,94.03,84.88,,75.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.39,50,,44.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.09,75,,66.47,percent of total billed charges,75% of total billed charges for outpatient setting,77.55,70,,62.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,12.84,,11.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.62,80,,70.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,12.84,,11.38,percent of total billed charges,12.84% of total billed charges,14.22,12.84,,11.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.01,65,,57.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.77,35,,31.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.7,90,,79.76,percent of total billed charges,90% of total billed charges for outpatient setting,14.22,99.7,
TRANSFERRIN,220188,CDM,301,RC,84466,HCPCS,Outpatient,,,57.42,51.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.19,70,,32.15,percent of total billed charges,70% of total billed charges for outpatient setting,48.74,84.88,,38.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.92,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.07,75,,34.46,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,70,,32.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.94,80,,36.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.64,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,100,,,Fee Schedule,100% of Custom Fee Schedule,51.68,90,,41.34,percent of total billed charges,90% of total billed charges for outpatient setting,12.76,51.68,
TRANSFERRIN SATURATION,220329,CDM,300,RC,83010,HCPCS,Outpatient,,,56.61,50.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.63,70,,31.7,percent of total billed charges,70% of total billed charges for outpatient setting,48.05,84.88,,38.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.6,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.46,75,,33.97,percent of total billed charges,75% of total billed charges for outpatient setting,39.63,70,,31.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.29,80,,36.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,100% of Custom Fee Schedule,50.95,90,,40.76,percent of total billed charges,90% of total billed charges for outpatient setting,12.58,50.95,
TRANSFUSION,5100140,CDM,391,RC,36430,HCPCS,Outpatient,,,908.97,908.97,,569.08,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,636.28,70,,509.02,percent of total billed charges,70% of total billed charges for outpatient setting,771.53,84.88,,617.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,521.65,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,681.73,75,,545.38,percent of total billed charges,75% of total billed charges for outpatient setting,636.28,70,,509.02,percent of total billed charges,70% of total billed charges for outpatient setting,604.64,170,,,Fee Schedule,170% of Medicare OPPS rate,764.7,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,116.71,12.84,,93.368,percent of total billed charges,12.84% of total billed charges,622.42,175,,,Fee Schedule,175% of Medicare OPPS rate,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,727.18,80,,581.74,percent of total billed charges,80% of total billed charges for outpatient setting,497.94,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,444.59,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,116.71,12.84,,93.37,percent of total billed charges,12.84% of total billed charges,116.71,12.84,,93.37,percent of total billed charges,12.84% of total billed charges,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,590.83,65,,472.66,percent of total billed charges,65% of total billed charges for outpatient setting,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,355.68,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,339.23,100,,,Fee Schedule,100% of Custom Fee Schedule,818.07,90,,654.46,percent of total billed charges,90% of total billed charges for outpatient setting,116.71,818.07,
TRANSFUSION,200355,CDM,391,RC,,,Outpatient,,,999.88,999.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,848.7,84.88,,678.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.94,50,,399.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.91,75,,599.93,percent of total billed charges,75% of total billed charges for outpatient setting,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.9,80,,639.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.92,65,,519.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.96,35,,279.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.89,90,,719.91,percent of total billed charges,90% of total billed charges for outpatient setting,128.38,899.89,
TRANSFUSION,6000035,CDM,391,RC,,,Outpatient,,,999.88,999.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,848.7,84.88,,678.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.94,50,,399.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.91,75,,599.93,percent of total billed charges,75% of total billed charges for outpatient setting,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.9,80,,639.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.92,65,,519.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.96,35,,279.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.89,90,,719.91,percent of total billed charges,90% of total billed charges for outpatient setting,128.38,899.89,
TRANSLUMINAL ATHERECTOMY EACH ADDITION P,2200385,CDM,323,RC,75993,HCPCS,Outpatient,,,1874.76,1406.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312.33,70,,1049.86,percent of total billed charges,70% of total billed charges for outpatient setting,1591.3,84.88,,1273.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,937.38,50,,749.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1406.07,75,,1124.86,percent of total billed charges,75% of total billed charges for outpatient setting,1312.33,70,,1049.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.72,12.84,,192.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1499.81,80,,1199.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.72,12.84,,192.58,percent of total billed charges,12.84% of total billed charges,240.72,12.84,,192.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.17,35,,524.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1687.28,90,,1349.82,percent of total billed charges,90% of total billed charges for outpatient setting,128,1687.28,
TRANSPEC SPECIMEN CONTAINER / 600102,69169061,CDM,270,RC,,,Outpatient,,,127.14,127.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,70,,71.2,percent of total billed charges,70% of total billed charges for outpatient setting,107.92,84.88,,86.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,63.57,50,,50.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.36,75,,76.29,percent of total billed charges,75% of total billed charges for outpatient setting,89,70,,71.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.71,80,,81.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,16.32,12.84,,13.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,82.64,65,,66.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.5,35,,35.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,114.43,90,,91.54,percent of total billed charges,90% of total billed charges for outpatient setting,16.32,114.43,
TRAP 4 CHAMBER POLYP / 710202,2111799,CDM,272,RC,,,Outpatient,,,35,35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,29.71,84.88,,23.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.5,50,,14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.25,75,,21,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,70,,19.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,80,,22.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,4.49,12.84,,3.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.75,65,,18.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,35,,9.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,90% of total billed charges for outpatient setting,4.49,31.5,
TRAP 4 CHAMBER POLYP / ET2213,2004579,CDM,272,RC,,,Outpatient,,,47.04,47.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,39.93,84.88,,31.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.52,50,,18.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.28,75,,28.22,percent of total billed charges,75% of total billed charges for outpatient setting,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.63,80,,30.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.58,65,,24.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,35,,13.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.34,90,,33.87,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,42.34,
TRAP 4 CHMBR SPEC / STE-298-25,798844,CDM,272,RC,,,Outpatient,,,30.4,30.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.28,70,,17.02,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,84.88,,20.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.2,50,,12.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,75,,18.24,percent of total billed charges,75% of total billed charges for outpatient setting,21.28,70,,17.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,80,,19.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,3.9,12.84,,3.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.76,65,,15.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.64,35,,8.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.36,90,,21.89,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,27.36,
TRAVASOL 8.5% LYTES SOL: 500ML,3302532,CDM,258,RC,,,Outpatient,,,490.81,490.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.57,70,,274.86,percent of total billed charges,70% of total billed charges for outpatient setting,416.6,84.88,,333.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,245.41,50,,196.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.11,75,,294.49,percent of total billed charges,75% of total billed charges for outpatient setting,343.57,70,,274.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,12.84,,50.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.65,80,,314.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,12.84,,50.42,percent of total billed charges,12.84% of total billed charges,63.02,12.84,,50.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,319.03,65,,255.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.78,35,,137.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,441.73,90,,353.38,percent of total billed charges,90% of total billed charges for outpatient setting,63.02,441.73,
TRAVOPROST(TRAVATAN)0.004%OPTHSOLN,3303315,CDM,259,RC,,,Outpatient,,,262.19,262.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.53,70,,146.82,percent of total billed charges,70% of total billed charges for outpatient setting,222.55,84.88,,178.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,131.1,50,,104.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.64,75,,157.31,percent of total billed charges,75% of total billed charges for outpatient setting,183.53,70,,146.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,12.84,,26.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.75,80,,167.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,12.84,,26.94,percent of total billed charges,12.84% of total billed charges,33.67,12.84,,26.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,170.42,65,,136.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.77,35,,73.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,235.97,90,,188.78,percent of total billed charges,90% of total billed charges for outpatient setting,33.67,235.97,
TRAY +03 STD HUMERAL / 110031402,7079700,CDM,278,RC,C1713,HCPCS,Outpatient,,,4375,4375,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625,60,,2100,percent of total billed charges,60% of total Billed charges for outpatient setting,3713.5,84.88,,2970.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3281.25,75,,2625,percent of total billed charges,75% of total billed charges for outpatient setting,2187.5,50,,1750,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,80,,2800,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4593.75,105,,3675,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.25,35,,1225,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2625,60,,2100,percent of total billed charges,60% of total billed charges for outpatient setting,561.75,4593.75,
TRAY +6 HUMERAL STANDARD / 110031405,7079697,CDM,272,RC,,,Outpatient,,,4375,4375,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3062.5,70,,2450,percent of total billed charges,70% of total billed charges for outpatient setting,3713.5,84.88,,2970.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,2187.5,50,,1750,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3281.25,75,,2625,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,80,,2800,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,561.75,12.84,,449.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2843.75,65,,2275,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.25,35,,1225,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3937.5,90,,3150,percent of total billed charges,90% of total billed charges for outpatient setting,561.75,3937.5,
TRAY 16FR 1000ML CATH LF / 775516,355649,CDM,272,RC,,,Outpatient,,,13.77,13.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.64,70,,7.71,percent of total billed charges,70% of total billed charges for outpatient setting,11.69,84.88,,9.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.89,50,,5.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.33,75,,8.26,percent of total billed charges,75% of total billed charges for outpatient setting,9.64,70,,7.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.02,80,,8.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,1.77,12.84,,1.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.95,65,,7.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,35,,3.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.39,90,,9.91,percent of total billed charges,90% of total billed charges for outpatient setting,1.77,12.39,
TRAY 22G ARTHROGRAM CARDINAL / 28-6625A,71000284,CDM,272,RC,,,Outpatient,,,91,91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,77.24,84.88,,61.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.5,50,,36.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.25,75,,54.6,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,70,,50.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,80,,58.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,11.68,12.84,,9.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.15,65,,47.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.85,35,,25.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,81.9,
TRAY 67MM TIBIAL TI / 141212,71000389,CDM,278,RC,C1713,HCPCS,Outpatient,,,1800,1800,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,60,,864,percent of total billed charges,60% of total Billed charges for outpatient setting,1527.84,84.88,,1222.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1350,75,,1080,percent of total billed charges,75% of total billed charges for outpatient setting,900,50,,720,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,80,,1152,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,231.12,12.84,,184.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1800,65,,1440,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,35,,504,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1080,60,,864,percent of total billed charges,60% of total billed charges for outpatient setting,231.12,1800,
TRAY CATH FOLEY 5CC 14FR,5050138,CDM,272,RC,,,Outpatient,,,24.73,24.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,70,,13.85,percent of total billed charges,70% of total billed charges for outpatient setting,20.99,84.88,,16.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.37,50,,9.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.55,75,,14.84,percent of total billed charges,75% of total billed charges for outpatient setting,17.31,70,,13.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.78,80,,15.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,3.18,12.84,,2.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.07,65,,12.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,35,,6.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.26,90,,17.81,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,22.26,
TRAY CONTINUOUS EPIDURAL/CE18TK10LA,6152647,CDM,272,RC,,,Outpatient,,,162.95,162.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.07,70,,91.26,percent of total billed charges,70% of total billed charges for outpatient setting,138.31,84.88,,110.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.48,50,,65.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.21,75,,97.77,percent of total billed charges,75% of total billed charges for outpatient setting,114.07,70,,91.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,12.84,,16.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.36,80,,104.29,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,12.84,,16.74,percent of total billed charges,12.84% of total billed charges,20.92,12.84,,16.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.92,65,,84.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.03,35,,45.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.66,90,,117.33,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,146.66,
TRAY FOLEY CATH 14FR BARD / A303314A,1521011,CDM,272,RC,,,Outpatient,,,105.01,105.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.51,70,,58.81,percent of total billed charges,70% of total billed charges for outpatient setting,89.13,84.88,,71.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,52.51,50,,42.01,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.76,75,,63.01,percent of total billed charges,75% of total billed charges for outpatient setting,73.51,70,,58.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,12.84,,10.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.01,80,,67.21,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,12.84,,10.78,percent of total billed charges,12.84% of total billed charges,13.48,12.84,,10.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.26,65,,54.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,35,,29.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,94.51,90,,75.61,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,94.51,
TRAY FOLEY CATHETER 14FR / KB4709S,8370125,CDM,272,RC,,,Outpatient,,,37.56,37.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,70,,21.03,percent of total billed charges,70% of total billed charges for outpatient setting,31.88,84.88,,25.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.78,50,,15.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.17,75,,22.54,percent of total billed charges,75% of total billed charges for outpatient setting,26.29,70,,21.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.05,80,,24.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,4.82,12.84,,3.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.41,65,,19.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,35,,10.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.8,90,,27.04,percent of total billed charges,90% of total billed charges for outpatient setting,4.82,33.8,
TRAY IRRIGATION PISTON SYRINGE / 68800,6150125,CDM,272,RC,,,Outpatient,,,10.71,10.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,84.88,,7.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.36,50,,4.29,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,75,,6.42,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,70,,6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.104,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,80,,6.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,1.38,12.84,,1.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.96,65,,5.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.75,35,,3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.64,90,,7.71,percent of total billed charges,90% of total billed charges for outpatient setting,1.38,9.64,
TRAY IRRIGATION W/PISTON SYRINGE/3T8100,5150207,CDM,272,RC,,,Outpatient,,,52.94,52.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.06,70,,29.65,percent of total billed charges,70% of total billed charges for outpatient setting,44.94,84.88,,35.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.47,50,,21.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.71,75,,31.77,percent of total billed charges,75% of total billed charges for outpatient setting,37.06,70,,29.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.35,80,,33.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,6.8,12.84,,5.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.41,65,,27.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.53,35,,14.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.65,90,,38.12,percent of total billed charges,90% of total billed charges for outpatient setting,6.8,47.65,
TRAY LUMBAR PUNCT AD 22GX31/2,2450046,CDM,272,RC,,,Outpatient,,,83.75,83.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.63,70,,46.9,percent of total billed charges,70% of total billed charges for outpatient setting,71.09,84.88,,56.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.88,50,,33.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.81,75,,50.25,percent of total billed charges,75% of total billed charges for outpatient setting,58.63,70,,46.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67,80,,53.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,10.75,12.84,,8.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.44,65,,43.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.31,35,,23.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.38,90,,60.3,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75.38,
TRAY SPECIMEN COLLECTION / 0750-210-000,7787715,CDM,271,RC,,,Outpatient,,,22.5,22.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,19.1,84.88,,15.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.25,50,,9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.88,75,,13.5,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,70,,12.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.89,12.84,,2.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,80,,14.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.89,12.84,,2.31,percent of total billed charges,12.84% of total billed charges,2.89,12.84,,2.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.63,65,,11.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,35,,6.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.25,90,,16.2,percent of total billed charges,90% of total billed charges for outpatient setting,2.89,20.25,
TRAY SPINAL BRAUN / 333851,6150041,CDM,272,RC,,,Outpatient,,,92.19,92.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.53,70,,51.62,percent of total billed charges,70% of total billed charges for outpatient setting,78.25,84.88,,62.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.1,50,,36.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.14,75,,55.31,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,70,,51.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,12.84,,9.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.75,80,,59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,12.84,,9.47,percent of total billed charges,12.84% of total billed charges,11.84,12.84,,9.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.92,65,,47.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.27,35,,25.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.97,90,,66.38,percent of total billed charges,90% of total billed charges for outpatient setting,11.84,82.97,
TRAY URETH 14FR RED RUBBER/3T6733B,5050052,CDM,272,RC,,,Outpatient,,,28.18,28.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,70,,15.78,percent of total billed charges,70% of total billed charges for outpatient setting,23.92,84.88,,19.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.09,50,,11.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.14,75,,16.91,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,70,,15.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.54,80,,18.03,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.32,65,,14.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.36,90,,20.29,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.36,
TRAY URETHRAL CATH 15FR/772415,5150204,CDM,272,RC,,,Outpatient,,,18.46,18.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.92,70,,10.34,percent of total billed charges,70% of total billed charges for outpatient setting,15.67,84.88,,12.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.23,50,,7.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.85,75,,11.08,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,70,,10.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.77,80,,11.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,2.37,12.84,,1.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12,65,,9.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,35,,5.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.61,90,,13.29,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,16.61,
TRAY WET SKIN PREP/4465B,6152746,CDM,270,RC,,,Outpatient,,,26.25,26.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,70,,14.7,percent of total billed charges,70% of total billed charges for outpatient setting,22.28,84.88,,17.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.13,50,,10.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.69,75,,15.75,percent of total billed charges,75% of total billed charges for outpatient setting,18.38,70,,14.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.696,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,80,,16.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,3.37,12.84,,2.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.06,65,,13.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,35,,7.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.63,90,,18.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.37,23.63,
TRAZODONE (ULTRAM) TAB : 50MG,3302101,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TRAZODONE (ULTRAM) TAB : 50MG UD,3302102,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TRAZODONE 100MG,3303075,CDM,259,RC,,,Outpatient,,,13.34,13.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.34,70,,7.47,percent of total billed charges,70% of total billed charges for outpatient setting,11.32,84.88,,9.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.67,50,,5.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.01,75,,8.01,percent of total billed charges,75% of total billed charges for outpatient setting,9.34,70,,7.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.67,80,,8.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,1.71,12.84,,1.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.67,65,,6.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,35,,3.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.01,90,,9.61,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,12.01,
TRAZODONE 50MG TAB,3302104,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TRAZODONE TAB: 150 MG,3303251,CDM,259,RC,,,Outpatient,,,13.61,13.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,84.88,,9.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.81,50,,5.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.21,75,,8.17,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,70,,7.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.89,80,,8.71,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,1.75,12.84,,1.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.85,65,,7.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.76,35,,3.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.25,90,,9.8,percent of total billed charges,90% of total billed charges for outpatient setting,1.75,12.25,
TRI TOME MID FOOT CORRECTION / SN21,7677269,CDM,278,RC,C1713,HCPCS,Outpatient,,,1400,1400,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,60,,672,percent of total billed charges,60% of total Billed charges for outpatient setting,1188.32,84.88,,950.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050,75,,840,percent of total billed charges,75% of total billed charges for outpatient setting,700,50,,560,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120,80,,896,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,179.76,12.84,,143.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1400,65,,1120,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490,35,,392,percent of total billed charges,35% of total Billed charges for Outpatient Setting,840,60,,672,percent of total billed charges,60% of total billed charges for outpatient setting,179.76,1400,
TRIAL STIMULATOR EXTERNAL  / 1601,69169715,CDM,272,RC,,,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600.6,65,,480.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,90,,665.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.64,831.6,
TRIAMCINOLONE (ARISTOCORT) CRM 0.1%:80GM,3302107,CDM,259,RC,,,Outpatient,,,14.9,14.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,70,,8.34,percent of total billed charges,70% of total billed charges for outpatient setting,12.65,84.88,,10.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.45,50,,5.96,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.18,75,,8.94,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,70,,8.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,80,,9.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,1.91,12.84,,1.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.69,65,,7.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.22,35,,4.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.41,90,,10.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.91,13.41,
TRIAMCINOLONE (ARISTOCORT) INJ 40MG/ML:1,3302113,CDM,636,RC,J3301,HCPCS,Outpatient,,,56.95,56.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.87,70,,31.9,percent of total billed charges,70% of total billed charges for outpatient setting,48.34,84.88,,38.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.71,75,,34.17,percent of total billed charges,75% of total billed charges for outpatient setting,39.87,70,,31.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,12.84,,5.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.56,80,,36.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,12.84,,5.85,percent of total billed charges,12.84% of total billed charges,7.31,12.84,,5.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.02,65,,29.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,100,,,Fee Schedule,100% of Custom Fee Schedule,51.26,90,,41.01,percent of total billed charges,90% of total billed charges for outpatient setting,1.23,51.26,
TRIAMCINOLONE (ARISTOSPAN) INJ 20MG/ML :,3302112,CDM,250,RC,,,Outpatient,,,25.34,25.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.74,70,,14.19,percent of total billed charges,70% of total billed charges for outpatient setting,21.51,84.88,,17.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.67,50,,10.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,75,,15.21,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,70,,14.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.27,80,,16.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,3.25,12.84,,2.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.47,65,,13.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.87,35,,7.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.81,90,,18.25,percent of total billed charges,90% of total billed charges for outpatient setting,3.25,22.81,
TRIAMCINOLONE (AZMACORT) OINT 0.1% :15GM,3302105,CDM,259,RC,,,Outpatient,,,7.14,7.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,6.06,84.88,,4.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.57,50,,2.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.36,75,,4.29,percent of total billed charges,75% of total billed charges for outpatient setting,5,70,,4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.71,80,,4.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,0.92,12.84,,0.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.64,65,,3.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,35,,2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.43,90,,5.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.92,6.43,
TRIAMCINOLONE (AZMACORT) OINT 0.1% :80GM,3302106,CDM,259,RC,,,Outpatient,,,13.74,13.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.62,70,,7.7,percent of total billed charges,70% of total billed charges for outpatient setting,11.66,84.88,,9.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.87,50,,5.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.31,75,,8.25,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,70,,7.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.99,80,,8.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,1.76,12.84,,1.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.93,65,,7.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,35,,3.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.37,90,,9.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.76,12.37,
TRIAMCINOLONE (AZMACORT)INH 100MCG:20GM,3302111,CDM,259,RC,,,Outpatient,,,160.89,160.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.62,70,,90.1,percent of total billed charges,70% of total billed charges for outpatient setting,136.56,84.88,,109.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,80.45,50,,64.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.67,75,,96.54,percent of total billed charges,75% of total billed charges for outpatient setting,112.62,70,,90.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,12.84,,16.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.71,80,,102.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,12.84,,16.53,percent of total billed charges,12.84% of total billed charges,20.66,12.84,,16.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,104.58,65,,83.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.31,35,,45.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,144.8,90,,115.84,percent of total billed charges,90% of total billed charges for outpatient setting,20.66,144.8,
TRIAMCINOLONE (KENALOG-40) SDV  1ML,3302109,CDM,250,RC,J3301,HCPCS,Outpatient,,,67.11,67.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.98,70,,37.58,percent of total billed charges,70% of total billed charges for outpatient setting,56.96,84.88,,45.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.23,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.33,75,,40.26,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,70,,37.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.69,80,,42.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,8.62,12.84,,6.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,43.62,65,,34.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,100,,,Fee Schedule,100% of Custom Fee Schedule,60.4,90,,48.32,percent of total billed charges,90% of total billed charges for outpatient setting,1.23,60.4,
TRIAMCINOLONE (KENALOG-40) SDV: 1ML,3302108,CDM,250,RC,,,Outpatient,,,26.97,26.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,70,,15.1,percent of total billed charges,70% of total billed charges for outpatient setting,22.89,84.88,,18.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.49,50,,10.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.23,75,,16.18,percent of total billed charges,75% of total billed charges for outpatient setting,18.88,70,,15.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,12.84,,2.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.58,80,,17.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,12.84,,2.77,percent of total billed charges,12.84% of total billed charges,3.46,12.84,,2.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.53,65,,14.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,35,,7.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.27,90,,19.42,percent of total billed charges,90% of total billed charges for outpatient setting,3.46,24.27,
TRIAMCINOLONE (NASACORT AQ) SPY: 16.5GM,3302110,CDM,259,RC,,,Outpatient,,,166.35,166.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.45,70,,93.16,percent of total billed charges,70% of total billed charges for outpatient setting,141.2,84.88,,112.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,83.18,50,,66.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.76,75,,99.81,percent of total billed charges,75% of total billed charges for outpatient setting,116.45,70,,93.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.36,12.84,,17.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.08,80,,106.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.36,12.84,,17.09,percent of total billed charges,12.84% of total billed charges,21.36,12.84,,17.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,108.13,65,,86.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.22,35,,46.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,149.72,90,,119.78,percent of total billed charges,90% of total billed charges for outpatient setting,21.36,149.72,
TRIAMCINOLONE ACETONIDE 0.1% OINT 15GMS,3303238,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
TRIAMPTER/HCTZ 37.5/25 CAPS,3302845,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TRIAVIL 2/25: TAB,3302822,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TRIAZOLAM (genHALCION) 0.25MG TAB,3302117,CDM,259,RC,,,Outpatient,,,92.9,92.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.03,70,,52.02,percent of total billed charges,70% of total billed charges for outpatient setting,78.85,84.88,,63.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,46.45,50,,37.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.68,75,,55.74,percent of total billed charges,75% of total billed charges for outpatient setting,65.03,70,,52.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,12.84,,9.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.32,80,,59.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,12.84,,9.54,percent of total billed charges,12.84% of total billed charges,11.93,12.84,,9.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.39,65,,48.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.52,35,,26.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,83.61,90,,66.89,percent of total billed charges,90% of total billed charges for outpatient setting,11.93,83.61,
TRIAZOLAM (HALCION)  TAB : 0.125MG U/D,3302116,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TRIAZOLAM (HALCION) TAB : 0.125MG,3302114,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TRIAZOLAM (HALCION) TAB : 0.125MG,3302115,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
TRICOR (FENOFIBRATE): 145 MG,3302889,CDM,259,RC,,,Outpatient,,,13.37,13.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,70,,7.49,percent of total billed charges,70% of total billed charges for outpatient setting,11.35,84.88,,9.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.69,50,,5.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.03,75,,8.02,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,70,,7.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.7,80,,8.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.72,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.69,65,,6.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,35,,3.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.03,90,,9.62,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,12.03,
TRICOR 48 MG: TAB,3303093,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TRIFLUOPERAZINE (STELAZINE) TAB: 1MG,3302118,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TRIGLYCERIDE,200550,CDM,300,RC,84478,HCPCS,Outpatient,,,25.83,23.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of Custom Fee Schedule,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,23.25,
TRIGLYCERIDE,200685,CDM,300,RC,84478,HCPCS,Outpatient,,,25.83,23.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of Custom Fee Schedule,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,23.25,
TRIGLYCERIDE,201295,CDM,300,RC,84478,HCPCS,Outpatient,,,25.83,23.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,21.92,84.88,,17.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.37,75,,15.5,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,70,,14.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,80,,16.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.4,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of Custom Fee Schedule,23.25,90,,18.6,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,23.25,
TRILEPTAL 300 MG:,3302984,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
TRIM NAILS,5100166,CDM,510,RC,,,Outpatient,,,253.49,253.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,215.16,84.88,,172.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,126.75,50,,101.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.12,75,,152.1,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,70,,141.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.79,80,,162.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,32.55,12.84,,26.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,164.77,65,,131.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.72,35,,70.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,228.14,90,,182.51,percent of total billed charges,90% of total billed charges for outpatient setting,32.55,228.14,
"TRIM SKIN LESION, > 4",5100164,CDM,510,RC,,,Outpatient,,,229.11,229.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,194.47,84.88,,155.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.56,50,,91.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.83,75,,137.46,percent of total billed charges,75% of total billed charges for outpatient setting,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.29,80,,146.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.92,65,,119.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,35,,64.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.2,90,,164.96,percent of total billed charges,90% of total billed charges for outpatient setting,29.42,206.2,
"TRIM SKIN LESION, 2 TO 4",5100163,CDM,510,RC,,,Outpatient,,,229.11,229.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,194.47,84.88,,155.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.56,50,,91.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.83,75,,137.46,percent of total billed charges,75% of total billed charges for outpatient setting,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.29,80,,146.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.92,65,,119.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,35,,64.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.2,90,,164.96,percent of total billed charges,90% of total billed charges for outpatient setting,29.42,206.2,
"TRIM SKIN LESION, SINGLE",5100162,CDM,510,RC,,,Outpatient,,,229.11,229.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,194.47,84.88,,155.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,114.56,50,,91.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.83,75,,137.46,percent of total billed charges,75% of total billed charges for outpatient setting,160.38,70,,128.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.29,80,,146.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,29.42,12.84,,23.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,148.92,65,,119.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,35,,64.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,206.2,90,,164.96,percent of total billed charges,90% of total billed charges for outpatient setting,29.42,206.2,
TRIMANO BEACH CHAIR KIT / AR-1644,69162236,CDM,272,RC,,,Outpatient,,,269.84,269.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.89,70,,151.11,percent of total billed charges,70% of total billed charges for outpatient setting,229.04,84.88,,183.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.92,50,,107.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.38,75,,161.9,percent of total billed charges,75% of total billed charges for outpatient setting,188.89,70,,151.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,12.84,,27.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.87,80,,172.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,12.84,,27.72,percent of total billed charges,12.84% of total billed charges,34.65,12.84,,27.72,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,175.4,65,,140.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.44,35,,75.55,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.86,90,,194.29,percent of total billed charges,90% of total billed charges for outpatient setting,34.65,242.86,
TRIMETHOBENZ (TIGAN) INJ 100MG/ML : 2ML,3302120,CDM,250,RC,,,Outpatient,,,8.55,8.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,7.26,84.88,,5.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.28,50,,3.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.41,75,,5.13,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,70,,4.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,80,,5.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,1.1,12.84,,0.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.56,65,,4.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,35,,2.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.7,90,,6.16,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,7.7,
TRIMETHOBENZAMDE (TRIMAZIDE) SUPP: 200MG,3302121,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TRIMETHOBENZAMIDE (TIGAN) CAP : 250MG,3302119,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
TRIMETHOPRIM 100 MG: TABS,3303299,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
TROCAR 11X100MM  XCEL / B11LT,69159295,CDM,272,RC,,,Outpatient,,,245,245,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.5,70,,137.2,percent of total billed charges,70% of total billed charges for outpatient setting,207.96,84.88,,166.37,percent of total billed charges,84.88% of total billed charges for outpatient setting,122.5,50,,98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.75,75,,147,percent of total billed charges,75% of total billed charges for outpatient setting,171.5,70,,137.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,12.84,,25.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196,80,,156.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.46,12.84,,25.17,percent of total billed charges,12.84% of total billed charges,31.46,12.84,,25.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,159.25,65,,127.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,35,,68.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,220.5,90,,176.4,percent of total billed charges,90% of total billed charges for outpatient setting,31.46,220.5,
TROCAR 11X100MM / CTF33,69159860,CDM,272,RC,,,Outpatient,,,125,125,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,70,percent of total billed charges,70% of total billed charges for outpatient setting,106.1,84.88,,84.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.5,50,,50,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.75,75,,75,percent of total billed charges,75% of total billed charges for outpatient setting,87.5,70,,70,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100,80,,80,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.25,65,,65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.75,35,,35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.5,90,,90,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.5,
TROCAR 11X100MM KII OPTICAL / CFR33,786040,CDM,272,RC,,,Outpatient,,,135,135,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,70,,75.6,percent of total billed charges,70% of total billed charges for outpatient setting,114.59,84.88,,91.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.5,50,,54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.25,75,,81,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,70,,75.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,12.84,,13.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,80,,86.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,17.33,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.75,65,,70.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,35,,37.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.5,90,,97.2,percent of total billed charges,90% of total billed charges for outpatient setting,17.33,121.5,
TROCAR 12X100MM  XCEL / 2B12LT,69159296,CDM,272,RC,,,Outpatient,,,529.32,529.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.52,70,,296.42,percent of total billed charges,70% of total billed charges for outpatient setting,449.29,84.88,,359.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,264.66,50,,211.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.99,75,,317.59,percent of total billed charges,75% of total billed charges for outpatient setting,370.52,70,,296.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.96,12.84,,54.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.46,80,,338.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.96,12.84,,54.37,percent of total billed charges,12.84% of total billed charges,67.96,12.84,,54.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344.06,65,,275.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.26,35,,148.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,476.39,90,,381.11,percent of total billed charges,90% of total billed charges for outpatient setting,67.96,476.39,
TROCAR 12X10MM / CTF73,69159861,CDM,272,RC,,,Outpatient,,,135,135,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,70,,75.6,percent of total billed charges,70% of total billed charges for outpatient setting,114.59,84.88,,91.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.5,50,,54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.25,75,,81,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,70,,75.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,12.84,,13.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,80,,86.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,17.33,12.84,,13.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.75,65,,70.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,35,,37.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.5,90,,97.2,percent of total billed charges,90% of total billed charges for outpatient setting,17.33,121.5,
TROCAR 12X150MM XCEL / B12XT,69161395,CDM,272,RC,,,Outpatient,,,264.97,264.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.48,70,,148.38,percent of total billed charges,70% of total billed charges for outpatient setting,224.91,84.88,,179.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,132.49,50,,105.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.73,75,,158.98,percent of total billed charges,75% of total billed charges for outpatient setting,185.48,70,,148.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.02,12.84,,27.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.98,80,,169.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.02,12.84,,27.22,percent of total billed charges,12.84% of total billed charges,34.02,12.84,,27.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,172.23,65,,137.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.74,35,,74.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,238.47,90,,190.78,percent of total billed charges,90% of total billed charges for outpatient setting,34.02,238.47,
TROCAR 15X100MM / COR37,69161220,CDM,272,RC,,,Outpatient,,,235,235,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.5,70,,131.6,percent of total billed charges,70% of total billed charges for outpatient setting,199.47,84.88,,159.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.5,50,,94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.25,75,,141,percent of total billed charges,75% of total billed charges for outpatient setting,164.5,70,,131.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,12.84,,24.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188,80,,150.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,12.84,,24.14,percent of total billed charges,12.84% of total billed charges,30.17,12.84,,24.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,152.75,65,,122.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.25,35,,65.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,211.5,90,,169.2,percent of total billed charges,90% of total billed charges for outpatient setting,30.17,211.5,
TROCAR 15X150MM / C0R39,69162745,CDM,272,RC,,,Outpatient,,,568.83,568.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.18,70,,318.54,percent of total billed charges,70% of total billed charges for outpatient setting,482.82,84.88,,386.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,284.42,50,,227.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.62,75,,341.3,percent of total billed charges,75% of total billed charges for outpatient setting,398.18,70,,318.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.04,12.84,,58.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.06,80,,364.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.04,12.84,,58.43,percent of total billed charges,12.84% of total billed charges,73.04,12.84,,58.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,369.74,65,,295.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.09,35,,159.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,511.95,90,,409.56,percent of total billed charges,90% of total billed charges for outpatient setting,73.04,511.95,
TROCAR 5MM XCEL BLADED / D5LT,6150119,CDM,272,RC,,,Outpatient,,,402,402,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.4,70,,225.12,percent of total billed charges,70% of total billed charges for outpatient setting,341.22,84.88,,272.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,201,50,,160.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.5,75,,241.2,percent of total billed charges,75% of total billed charges for outpatient setting,281.4,70,,225.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,12.84,,41.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.6,80,,257.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,12.84,,41.3,percent of total billed charges,12.84% of total billed charges,51.62,12.84,,41.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,261.3,65,,209.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,35,,112.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,361.8,90,,289.44,percent of total billed charges,90% of total billed charges for outpatient setting,51.62,361.8,
TROCAR 5MM XCEL X 150MM (LONG) B5XT,69160397,CDM,272,RC,,,Outpatient,,,268.91,268.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.24,70,,150.59,percent of total billed charges,70% of total billed charges for outpatient setting,228.25,84.88,,182.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,134.46,50,,107.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.68,75,,161.34,percent of total billed charges,75% of total billed charges for outpatient setting,188.24,70,,150.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.53,12.84,,27.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.13,80,,172.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.53,12.84,,27.62,percent of total billed charges,12.84% of total billed charges,34.53,12.84,,27.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,174.79,65,,139.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.12,35,,75.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,242.02,90,,193.62,percent of total billed charges,90% of total billed charges for outpatient setting,34.53,242.02,
TROCAR 5MM XCEL X 75MM (SHORT) B5ST,69160634,CDM,272,RC,,,Outpatient,,,231.83,231.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.28,70,,129.82,percent of total billed charges,70% of total billed charges for outpatient setting,196.78,84.88,,157.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.92,50,,92.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.87,75,,139.1,percent of total billed charges,75% of total billed charges for outpatient setting,162.28,70,,129.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,12.84,,23.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.46,80,,148.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,12.84,,23.82,percent of total billed charges,12.84% of total billed charges,29.77,12.84,,23.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,150.69,65,,120.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.14,35,,64.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,208.65,90,,166.92,percent of total billed charges,90% of total billed charges for outpatient setting,29.77,208.65,
TROCAR 5x100MM / CTF03,69159859,CDM,272,RC,,,Outpatient,,,107.1,107.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.97,70,,59.98,percent of total billed charges,70% of total billed charges for outpatient setting,90.91,84.88,,72.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.55,50,,42.84,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,75,,64.26,percent of total billed charges,75% of total billed charges for outpatient setting,74.97,70,,59.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.68,80,,68.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,13.75,12.84,,11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,69.62,65,,55.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.49,35,,29.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,96.39,90,,77.11,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,96.39,
TROCAR 5x100mm BLADED CTB03,69162053,CDM,272,RC,,,Outpatient,,,133.68,133.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,113.47,84.88,,90.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.84,50,,53.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.26,75,,80.21,percent of total billed charges,75% of total billed charges for outpatient setting,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.94,80,,85.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.89,65,,69.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,35,,37.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.31,90,,96.25,percent of total billed charges,90% of total billed charges for outpatient setting,17.16,120.31,
TROCAR 5X100MM XCEL / 2B5LT,69159294,CDM,272,RC,,,Outpatient,,,529.32,529.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.52,70,,296.42,percent of total billed charges,70% of total billed charges for outpatient setting,449.29,84.88,,359.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,264.66,50,,211.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.99,75,,317.59,percent of total billed charges,75% of total billed charges for outpatient setting,370.52,70,,296.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.96,12.84,,54.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.46,80,,338.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.96,12.84,,54.37,percent of total billed charges,12.84% of total billed charges,67.96,12.84,,54.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,344.06,65,,275.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.26,35,,148.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,476.39,90,,381.11,percent of total billed charges,90% of total billed charges for outpatient setting,67.96,476.39,
TROCAR 5X150MM / CTF01,69161520,CDM,272,RC,,,Outpatient,,,102,102,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.4,70,,57.12,percent of total billed charges,70% of total billed charges for outpatient setting,86.58,84.88,,69.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,51,50,,40.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,75,,61.2,percent of total billed charges,75% of total billed charges for outpatient setting,71.4,70,,57.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,80,,65.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,13.1,12.84,,10.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,66.3,65,,53.04,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,35,,28.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.8,90,,73.44,percent of total billed charges,90% of total billed charges for outpatient setting,13.1,91.8,
TROCAR 5X55MM / CTR05,69161523,CDM,272,RC,,,Outpatient,,,173.04,173.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,84.88,,117.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.52,50,,69.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.78,75,,103.82,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,70,,96.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.43,80,,110.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,22.22,12.84,,17.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,112.48,65,,89.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.56,35,,48.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,155.74,90,,124.59,percent of total billed charges,90% of total billed charges for outpatient setting,22.22,155.74,
TROCAR 5X75MM XCEL / 2B5ST,69161744,CDM,272,RC,,,Outpatient,,,544.87,544.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.41,70,,305.13,percent of total billed charges,70% of total billed charges for outpatient setting,462.49,84.88,,369.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,272.44,50,,217.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.65,75,,326.92,percent of total billed charges,75% of total billed charges for outpatient setting,381.41,70,,305.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.96,12.84,,55.968,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.9,80,,348.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.96,12.84,,55.97,percent of total billed charges,12.84% of total billed charges,69.96,12.84,,55.97,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,354.17,65,,283.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.7,35,,152.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,490.38,90,,392.3,percent of total billed charges,90% of total billed charges for outpatient setting,69.96,490.38,
TROCAR 8X100MM XCEL / B8LT,69161393,CDM,272,RC,,,Outpatient,,,465.64,465.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.95,70,,260.76,percent of total billed charges,70% of total billed charges for outpatient setting,395.24,84.88,,316.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,232.82,50,,186.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,349.23,75,,279.38,percent of total billed charges,75% of total billed charges for outpatient setting,325.95,70,,260.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.79,12.84,,47.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.51,80,,298.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.79,12.84,,47.83,percent of total billed charges,12.84% of total billed charges,59.79,12.84,,47.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,302.67,65,,242.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,35,,130.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,419.08,90,,335.26,percent of total billed charges,90% of total billed charges for outpatient setting,59.79,419.08,
TROCAR APPLE 5MM PYRAMIDAL TIP / 900-800,6150657,CDM,272,RC,,,Outpatient,,,211.1,211.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.77,70,,118.22,percent of total billed charges,70% of total billed charges for outpatient setting,179.18,84.88,,143.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,105.55,50,,84.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.33,75,,126.66,percent of total billed charges,75% of total billed charges for outpatient setting,147.77,70,,118.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.11,12.84,,21.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.88,80,,135.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.11,12.84,,21.69,percent of total billed charges,12.84% of total billed charges,27.11,12.84,,21.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,137.22,65,,109.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.89,35,,59.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,189.99,90,,151.99,percent of total billed charges,90% of total billed charges for outpatient setting,27.11,189.99,
TROCAR BLUNT (ORIGIN) 12mm / OMST12BT,69160639,CDM,272,RC,,,Outpatient,,,623.78,623.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.65,70,,349.32,percent of total billed charges,70% of total billed charges for outpatient setting,529.46,84.88,,423.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,311.89,50,,249.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,467.84,75,,374.27,percent of total billed charges,75% of total billed charges for outpatient setting,436.65,70,,349.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.09,12.84,,64.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.02,80,,399.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.09,12.84,,64.07,percent of total billed charges,12.84% of total billed charges,80.09,12.84,,64.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,405.46,65,,324.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.32,35,,174.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,561.4,90,,449.12,percent of total billed charges,90% of total billed charges for outpatient setting,80.09,561.4,
TROCAR BLUNT 10MM ORIGIN // OMS-T10BTS,6150669,CDM,272,RC,,,Outpatient,,,301.73,301.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.21,70,,168.97,percent of total billed charges,70% of total billed charges for outpatient setting,256.11,84.88,,204.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,150.87,50,,120.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.3,75,,181.04,percent of total billed charges,75% of total billed charges for outpatient setting,211.21,70,,168.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.74,12.84,,30.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.38,80,,193.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.74,12.84,,30.99,percent of total billed charges,12.84% of total billed charges,38.74,12.84,,30.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,196.12,65,,156.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.61,35,,84.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,271.56,90,,217.25,percent of total billed charges,90% of total billed charges for outpatient setting,38.74,271.56,
TROCAR BLUNT 12X130MM / COR50,69162702,CDM,272,RC,,,Outpatient,,,227.12,227.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,192.78,84.88,,154.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,113.56,50,,90.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.34,75,,136.27,percent of total billed charges,75% of total billed charges for outpatient setting,158.98,70,,127.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.7,80,,145.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,29.16,12.84,,23.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,147.63,65,,118.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.49,35,,63.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,204.41,90,,163.53,percent of total billed charges,90% of total billed charges for outpatient setting,29.16,204.41,
TROCAR CATHETER 20FR./88-561043,5150248,CDM,272,RC,,,Outpatient,,,94.35,94.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,84.88,,64.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.18,50,,37.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.76,75,,56.61,percent of total billed charges,75% of total billed charges for outpatient setting,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,80,,60.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.33,65,,49.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,35,,26.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.92,90,,67.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,84.92,
TROCAR CATHETER 28FR./88-561068,5150250,CDM,272,RC,,,Outpatient,,,94.35,94.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,84.88,,64.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,47.18,50,,37.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.76,75,,56.61,percent of total billed charges,75% of total billed charges for outpatient setting,66.05,70,,52.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,80,,60.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,12.11,12.84,,9.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,61.33,65,,49.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,35,,26.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,84.92,90,,67.94,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,84.92,
TROCAR DILATING TIP BLADED 11mm/D11LT,69160445,CDM,272,RC,,,Outpatient,,,260.98,260.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.69,70,,146.15,percent of total billed charges,70% of total billed charges for outpatient setting,221.52,84.88,,177.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.49,50,,104.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.74,75,,156.59,percent of total billed charges,75% of total billed charges for outpatient setting,182.69,70,,146.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.51,12.84,,26.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.78,80,,167.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.51,12.84,,26.81,percent of total billed charges,12.84% of total billed charges,33.51,12.84,,26.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,169.64,65,,135.71,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.34,35,,73.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,234.88,90,,187.9,percent of total billed charges,90% of total billed charges for outpatient setting,33.51,234.88,
TROCAR LONG 5MM CORE/CD7150G,6150865,CDM,272,RC,,,Outpatient,,,253.16,253.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.21,70,,141.77,percent of total billed charges,70% of total billed charges for outpatient setting,214.88,84.88,,171.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,126.58,50,,101.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.87,75,,151.9,percent of total billed charges,75% of total billed charges for outpatient setting,177.21,70,,141.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.51,12.84,,26.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.53,80,,162.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.51,12.84,,26.01,percent of total billed charges,12.84% of total billed charges,32.51,12.84,,26.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,164.55,65,,131.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.61,35,,70.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,227.84,90,,182.27,percent of total billed charges,90% of total billed charges for outpatient setting,32.51,227.84,
TROCAR STARTER STYLET P2ST1060,69162317,CDM,272,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.19,65,,224.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.55,389.34,
T-ROPE KNTLSS SYN RPR / AR-8925T,71000169,CDM,278,RC,C1713,HCPCS,Outpatient,,,3139.5,3139.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1883.7,60,,1506.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2664.81,84.88,,2131.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2354.63,75,,1883.7,percent of total billed charges,75% of total billed charges for outpatient setting,1569.75,50,,1255.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.6,80,,2009.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3296.48,105,,2637.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.83,35,,879.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1883.7,60,,1506.96,percent of total billed charges,60% of total billed charges for outpatient setting,403.11,3296.48,
T-ROPE KNTLSS SYNDSMOSIS RPR / AR-8926SS,69162327,CDM,278,RC,C1713,HCPCS,Outpatient,,,3331.02,3331.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1998.61,60,,1598.89,percent of total billed charges,60% of total Billed charges for outpatient setting,2827.37,84.88,,2261.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2498.27,75,,1998.62,percent of total billed charges,75% of total billed charges for outpatient setting,1665.51,50,,1332.41,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.7,12.84,,342.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2664.82,80,,2131.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.7,12.84,,342.16,percent of total billed charges,12.84% of total billed charges,427.7,12.84,,342.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3497.57,105,,2798.06,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1165.86,35,,932.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1998.61,60,,1598.89,percent of total billed charges,60% of total billed charges for outpatient setting,427.7,3497.57,
T-ROPE SYNDSMOSIS XP SS / AR-8925SS,69169438,CDM,278,RC,C1713,HCPCS,Outpatient,,,3139.5,3139.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1883.7,60,,1506.96,percent of total billed charges,60% of total Billed charges for outpatient setting,2664.81,84.88,,2131.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2354.63,75,,1883.7,percent of total billed charges,75% of total billed charges for outpatient setting,1569.75,50,,1255.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.6,80,,2009.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,403.11,12.84,,322.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3296.48,105,,2637.18,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.83,35,,879.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1883.7,60,,1506.96,percent of total billed charges,60% of total billed charges for outpatient setting,403.11,3296.48,
TROPICAMIDE (genMYDRIACYL)OPHTH  1% 15ML,3310330,CDM,259,RC,,,Outpatient,,,39.69,39.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,33.69,84.88,,26.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.85,50,,15.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.77,75,,23.82,percent of total billed charges,75% of total billed charges for outpatient setting,27.78,70,,22.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.75,80,,25.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,5.1,12.84,,4.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,25.8,65,,20.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.89,35,,11.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,35.72,90,,28.58,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,35.72,
TROPICAMIDE (MYDRIACYL) OPTH SOL 1%:3ML,3302123,CDM,259,RC,,,Outpatient,,,33.65,33.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,28.56,84.88,,22.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.83,50,,13.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.24,75,,20.19,percent of total billed charges,75% of total billed charges for outpatient setting,23.56,70,,18.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,12.84,,3.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,80,,21.54,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,4.32,12.84,,3.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.87,65,,17.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.78,35,,9.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.29,90,,24.23,percent of total billed charges,90% of total billed charges for outpatient setting,4.32,30.29,
TROPICAMIDE (MYDRIACYL)OPTH SOL 1% : 3ML,3302122,CDM,259,RC,,,Outpatient,,,13.47,13.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.43,70,,7.54,percent of total billed charges,70% of total billed charges for outpatient setting,11.43,84.88,,9.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.74,50,,5.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.1,75,,8.08,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,70,,7.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,80,,8.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,1.73,12.84,,1.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.76,65,,7.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,35,,3.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.12,90,,9.7,percent of total billed charges,90% of total billed charges for outpatient setting,1.73,12.12,
TROPICAMIDE (MYDRIACYL)OPTH SOL 1% :15ML,3302124,CDM,259,RC,,,Outpatient,,,101.3,101.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,70,,56.73,percent of total billed charges,70% of total billed charges for outpatient setting,85.98,84.88,,68.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.65,50,,40.52,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.98,75,,60.78,percent of total billed charges,75% of total billed charges for outpatient setting,70.91,70,,56.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,12.84,,10.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.04,80,,64.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,12.84,,10.41,percent of total billed charges,12.84% of total billed charges,13.01,12.84,,10.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,65.85,65,,52.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.46,35,,28.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,91.17,90,,72.94,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,91.17,
TROPONIN,222017,CDM,300,RC,84484,HCPCS,Outpatient,,,56.12,50.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.28,70,,31.42,percent of total billed charges,70% of total billed charges for outpatient setting,47.63,84.88,,38.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,42.09,75,,33.67,percent of total billed charges,75% of total billed charges for outpatient setting,39.28,70,,31.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.9,80,,35.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of Custom Fee Schedule,50.51,90,,40.41,percent of total billed charges,90% of total billed charges for outpatient setting,12.47,50.51,
TRYPAN BLUE PF 0.06% 0.5MLS,3302903,CDM,259,RC,,,Outpatient,,,293.16,293.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.21,70,,164.17,percent of total billed charges,70% of total billed charges for outpatient setting,248.83,84.88,,199.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,146.58,50,,117.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.87,75,,175.9,percent of total billed charges,75% of total billed charges for outpatient setting,205.21,70,,164.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.64,12.84,,30.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.53,80,,187.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.64,12.84,,30.11,percent of total billed charges,12.84% of total billed charges,37.64,12.84,,30.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,190.55,65,,152.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.61,35,,82.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,263.84,90,,211.07,percent of total billed charges,90% of total billed charges for outpatient setting,37.64,263.84,
TRYPSIN,201462,CDM,301,RC,83519,HCPCS,Outpatient,,,82.8,74.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,70.28,84.88,,56.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,62.1,75,,49.68,percent of total billed charges,75% of total billed charges for outpatient setting,57.96,70,,46.37,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.24,80,,52.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.73,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,100,,,Fee Schedule,100% of Custom Fee Schedule,74.52,90,,59.62,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,74.52,
TRYPSIN BAL (GRANULEX) SPY : 120 ML,3302125,CDM,259,RC,,,Outpatient,,,51.84,51.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,70,,29.03,percent of total billed charges,70% of total billed charges for outpatient setting,44,84.88,,35.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.92,50,,20.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,75,,31.1,percent of total billed charges,75% of total billed charges for outpatient setting,36.29,70,,29.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,12.84,,5.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.47,80,,33.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,12.84,,5.33,percent of total billed charges,12.84% of total billed charges,6.66,12.84,,5.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.7,65,,26.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,35,,14.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.66,90,,37.33,percent of total billed charges,90% of total billed charges for outpatient setting,6.66,46.66,
TRYPTASE,220174,CDM,301,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
TSH,200225,CDM,301,RC,84443,HCPCS,Outpatient,,,75.6,68.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.17,84.88,,51.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.7,75,,45.36,percent of total billed charges,75% of total billed charges for outpatient setting,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,80,,48.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,100,,,Fee Schedule,100% of Custom Fee Schedule,68.04,90,,54.43,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,68.04,
TSH,200560,CDM,300,RC,84443,HCPCS,Outpatient,,,75.6,68.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,64.17,84.88,,51.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.86,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.7,75,,45.36,percent of total billed charges,75% of total billed charges for outpatient setting,52.92,70,,42.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,80,,48.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.53,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,100,,,Fee Schedule,100% of Custom Fee Schedule,68.04,90,,54.43,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,68.04,
TSH RECEPTOR ANTIBODIES,220115,CDM,300,RC,83520,HCPCS,Outpatient,,,77.72,69.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,65.97,84.88,,52.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.02,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,58.29,75,,46.63,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,70,,43.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.18,80,,49.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,100,,,Fee Schedule,100% of Custom Fee Schedule,69.95,90,,55.96,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,69.95,
T-SPINE 3 VWS,2400235,CDM,320,RC,72072,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
T-SPINE MIN 4 VWS,2400240,CDM,320,RC,72074,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
TTE W/CONTRAST 2D & CF W/DOPPLER ECHO,2610021,CDM,483,RC,C8929,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
TTE W/CONTRAST 2D LIMITED,2610020,CDM,483,RC,C8924,HCPCS,Outpatient,,,1141.31,1141.31,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,595.47,100,,,Fee Schedule,100% of Custom Fee Schedule,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,146.54,1027.18,
TTE W/CONTRAST 2D REST & W/STRESS,2610022,CDM,483,RC,C8930,HCPCS,Outpatient,,,2217.32,2217.32,,1025.76,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1882.06,84.88,,1505.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,948.36,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1662.99,75,,1330.39,percent of total billed charges,75% of total billed charges for outpatient setting,1552.12,70,,1241.7,percent of total billed charges,70% of total billed charges for outpatient setting,1089.86,170,,,Fee Schedule,170% of Medicare OPPS rate,1378.37,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,1121.93,175,,,Fee Schedule,175% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1773.86,80,,1419.09,percent of total billed charges,80% of total billed charges for outpatient setting,897.54,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,801.37,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,284.7,12.84,,227.76,percent of total billed charges,12.84% of total billed charges,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,388,100,,,Case rate,pays based on fixed rate ,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,641.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,778.28,100,,,Fee Schedule,100% of Custom Fee Schedule,1995.59,90,,1596.47,percent of total billed charges,90% of total billed charges for outpatient setting,284.7,1995.59,
T-TUBE CATTELL 10FR / DC10015,69160288,CDM,272,RC,,,Outpatient,,,64.66,64.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.26,70,,36.21,percent of total billed charges,70% of total billed charges for outpatient setting,54.88,84.88,,43.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,32.33,50,,25.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.5,75,,38.8,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,70,,36.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.73,80,,41.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,8.3,12.84,,6.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,42.03,65,,33.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.63,35,,18.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,58.19,90,,46.55,percent of total billed charges,90% of total billed charges for outpatient setting,8.3,58.19,
T-TUBE CATTELL 12FR / 0100160,69160289,CDM,272,RC,,,Outpatient,,,57.76,57.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.43,70,,32.34,percent of total billed charges,70% of total billed charges for outpatient setting,49.03,84.88,,39.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.88,50,,23.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.32,75,,34.66,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,70,,32.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,12.84,,5.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.21,80,,36.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,12.84,,5.94,percent of total billed charges,12.84% of total billed charges,7.42,12.84,,5.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.54,65,,30.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,35,,16.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.98,90,,41.58,percent of total billed charges,90% of total billed charges for outpatient setting,7.42,51.98,
T-TUBE CATTELL 14FR / 0100170,69160290,CDM,272,RC,,,Outpatient,,,57.69,57.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,48.97,84.88,,39.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.85,50,,23.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.27,75,,34.62,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.15,80,,36.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.5,65,,30,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.19,35,,16.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.92,90,,41.54,percent of total billed charges,90% of total billed charges for outpatient setting,7.41,51.92,
T-TUBE CATTELL 16FR / 0100180,69160291,CDM,272,RC,,,Outpatient,,,57.69,57.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,48.97,84.88,,39.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.85,50,,23.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.27,75,,34.62,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,70,,32.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.15,80,,36.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,7.41,12.84,,5.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.5,65,,30,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.19,35,,16.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.92,90,,41.54,percent of total billed charges,90% of total billed charges for outpatient setting,7.41,51.92,
T-TUBE MODIFIED SILICONE / 510-111,69161542,CDM,278,RC,,,Outpatient,,,117.3,117.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,60,,56.3,percent of total billed charges,60% of total Billed charges for outpatient setting,99.56,84.88,,79.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.65,50,,46.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.98,75,,70.38,percent of total billed charges,75% of total billed charges for outpatient setting,58.65,50,,46.92,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.06,12.84,,12.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.84,80,,75.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.06,12.84,,12.05,percent of total billed charges,12.84% of total billed charges,15.06,12.84,,12.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,117.3,65,,93.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.06,35,,32.85,percent of total billed charges,35% of total Billed charges for Outpatient Setting,70.38,60,,56.3,percent of total billed charges,60% of total billed charges for outpatient setting,15.06,117.3,
TU (THYRONINE UPTAKE),201265,CDM,300,RC,84449,HCPCS,Outpatient,,,81,72.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,70,,45.36,percent of total billed charges,70% of total billed charges for outpatient setting,68.75,84.88,,55,percent of total billed charges,84.88% of total billed charges for outpatient setting,30.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,60.75,75,,48.6,percent of total billed charges,75% of total billed charges for outpatient setting,56.7,70,,45.36,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,80,,51.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,26.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.12,100,,,Fee Schedule,100% of Custom Fee Schedule,72.9,90,,58.32,percent of total billed charges,90% of total billed charges for outpatient setting,18,72.9,
TUBE 10FR 36IN SALEM SUMP / 004210,3750047,CDM,272,RC,,,Outpatient,,,21.6,21.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,18.33,84.88,,14.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.8,50,,8.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,75,,12.96,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,80,,13.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.04,65,,11.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,35,,6.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.44,90,,15.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.77,19.44,
TUBE 16 FR NG,7651138,CDM,272,RC,,,Outpatient,,,35.56,35.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.89,70,,19.91,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,84.88,,24.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.78,50,,14.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.67,75,,21.34,percent of total billed charges,75% of total billed charges for outpatient setting,24.89,70,,19.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,12.84,,3.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.45,80,,22.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.57,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,4.57,12.84,,3.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.11,65,,18.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.45,35,,9.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32,90,,25.6,percent of total billed charges,90% of total billed charges for outpatient setting,4.57,32,
TUBE 16FR 48IN SALEM SUMP / 0042160,3750050,CDM,272,RC,,,Outpatient,,,21.6,21.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,18.33,84.88,,14.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.8,50,,8.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,75,,12.96,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,80,,13.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.04,65,,11.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,35,,6.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.44,90,,15.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.77,19.44,
TUBE 2.0MM UNCUFFED / 86232,3750037,CDM,272,RC,,,Outpatient,,,7.68,7.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,84.88,,5.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.76,75,,4.61,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,35,,2.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.91,90,,5.53,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.91,
TUBE 2.5MM UNCUFFED,3750038,CDM,272,RC,,,Outpatient,,,7.68,7.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,84.88,,5.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.76,75,,4.61,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,35,,2.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.91,90,,5.53,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.91,
TUBE 3.0MM UNCUFFED / 86234,3750039,CDM,272,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,9.34,84.88,,7.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.5,50,,4.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.25,75,,6.6,percent of total billed charges,75% of total billed charges for outpatient setting,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,80,,7.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.15,65,,5.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,35,,3.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.9,90,,7.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,9.9,
TUBE 3.5MM UNCUFFED / 86235,3750040,CDM,272,RC,,,Outpatient,,,10.08,10.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,70,,5.65,percent of total billed charges,70% of total billed charges for outpatient setting,8.56,84.88,,6.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.04,50,,4.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.56,75,,6.05,percent of total billed charges,75% of total billed charges for outpatient setting,7.06,70,,5.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,80,,6.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.55,65,,5.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,35,,2.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.07,90,,7.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.29,9.07,
TUBE 32FR CHEST STRAIGHT / 8888570556,6150882,CDM,272,RC,,,Outpatient,,,47.04,47.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,39.93,84.88,,31.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.52,50,,18.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.28,75,,28.22,percent of total billed charges,75% of total billed charges for outpatient setting,32.93,70,,26.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.63,80,,30.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,6.04,12.84,,4.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,30.58,65,,24.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,35,,13.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,42.34,90,,33.87,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,42.34,
TUBE 4 SHILEY TRACH TAPERGUARD / 4CN65H,6150726,CDM,272,RC,,,Outpatient,,,185.7,185.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.99,70,,103.99,percent of total billed charges,70% of total billed charges for outpatient setting,157.62,84.88,,126.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,92.85,50,,74.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.28,75,,111.42,percent of total billed charges,75% of total billed charges for outpatient setting,129.99,70,,103.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.56,80,,118.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,23.84,12.84,,19.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,120.71,65,,96.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65,35,,52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,167.13,90,,133.7,percent of total billed charges,90% of total billed charges for outpatient setting,23.84,167.13,
TUBE 4.0MM CUFFED / 86045,3750026,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
TUBE 4.0MM UNCUFFED / 86225,3750041,CDM,272,RC,,,Outpatient,,,10.08,10.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,70,,5.65,percent of total billed charges,70% of total billed charges for outpatient setting,8.56,84.88,,6.85,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.04,50,,4.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.56,75,,6.05,percent of total billed charges,75% of total billed charges for outpatient setting,7.06,70,,5.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.06,80,,6.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,1.29,12.84,,1.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.55,65,,5.24,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,35,,2.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.07,90,,7.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.29,9.07,
TUBE 4.5MM CUFFED / 86046,3750027,CDM,272,RC,,,Outpatient,,,12.85,12.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,84.88,,8.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.43,50,,5.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.64,75,,7.71,percent of total billed charges,75% of total billed charges for outpatient setting,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,80,,8.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.35,65,,6.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.57,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.57,
TUBE 4.5MM UNCUFFED / 86226,3750042,CDM,272,RC,,,Outpatient,,,25.8,25.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,21.9,84.88,,17.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.9,50,,10.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.35,75,,15.48,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,70,,14.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,80,,16.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,3.31,12.84,,2.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.77,65,,13.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,35,,7.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.22,90,,18.58,percent of total billed charges,90% of total billed charges for outpatient setting,3.31,23.22,
TUBE 5.0MM CUFFED / 86047,3750028,CDM,272,RC,,,Outpatient,,,12.87,12.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,10.92,84.88,,8.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.44,50,,5.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,75,,7.72,percent of total billed charges,75% of total billed charges for outpatient setting,9.01,70,,7.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,80,,8.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.37,65,,6.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.58,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.58,
TUBE 5.0MM UNCUFFED,3750043,CDM,272,RC,,,Outpatient,,,7.68,7.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,84.88,,5.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.76,75,,4.61,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,35,,2.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.91,90,,5.53,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.91,
TUBE 5.5MM CUFFED / 86048,3750029,CDM,272,RC,,,Outpatient,,,12.85,12.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,84.88,,8.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.43,50,,5.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.64,75,,7.71,percent of total billed charges,75% of total billed charges for outpatient setting,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,80,,8.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.35,65,,6.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.57,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.57,
TUBE 5.5MM UNCUFFED / 86239,3750044,CDM,272,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,9.34,84.88,,7.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.5,50,,4.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.25,75,,6.6,percent of total billed charges,75% of total billed charges for outpatient setting,7.7,70,,6.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.128,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.8,80,,7.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,1.41,12.84,,1.13,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.15,65,,5.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,35,,3.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.9,90,,7.92,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,9.9,
TUBE 6.0MM UNCUFFED,3750045,CDM,272,RC,,,Outpatient,,,7.68,7.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,84.88,,5.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.84,50,,3.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.76,75,,4.61,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,70,,4.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,80,,4.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.99,65,,3.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.69,35,,2.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.91,90,,5.53,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.91,
TUBE 6.5MM CUFFED / 86050,3750031,CDM,272,RC,,,Outpatient,,,12.85,12.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,84.88,,8.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.43,50,,5.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.64,75,,7.71,percent of total billed charges,75% of total billed charges for outpatient setting,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,80,,8.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.35,65,,6.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.57,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.57,
TUBE 6.5MM UNCUFFED,5050056,CDM,272,RC,,,Outpatient,,,8.28,8.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,7.03,84.88,,5.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.14,50,,3.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.21,75,,4.97,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,80,,5.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,65,,4.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,35,,2.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.45,90,,5.96,percent of total billed charges,90% of total billed charges for outpatient setting,1.06,7.45,
TUBE 7.0MM CUFFED / 86051,3750032,CDM,272,RC,,,Outpatient,,,12.85,12.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,84.88,,8.73,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.43,50,,5.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.64,75,,7.71,percent of total billed charges,75% of total billed charges for outpatient setting,9,70,,7.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,80,,8.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,1.65,12.84,,1.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.35,65,,6.68,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,35,,3.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.57,90,,9.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,11.57,
TUBE 7.0MM UNCUFFED,5050057,CDM,272,RC,,,Outpatient,,,8.28,8.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,7.03,84.88,,5.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.14,50,,3.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.21,75,,4.97,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,70,,4.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.62,80,,5.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,1.06,12.84,,0.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,65,,4.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,35,,2.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.45,90,,5.96,percent of total billed charges,90% of total billed charges for outpatient setting,1.06,7.45,
TUBE 7.5 ORAL CUFFED / 86451,370094,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
TUBE 7.5MM CUFFED / 86052,3750033,CDM,272,RC,,,Outpatient,,,12.25,12.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.4,84.88,,8.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.13,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.19,75,,7.35,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.8,80,,7.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,35,,3.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.03,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.03,
TUBE 7.5MM CUFFED MURPHY / 86112,370070,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
TUBE 8.0MM CUFFED / 86053,3750034,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
TUBE 8.5MM CUFFED / 86054,3750035,CDM,272,RC,,,Outpatient,,,16.55,16.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.05,84.88,,11.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.41,75,,9.93,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,80,,10.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,35,,4.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
TUBE 9.0MM CUFFED / 86055,3750036,CDM,272,RC,,,Outpatient,,,16.55,16.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,14.05,84.88,,11.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.28,50,,6.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.41,75,,9.93,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,70,,9.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.24,80,,10.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,2.13,12.84,,1.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.76,65,,8.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.79,35,,4.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.9,90,,11.92,percent of total billed charges,90% of total billed charges for outpatient setting,2.13,14.9,
TUBE BAXTER BEVEL VENT / VT-0602-01,71000248,CDM,272,RC,,,Outpatient,,,124.98,124.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,106.08,84.88,,84.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.49,50,,49.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.74,75,,74.99,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,70,,69.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.98,80,,79.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,16.05,12.84,,12.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.24,65,,64.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.74,35,,34.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.48,90,,89.98,percent of total billed charges,90% of total billed charges for outpatient setting,16.05,112.48,
TUBE CONN 5MMX1.8M NON-CONDUCT,5150052,CDM,270,RC,,,Outpatient,,,3.08,3.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.61,84.88,,2.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.54,50,,1.23,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.31,75,,1.85,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,80,,1.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2,65,,1.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.77,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.77,
TUBE CUFFED 24FR 6.0MM / 86049,3750030,CDM,272,RC,,,Outpatient,,,12.24,12.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,10.39,84.88,,8.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.12,50,,4.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,75,,7.34,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,70,,6.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.79,80,,7.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,1.57,12.84,,1.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.96,65,,6.37,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,35,,3.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.02,90,,8.82,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,11.02,
TUBE EMG 7MM NIM / 8229737,69161633,CDM,272,RC,,,Outpatient,,,1063.6,1063.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.52,70,,595.62,percent of total billed charges,70% of total billed charges for outpatient setting,902.78,84.88,,722.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,531.8,50,,425.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,797.7,75,,638.16,percent of total billed charges,75% of total billed charges for outpatient setting,744.52,70,,595.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.57,12.84,,109.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.88,80,,680.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.57,12.84,,109.26,percent of total billed charges,12.84% of total billed charges,136.57,12.84,,109.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,691.34,65,,553.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.26,35,,297.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,957.24,90,,765.79,percent of total billed charges,90% of total billed charges for outpatient setting,136.57,957.24,
TUBE EMG 8MM NIM / 8229738,69161634,CDM,272,RC,,,Outpatient,,,1111.7,1111.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.19,70,,622.55,percent of total billed charges,70% of total billed charges for outpatient setting,943.61,84.88,,754.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,555.85,50,,444.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,833.78,75,,667.02,percent of total billed charges,75% of total billed charges for outpatient setting,778.19,70,,622.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.74,12.84,,114.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.36,80,,711.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.74,12.84,,114.19,percent of total billed charges,12.84% of total billed charges,142.74,12.84,,114.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,722.61,65,,578.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.1,35,,311.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1000.53,90,,800.42,percent of total billed charges,90% of total billed charges for outpatient setting,142.74,1000.53,
TUBE EMG 9mm (NIM),69161811,CDM,272,RC,,,Outpatient,,,1111.7,1111.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.19,70,,622.55,percent of total billed charges,70% of total billed charges for outpatient setting,943.61,84.88,,754.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,555.85,50,,444.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,833.78,75,,667.02,percent of total billed charges,75% of total billed charges for outpatient setting,778.19,70,,622.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.74,12.84,,114.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.36,80,,711.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.74,12.84,,114.19,percent of total billed charges,12.84% of total billed charges,142.74,12.84,,114.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,722.61,65,,578.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.1,35,,311.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1000.53,90,,800.42,percent of total billed charges,90% of total billed charges for outpatient setting,142.74,1000.53,
TUBE ENDOTRACHEAL LASER SHIELD 6MM,69161469,CDM,272,RC,,,Outpatient,,,726.77,726.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.74,70,,406.99,percent of total billed charges,70% of total billed charges for outpatient setting,616.88,84.88,,493.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,363.39,50,,290.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,545.08,75,,436.06,percent of total billed charges,75% of total billed charges for outpatient setting,508.74,70,,406.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.32,12.84,,74.656,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.42,80,,465.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.32,12.84,,74.66,percent of total billed charges,12.84% of total billed charges,93.32,12.84,,74.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,472.4,65,,377.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.37,35,,203.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,654.09,90,,523.27,percent of total billed charges,90% of total billed charges for outpatient setting,93.32,654.09,
TUBE FEEDING 5FR / 88-260802,6152182,CDM,272,RC,,,Outpatient,,,9.93,9.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,70,,5.56,percent of total billed charges,70% of total billed charges for outpatient setting,8.43,84.88,,6.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.97,50,,3.98,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.45,75,,5.96,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,70,,5.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.94,80,,6.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,1.28,12.84,,1.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.45,65,,5.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.48,35,,2.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.94,90,,7.15,percent of total billed charges,90% of total billed charges for outpatient setting,1.28,8.94,
TUBE LUKI ASPIRATING / 8646-04,6050031,CDM,270,RC,,,Outpatient,,,28.32,28.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,24.04,84.88,,19.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.16,50,,11.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.24,75,,16.99,percent of total billed charges,75% of total billed charges for outpatient setting,19.82,70,,15.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.66,80,,18.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,3.64,12.84,,2.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.41,65,,14.73,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,35,,7.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.49,90,,20.39,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,25.49,
TUBE NG FEEDING 12FR KANGAROO / 88847115,70000477,CDM,270,RC,,,Outpatient,,,51.18,51.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.83,70,,28.66,percent of total billed charges,70% of total billed charges for outpatient setting,43.44,84.88,,34.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.59,50,,20.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.39,75,,30.71,percent of total billed charges,75% of total billed charges for outpatient setting,35.83,70,,28.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.57,12.84,,5.256,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.94,80,,32.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.57,12.84,,5.26,percent of total billed charges,12.84% of total billed charges,6.57,12.84,,5.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.27,65,,26.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.91,35,,14.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.06,90,,36.85,percent of total billed charges,90% of total billed charges for outpatient setting,6.57,46.06,
TUBE SALEM SMP 18FR 48IN / 0042180,5050098,CDM,272,RC,,,Outpatient,,,8.1,8.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,70,,4.54,percent of total billed charges,70% of total billed charges for outpatient setting,6.88,84.88,,5.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.05,50,,3.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.08,75,,4.86,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,70,,4.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,80,,5.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,1.04,12.84,,0.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.27,65,,4.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.84,35,,2.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.29,90,,5.83,percent of total billed charges,90% of total billed charges for outpatient setting,1.04,7.29,
TUBE SALEM SUMP 12FR 48IN / 0042120,6150195,CDM,272,RC,,,Outpatient,,,21.6,21.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,18.33,84.88,,14.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.8,50,,8.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,75,,12.96,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,70,,12.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.216,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,80,,13.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,2.77,12.84,,2.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,14.04,65,,11.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,35,,6.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,19.44,90,,15.55,percent of total billed charges,90% of total billed charges for outpatient setting,2.77,19.44,
TUBE SALEM SUMP 14FR 48IN / 0042140,3750049,CDM,272,RC,,,Outpatient,,,7.71,7.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,70,,4.32,percent of total billed charges,70% of total billed charges for outpatient setting,6.54,84.88,,5.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.86,50,,3.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.78,75,,4.62,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,70,,4.32,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,80,,4.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,0.99,12.84,,0.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.01,65,,4.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,35,,2.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.94,90,,5.55,percent of total billed charges,90% of total billed charges for outpatient setting,0.99,6.94,
TUBE SET AIRSEAL / ASM-EVAC1,69162118,CDM,272,RC,,,Outpatient,,,321.64,321.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.15,70,,180.12,percent of total billed charges,70% of total billed charges for outpatient setting,273.01,84.88,,218.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,160.82,50,,128.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.23,75,,192.98,percent of total billed charges,75% of total billed charges for outpatient setting,225.15,70,,180.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.3,12.84,,33.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.31,80,,205.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.3,12.84,,33.04,percent of total billed charges,12.84% of total billed charges,41.3,12.84,,33.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,209.07,65,,167.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.57,35,,90.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,289.48,90,,231.58,percent of total billed charges,90% of total billed charges for outpatient setting,41.3,289.48,
TUBE SMOKE EVAC AIRSEAL / SEM-EVAC,69162660,CDM,272,RC,,,Outpatient,,,334.18,334.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,283.65,84.88,,226.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,167.09,50,,133.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.64,75,,200.51,percent of total billed charges,75% of total billed charges for outpatient setting,233.93,70,,187.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.34,80,,213.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,42.91,12.84,,34.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,217.22,65,,173.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.96,35,,93.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,300.76,90,,240.61,percent of total billed charges,90% of total billed charges for outpatient setting,42.91,300.76,
TUBE SS W/ FILTER 16FR 48IN / 0046160,70000804,CDM,272,RC,,,Outpatient,,,30.66,30.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.46,70,,17.17,percent of total billed charges,70% of total billed charges for outpatient setting,26.02,84.88,,20.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.33,50,,12.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,75,,18.4,percent of total billed charges,75% of total billed charges for outpatient setting,21.46,70,,17.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.53,80,,19.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,3.94,12.84,,3.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.93,65,,15.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,35,,8.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.59,90,,22.07,percent of total billed charges,90% of total billed charges for outpatient setting,3.94,27.59,
TUBE TRACH 6 SHILEY LOW PRESSURE,6150727,CDM,272,RC,,,Outpatient,,,183.91,183.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.74,70,,102.99,percent of total billed charges,70% of total billed charges for outpatient setting,156.1,84.88,,124.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.96,50,,73.57,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.93,75,,110.34,percent of total billed charges,75% of total billed charges for outpatient setting,128.74,70,,102.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,12.84,,18.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.13,80,,117.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,12.84,,18.89,percent of total billed charges,12.84% of total billed charges,23.61,12.84,,18.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,119.54,65,,95.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,35,,51.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,165.52,90,,132.42,percent of total billed charges,90% of total billed charges for outpatient setting,23.61,165.52,
TUBE TRACH 8 SHILEY LOW PRESSURE,6150728,CDM,272,RC,,,Outpatient,,,248.62,248.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.03,70,,139.22,percent of total billed charges,70% of total billed charges for outpatient setting,211.03,84.88,,168.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,124.31,50,,99.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.47,75,,149.18,percent of total billed charges,75% of total billed charges for outpatient setting,174.03,70,,139.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.92,12.84,,25.536,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.9,80,,159.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.92,12.84,,25.54,percent of total billed charges,12.84% of total billed charges,31.92,12.84,,25.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.6,65,,129.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.02,35,,69.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.76,90,,179.01,percent of total billed charges,90% of total billed charges for outpatient setting,31.92,223.76,
TUBE TRACH RAE ORAL CUFFED 5.0,5050065,CDM,272,RC,,,Outpatient,,,31.78,31.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,26.97,84.88,,21.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.89,50,,12.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.84,75,,19.07,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,70,,17.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.42,80,,20.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,4.08,12.84,,3.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.66,65,,16.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.12,35,,8.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.6,90,,22.88,percent of total billed charges,90% of total billed charges for outpatient setting,4.08,28.6,
TUBERCULIN (APLISOL 50 TEST) 5TU MDV:,3302127,CDM,250,RC,,,Outpatient,,,83.95,83.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.77,70,,47.02,percent of total billed charges,70% of total billed charges for outpatient setting,71.26,84.88,,57.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.98,50,,33.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.96,75,,50.37,percent of total billed charges,75% of total billed charges for outpatient setting,58.77,70,,47.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,12.84,,8.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.16,80,,53.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.78,12.84,,8.62,percent of total billed charges,12.84% of total billed charges,10.78,12.84,,8.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.57,65,,43.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,35,,23.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,75.56,90,,60.45,percent of total billed charges,90% of total billed charges for outpatient setting,10.78,75.56,
TUBERCULIN (TUBERSOL 10T) 5TU MDV 1ML,3302126,CDM,250,RC,,,Outpatient,,,51.45,51.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.02,70,,28.82,percent of total billed charges,70% of total billed charges for outpatient setting,43.67,84.88,,34.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.73,50,,20.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.59,75,,30.87,percent of total billed charges,75% of total billed charges for outpatient setting,36.02,70,,28.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,12.84,,5.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.16,80,,32.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,12.84,,5.29,percent of total billed charges,12.84% of total billed charges,6.61,12.84,,5.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.44,65,,26.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.01,35,,14.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.31,90,,37.05,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,46.31,
TUBING 0.25IN 12FT SUCTION / N612,6150833,CDM,272,RC,,,Outpatient,,,8.01,8.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.61,70,,4.49,percent of total billed charges,70% of total billed charges for outpatient setting,6.8,84.88,,5.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.01,50,,3.21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.01,75,,4.81,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,70,,4.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.41,80,,5.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.21,65,,4.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.8,35,,2.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.21,90,,5.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,7.21,
TUBING 24IN ARTERIAL PRESSURE / 42366040,69161375,CDM,272,RC,,,Outpatient,,,28.48,28.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,70,,15.95,percent of total billed charges,70% of total billed charges for outpatient setting,24.17,84.88,,19.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.24,50,,11.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.36,75,,17.09,percent of total billed charges,75% of total billed charges for outpatient setting,19.94,70,,15.95,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.66,12.84,,2.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.78,80,,18.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.66,12.84,,2.93,percent of total billed charges,12.84% of total billed charges,3.66,12.84,,2.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.51,65,,14.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,35,,7.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.63,90,,20.5,percent of total billed charges,90% of total billed charges for outpatient setting,3.66,25.63,
TUBING 6FT SUCTION / N56A,153582,CDM,272,RC,,,Outpatient,,,4.86,4.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,4.13,84.88,,3.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.43,50,,1.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.65,75,,2.92,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.89,80,,3.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.16,65,,2.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,35,,1.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.37,90,,3.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.37,
TUBING 7MM 12FT SUCTION / N712,6051152,CDM,272,RC,,,Outpatient,,,10.83,10.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.58,70,,6.06,percent of total billed charges,70% of total billed charges for outpatient setting,9.19,84.88,,7.35,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.42,50,,4.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.12,75,,6.5,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,70,,6.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,80,,6.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,1.39,12.84,,1.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.04,65,,5.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,35,,3.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.75,90,,7.8,percent of total billed charges,90% of total billed charges for outpatient setting,1.39,9.75,
TUBING ARTHREX PUMP / AR-6410,69162238,CDM,272,RC,,,Outpatient,,,256.2,256.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.34,70,,143.47,percent of total billed charges,70% of total billed charges for outpatient setting,217.46,84.88,,173.97,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.1,50,,102.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,75,,153.72,percent of total billed charges,75% of total billed charges for outpatient setting,179.34,70,,143.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.96,80,,163.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,32.9,12.84,,26.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.53,65,,133.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.67,35,,71.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,230.58,90,,184.46,percent of total billed charges,90% of total billed charges for outpatient setting,32.9,230.58,
TUBING ARTHROSCOPY LINVATEC / 10K100,69159343,CDM,272,RC,,,Outpatient,,,156.5,156.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.55,70,,87.64,percent of total billed charges,70% of total billed charges for outpatient setting,132.84,84.88,,106.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.25,50,,62.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.38,75,,93.9,percent of total billed charges,75% of total billed charges for outpatient setting,109.55,70,,87.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,12.84,,16.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.2,80,,100.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,12.84,,16.07,percent of total billed charges,12.84% of total billed charges,20.09,12.84,,16.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,101.73,65,,81.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.78,35,,43.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.85,90,,112.68,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,140.85,
TUBING CONN 5MM 3/16X12 / OR512,5050169,CDM,270,RC,,,Outpatient,,,5.1,5.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.57,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,4.33,84.88,,3.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.55,50,,2.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.83,75,,3.06,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,70,,2.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,80,,3.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,0.65,12.84,,0.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.32,65,,2.66,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.79,35,,1.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.59,90,,3.67,percent of total billed charges,90% of total billed charges for outpatient setting,0.65,4.59,
TUBING CONNECTOR  Y  3/8,6150121,CDM,272,RC,,,Outpatient,,,19.24,19.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.47,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,16.33,84.88,,13.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.62,50,,7.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.43,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,70,,10.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,80,,12.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,2.47,12.84,,1.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.51,65,,10.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.73,35,,5.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.32,90,,13.86,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,17.32,
TUBING DSE 9IN -LLETZ SPECULUM / 8009,69162837,CDM,272,RC,,,Outpatient,,,16.35,16.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.45,70,,9.16,percent of total billed charges,70% of total billed charges for outpatient setting,13.88,84.88,,11.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.18,50,,6.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.26,75,,9.81,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,70,,9.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.08,80,,10.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,2.1,12.84,,1.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,10.63,65,,8.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,35,,4.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,14.72,90,,11.78,percent of total billed charges,90% of total billed charges for outpatient setting,2.1,14.72,
TUBING IN/OUTFLOW ARTHREX / AR-6436,71000490,CDM,272,RC,,,Outpatient,,,394.8,394.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.36,70,,221.09,percent of total billed charges,70% of total billed charges for outpatient setting,335.11,84.88,,268.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,197.4,50,,157.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.1,75,,236.88,percent of total billed charges,75% of total billed charges for outpatient setting,276.36,70,,221.09,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,12.84,,40.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.84,80,,252.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,12.84,,40.55,percent of total billed charges,12.84% of total billed charges,50.69,12.84,,40.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,256.62,65,,205.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.18,35,,110.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,355.32,90,,284.26,percent of total billed charges,90% of total billed charges for outpatient setting,50.69,355.32,
TUBING NIPPLE GREEN / 001840,510076,CDM,270,RC,,,Outpatient,,,2.34,2.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,70,,1.31,percent of total billed charges,70% of total billed charges for outpatient setting,1.99,84.88,,1.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.17,50,,0.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.76,75,,1.41,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,70,,1.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,80,,1.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,0.3,12.84,,0.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.52,65,,1.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.82,35,,0.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.11,90,,1.69,percent of total billed charges,90% of total billed charges for outpatient setting,0.3,2.11,
TUBING NIPPLE GREEN / FM-SWIVEL-G100,70000808,CDM,270,RC,,,Outpatient,,,4.8,4.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,70,,2.69,percent of total billed charges,70% of total billed charges for outpatient setting,4.07,84.88,,3.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.4,50,,1.92,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.6,75,,2.88,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,70,,2.69,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,80,,3.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.12,65,,2.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.68,35,,1.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.32,90,,3.46,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.32,
TUBING NIPPLE YELLOW / FM-SWIVEL-Y100,70000809,CDM,270,RC,,,Outpatient,,,7.75,7.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.43,70,,4.34,percent of total billed charges,70% of total billed charges for outpatient setting,6.58,84.88,,5.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.88,50,,3.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.81,75,,4.65,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,70,,4.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,80,,4.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,1,12.84,,0.8,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.04,65,,4.03,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.71,35,,2.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.98,90,,5.58,percent of total billed charges,90% of total billed charges for outpatient setting,1,6.98,
TUBING OXYGEN W/U CONNECT IT/001350,6153046,CDM,270,RC,,,Outpatient,,,2.82,2.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,70,,1.58,percent of total billed charges,70% of total billed charges for outpatient setting,2.39,84.88,,1.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.41,50,,1.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.12,75,,1.7,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,70,,1.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.36,12.84,,0.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,80,,1.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.36,12.84,,0.29,percent of total billed charges,12.84% of total billed charges,0.36,12.84,,0.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.83,65,,1.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,35,,0.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.54,90,,2.03,percent of total billed charges,90% of total billed charges for outpatient setting,0.36,2.54,
TUBING SET IN/OUTFLOW /MYOSURE AQL-112,69161786,CDM,272,RC,,,Outpatient,,,486.68,486.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.68,70,,272.54,percent of total billed charges,70% of total billed charges for outpatient setting,413.09,84.88,,330.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,243.34,50,,194.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.01,75,,292.01,percent of total billed charges,75% of total billed charges for outpatient setting,340.68,70,,272.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.49,12.84,,49.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.34,80,,311.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.49,12.84,,49.99,percent of total billed charges,12.84% of total billed charges,62.49,12.84,,49.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,316.34,65,,253.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.34,35,,136.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,438.01,90,,350.41,percent of total billed charges,90% of total billed charges for outpatient setting,62.49,438.01,
TUBING SMARTCAP ENDO / 100145CO2,133620,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,59.42,84.88,,47.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,35,50,,28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,75,,42,percent of total billed charges,75% of total billed charges for outpatient setting,49,70,,39.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,80,,44.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,8.99,12.84,,7.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.5,65,,36.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,35,,19.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63,90,,50.4,percent of total billed charges,90% of total billed charges for outpatient setting,8.99,63,
TUBING SMOKE EVACUATION / VT10624,6150564,CDM,272,RC,,,Outpatient,,,63,63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,70,,35.28,percent of total billed charges,70% of total billed charges for outpatient setting,53.47,84.88,,42.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,31.5,50,,25.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.25,75,,37.8,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,70,,35.28,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,12.84,,6.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,80,,40.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,12.84,,6.47,percent of total billed charges,12.84% of total billed charges,8.09,12.84,,6.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,40.95,65,,32.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,35,,17.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,56.7,90,,45.36,percent of total billed charges,90% of total billed charges for outpatient setting,8.09,56.7,
TUBING SUCTION 12'  / 88-301721,5150161,CDM,270,RC,,,Outpatient,,,11.1,11.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,70,,6.22,percent of total billed charges,70% of total billed charges for outpatient setting,9.42,84.88,,7.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.55,50,,4.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.33,75,,6.66,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,70,,6.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,80,,7.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,1.43,12.84,,1.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.22,65,,5.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.89,35,,3.11,percent of total billed charges,35% of total Billed charges for Outpatient Setting,9.99,90,,7.99,percent of total billed charges,90% of total billed charges for outpatient setting,1.43,9.99,
TUBING SUCTION D&C / 23116,6150751,CDM,272,RC,,,Outpatient,,,40.32,40.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.22,70,,22.58,percent of total billed charges,70% of total billed charges for outpatient setting,34.22,84.88,,27.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.16,50,,16.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.24,75,,24.19,percent of total billed charges,75% of total billed charges for outpatient setting,28.22,70,,22.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,12.84,,4.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.26,80,,25.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,5.18,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.21,65,,20.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,35,,11.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.29,90,,29.03,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,36.29,
TUBING SUCTION DISPOSABLE / LS7012,69159185,CDM,270,RC,,,Outpatient,,,83.28,83.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.3,70,,46.64,percent of total billed charges,70% of total billed charges for outpatient setting,70.69,84.88,,56.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,41.64,50,,33.31,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.46,75,,49.97,percent of total billed charges,75% of total billed charges for outpatient setting,58.3,70,,46.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,12.84,,8.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.62,80,,53.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,12.84,,8.55,percent of total billed charges,12.84% of total billed charges,10.69,12.84,,8.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,54.13,65,,43.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,35,,23.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,74.95,90,,59.96,percent of total billed charges,90% of total billed charges for outpatient setting,10.69,74.95,
TUBING SYRINGE PUMP / 2C9218,6150858,CDM,272,RC,,,Outpatient,,,20.61,20.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.43,70,,11.54,percent of total billed charges,70% of total billed charges for outpatient setting,17.49,84.88,,13.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.31,50,,8.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.46,75,,12.37,percent of total billed charges,75% of total billed charges for outpatient setting,14.43,70,,11.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,80,,13.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.4,65,,10.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,35,,5.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.55,90,,14.84,percent of total billed charges,90% of total billed charges for outpatient setting,2.65,18.55,
TUBING TURP 4 LEAD IRRG SET / 313004,69160874,CDM,272,RC,,,Outpatient,,,52.31,52.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,70,,29.3,percent of total billed charges,70% of total billed charges for outpatient setting,44.4,84.88,,35.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.16,50,,20.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.23,75,,31.38,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,70,,29.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.72,12.84,,5.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.85,80,,33.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.72,12.84,,5.38,percent of total billed charges,12.84% of total billed charges,6.72,12.84,,5.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34,65,,27.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,35,,14.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.08,90,,37.66,percent of total billed charges,90% of total billed charges for outpatient setting,6.72,47.08,
TUBING TURP Y TYPE 2 LEAD / 2C4041,6150082,CDM,272,RC,,,Outpatient,,,58.17,58.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.72,70,,32.58,percent of total billed charges,70% of total billed charges for outpatient setting,49.37,84.88,,39.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.09,50,,23.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.63,75,,34.9,percent of total billed charges,75% of total billed charges for outpatient setting,40.72,70,,32.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,12.84,,5.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.54,80,,37.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,12.84,,5.98,percent of total billed charges,12.84% of total billed charges,7.47,12.84,,5.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.81,65,,30.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,35,,16.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.35,90,,41.88,percent of total billed charges,90% of total billed charges for outpatient setting,7.47,52.35,
TUCKS PADS 40 JAR,3302740,CDM,259,RC,,,Outpatient,,,36.88,36.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.82,70,,20.66,percent of total billed charges,70% of total billed charges for outpatient setting,31.3,84.88,,25.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,50,,14.75,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.66,75,,22.13,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,70,,20.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,12.84,,3.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.5,80,,23.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,12.84,,3.79,percent of total billed charges,12.84% of total billed charges,4.74,12.84,,3.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.97,65,,19.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.91,35,,10.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,33.19,90,,26.55,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,33.19,
"TULAREMIA, FRANCISELLA TULARENSIS AB TOT",201076,CDM,302,RC,86668,HCPCS,Outpatient,,,63.72,57.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.6,70,,35.68,percent of total billed charges,70% of total billed charges for outpatient setting,54.09,84.88,,43.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.69,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.79,75,,38.23,percent of total billed charges,75% of total billed charges for outpatient setting,44.6,70,,35.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.98,80,,40.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.18,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.72,100,,,Fee Schedule,100% of Custom Fee Schedule,57.35,90,,45.88,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,57.35,
TUMOR IMMUNOCHEMISTRY QUANT OR SEMIQUAN,900041,CDM,310,RC,88360,HCPCS,Outpatient,,,594.58,535.12,,213.83,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,504.68,84.88,,403.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.94,75,,356.75,percent of total billed charges,75% of total billed charges for outpatient setting,416.21,70,,332.97,percent of total billed charges,70% of total billed charges for outpatient setting,227.2,170,,,Fee Schedule,170% of Medicare OPPS rate,287.34,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,76.34,12.84,,61.072,percent of total billed charges,12.84% of total billed charges,233.88,175,,,Fee Schedule,175% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,475.66,80,,380.53,percent of total billed charges,80% of total billed charges for outpatient setting,187.1,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,167.06,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,76.34,12.84,,61.07,percent of total billed charges,12.84% of total billed charges,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,133.64,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,535.12,90,,428.1,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,535.12,
TUMOR IMMUNOHISTOCHEM COMP,900043,CDM,310,RC,88361,HCPCS,Outpatient,,,1161.02,1044.92,,417.58,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,985.47,84.88,,788.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,299.62,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,870.77,75,,696.62,percent of total billed charges,75% of total billed charges for outpatient setting,812.71,70,,650.17,percent of total billed charges,70% of total billed charges for outpatient setting,443.68,170,,,Fee Schedule,170% of Medicare OPPS rate,561.12,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,456.73,175,,,Fee Schedule,175% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,928.82,80,,743.06,percent of total billed charges,80% of total billed charges for outpatient setting,365.38,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,326.23,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,260.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,43.46,100,,,Fee Schedule,100% of Custom Fee Schedule,1044.92,90,,835.94,percent of total billed charges,90% of total billed charges for outpatient setting,43.46,1044.92,
TUNNEL SMOOTHER GORE 7.9 / CLSMO,69160783,CDM,272,RC,,,Outpatient,,,786.27,786.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.39,70,,440.31,percent of total billed charges,70% of total billed charges for outpatient setting,667.39,84.88,,533.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,393.14,50,,314.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.7,75,,471.76,percent of total billed charges,75% of total billed charges for outpatient setting,550.39,70,,440.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.96,12.84,,80.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.02,80,,503.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.96,12.84,,80.77,percent of total billed charges,12.84% of total billed charges,100.96,12.84,,80.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,511.08,65,,408.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.19,35,,220.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,707.64,90,,566.11,percent of total billed charges,90% of total billed charges for outpatient setting,100.96,707.64,
TUNNELER & SHEATH ON-Q PUMP / T17X8,69160548,CDM,272,RC,,,Outpatient,,,170.44,170.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.31,70,,95.45,percent of total billed charges,70% of total billed charges for outpatient setting,144.67,84.88,,115.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,85.22,50,,68.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.83,75,,102.26,percent of total billed charges,75% of total billed charges for outpatient setting,119.31,70,,95.45,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,12.84,,17.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.35,80,,109.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,21.88,12.84,,17.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.79,65,,88.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.65,35,,47.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,153.4,90,,122.72,percent of total billed charges,90% of total billed charges for outpatient setting,21.88,153.4,
TUNNELER MODEL 402 (VNS),69161756,CDM,272,RC,,,Outpatient,,,1540.06,1540.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1078.04,70,,862.43,percent of total billed charges,70% of total billed charges for outpatient setting,1307.2,84.88,,1045.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,770.03,50,,616.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1155.05,75,,924.04,percent of total billed charges,75% of total billed charges for outpatient setting,1078.04,70,,862.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.74,12.84,,158.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1232.05,80,,985.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.74,12.84,,158.19,percent of total billed charges,12.84% of total billed charges,197.74,12.84,,158.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1001.04,65,,800.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.02,35,,431.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1386.05,90,,1108.84,percent of total billed charges,90% of total billed charges for outpatient setting,197.74,1386.05,
TUSSIONEX : 10 ML,3302824,CDM,259,RC,,,Outpatient,,,17.78,17.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.45,70,,9.96,percent of total billed charges,70% of total billed charges for outpatient setting,15.09,84.88,,12.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,50,,7.11,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.34,75,,10.67,percent of total billed charges,75% of total billed charges for outpatient setting,12.45,70,,9.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,80,,11.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,2.28,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.56,65,,9.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.22,35,,4.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16,90,,12.8,percent of total billed charges,90% of total billed charges for outpatient setting,2.28,16,
TUTOPLAST 1.5X1.5CM PERICARDIUM / 68250,71000851,CDM,278,RC,L8610,HCPCS,Outpatient,,,1276,1276,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.6,60,,612.48,percent of total billed charges,60% of total Billed charges for outpatient setting,1083.07,84.88,,866.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,638,50,,510.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,957,75,,765.6,percent of total billed charges,75% of total billed charges for outpatient setting,638,50,,510.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.84,12.84,,131.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.8,80,,816.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.84,12.84,,131.07,percent of total billed charges,12.84% of total billed charges,163.84,12.84,,131.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1276,65,,1020.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.6,60,,612.48,percent of total billed charges,60% of total billed charges for outpatient setting,163.84,1276,
TUTOPLAST 1X1CM PERICARDIUM / 68251,71000850,CDM,278,RC,L8610,HCPCS,Outpatient,,,1208,1208,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.8,60,,579.84,percent of total billed charges,60% of total Billed charges for outpatient setting,1025.35,84.88,,820.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,604,50,,483.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,906,75,,724.8,percent of total billed charges,75% of total billed charges for outpatient setting,604,50,,483.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.11,12.84,,124.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.4,80,,773.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.11,12.84,,124.09,percent of total billed charges,12.84% of total billed charges,155.11,12.84,,124.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1208,65,,966.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.8,60,,579.84,percent of total billed charges,60% of total billed charges for outpatient setting,155.11,1208,
TYGACIL(TIGECYCLINE):50 MG,3303199,CDM,250,RC,J3243,HCPCS,Outpatient,,,572.05,572.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.44,70,,320.35,percent of total billed charges,70% of total billed charges for outpatient setting,485.56,84.88,,388.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.07,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,429.04,75,,343.23,percent of total billed charges,75% of total billed charges for outpatient setting,400.44,70,,320.35,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.45,12.84,,58.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.64,80,,366.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.45,12.84,,58.76,percent of total billed charges,12.84% of total billed charges,73.45,12.84,,58.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,371.83,65,,297.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,100,,,Fee Schedule,100% of Custom Fee Schedule,514.85,90,,411.88,percent of total billed charges,90% of total billed charges for outpatient setting,1.07,514.85,
TYPHOID VAC (TYPHIM VI) 10ML MDV:20 DOSE,3302128,CDM,250,RC,,,Outpatient,,,2160.31,2160.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512.22,70,,1209.78,percent of total billed charges,70% of total billed charges for outpatient setting,1833.67,84.88,,1466.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,1080.16,50,,864.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1620.23,75,,1296.18,percent of total billed charges,75% of total billed charges for outpatient setting,1512.22,70,,1209.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.38,12.84,,221.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728.25,80,,1382.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.38,12.84,,221.9,percent of total billed charges,12.84% of total billed charges,277.38,12.84,,221.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1404.2,65,,1123.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.11,35,,604.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1944.28,90,,1555.42,percent of total billed charges,90% of total billed charges for outpatient setting,277.38,1944.28,
UA W MICRO AUTO,200315,CDM,307,RC,81001,HCPCS,Outpatient,,,14.27,12.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,84.88,,9.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.7,75,,8.56,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,80,,9.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,100% of Custom Fee Schedule,12.84,90,,10.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.17,12.84,
UA W/O MICRO AUTO,200310,CDM,307,RC,81003,HCPCS,Outpatient,,,10.13,9.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,8.6,84.88,,6.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,7.6,75,,6.08,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,80,,6.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of Custom Fee Schedule,9.12,90,,7.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,9.12,
UGI ACR CONT W/ KUB,2400620,CDM,320,RC,74246,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UGI ACR CONT W/O KUB,2400615,CDM,320,RC,74246,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UGI ACR CONT W/SBF DRP,2500000,CDM,320,RC,74249,HCPCS,Outpatient,,,343.29,257.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.3,70,,192.24,percent of total billed charges,70% of total billed charges for outpatient setting,291.38,84.88,,233.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,171.65,50,,137.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.47,75,,205.98,percent of total billed charges,75% of total billed charges for outpatient setting,240.3,70,,192.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.08,12.84,,35.264,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.63,80,,219.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.08,12.84,,35.26,percent of total billed charges,12.84% of total billed charges,44.08,12.84,,35.26,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,308.96,90,,247.17,percent of total billed charges,90% of total billed charges for outpatient setting,44.08,308.96,
UGI ACR CONT W/SBF-1,2400625,CDM,320,RC,74246,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UGI W/KUB DOUBLE CONTRAST STUDY,2400605,CDM,320,RC,74246,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UGI W/O KUB,2400600,CDM,320,RC,74240,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UGI W/SBF-1,2400610,CDM,320,RC,74240,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.08,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,179.9,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
ULTRA FAST-FIX CURVED NDL DEL,69161929,CDM,278,RC,,,Outpatient,,,1379.99,1379.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.99,60,,662.39,percent of total billed charges,60% of total Billed charges for outpatient setting,1171.34,84.88,,937.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,690,50,,552,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1034.99,75,,827.99,percent of total billed charges,75% of total billed charges for outpatient setting,690,50,,552,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,12.84,,141.752,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.99,80,,883.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.19,12.84,,141.75,percent of total billed charges,12.84% of total billed charges,177.19,12.84,,141.75,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1379.99,65,,1103.99,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483,35,,386.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,827.99,60,,662.39,percent of total billed charges,60% of total billed charges for outpatient setting,177.19,1379.99,
ULTRA FST-FX MENISCL KNT PSH/CT 72201537,69161930,CDM,278,RC,,,Outpatient,,,596.99,596.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.19,60,,286.55,percent of total billed charges,60% of total Billed charges for outpatient setting,506.73,84.88,,405.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,298.5,50,,238.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447.74,75,,358.19,percent of total billed charges,75% of total billed charges for outpatient setting,298.5,50,,238.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.65,12.84,,61.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.59,80,,382.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.65,12.84,,61.32,percent of total billed charges,12.84% of total billed charges,76.65,12.84,,61.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,596.99,65,,477.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.95,35,,167.16,percent of total billed charges,35% of total Billed charges for Outpatient Setting,358.19,60,,286.55,percent of total billed charges,60% of total billed charges for outpatient setting,76.65,596.99,
ULTRACE (PANCREASE) CAPS,3303155,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
ULTRACET:37.5 TRAMADOL/APAP 325 MG,3302834,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
Ultracut 4.2mm  C9405A,69161881,CDM,272,RC,,,Outpatient,,,312.89,312.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.02,70,,175.22,percent of total billed charges,70% of total billed charges for outpatient setting,265.58,84.88,,212.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,156.45,50,,125.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.67,75,,187.74,percent of total billed charges,75% of total billed charges for outpatient setting,219.02,70,,175.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,12.84,,32.144,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.31,80,,200.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,12.84,,32.14,percent of total billed charges,12.84% of total billed charges,40.18,12.84,,32.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,203.38,65,,162.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.51,35,,87.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,281.6,90,,225.28,percent of total billed charges,90% of total billed charges for outpatient setting,40.18,281.6,
ULTRASOUND ALOKA / ROBOTIC NEPHRECTOMY,69169796,CDM,360,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,891.24,84.88,,712.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,525,50,,420,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.5,75,,630,percent of total billed charges,75% of total billed charges for outpatient setting,735,70,,588,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.856,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,80,,672,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,134.82,12.84,,107.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,35,,294,percent of total billed charges,35% of total Billed charges for Outpatient Setting,945,90,,756,percent of total billed charges,90% of total billed charges for outpatient setting,134.82,945,
ULTRASOUND BK / ROBOTIC NEPHRECTOMY,71000100,CDM,360,RC,,,Outpatient,,,2000,2000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,1697.6,84.88,,1358.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1000,50,,800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500,75,,1200,percent of total billed charges,75% of total billed charges for outpatient setting,1400,70,,1120,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,80,,1280,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,256.8,12.84,,205.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,35,,560,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1800,90,,1440,percent of total billed charges,90% of total billed charges for outpatient setting,256.8,1800,
ULTRASOUND BK5000 / ROBOTIC NEPHRECTOMY,71000080,CDM,360,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,1867.36,84.88,,1493.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1100,50,,880,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650,75,,1320,percent of total billed charges,75% of total billed charges for outpatient setting,1540,70,,1232,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760,80,,1408,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,282.48,12.84,,225.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770,35,,616,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1980,90,,1584,percent of total billed charges,90% of total billed charges for outpatient setting,282.48,1980,
UMBILICAL TAPE / U11T,6152267,CDM,272,RC,,,Outpatient,,,40.25,40.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.18,70,,22.54,percent of total billed charges,70% of total billed charges for outpatient setting,34.16,84.88,,27.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,20.13,50,,16.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.19,75,,24.15,percent of total billed charges,75% of total billed charges for outpatient setting,28.18,70,,22.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,12.84,,4.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,80,,25.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,5.17,12.84,,4.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,26.16,65,,20.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.09,35,,11.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,90% of total billed charges for outpatient setting,5.17,36.23,
UNASYN 3GM INJ,3303355,CDM,250,RC,,,Outpatient,,,151.08,151.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.76,70,,84.61,percent of total billed charges,70% of total billed charges for outpatient setting,128.24,84.88,,102.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.54,50,,60.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.31,75,,90.65,percent of total billed charges,75% of total billed charges for outpatient setting,105.76,70,,84.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,80,,96.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.2,65,,78.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,35,,42.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.97,90,,108.78,percent of total billed charges,90% of total billed charges for outpatient setting,19.4,135.97,
UNASYN INJ 3GM,3302534,CDM,250,RC,,,Outpatient,,,151.08,151.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.76,70,,84.61,percent of total billed charges,70% of total billed charges for outpatient setting,128.24,84.88,,102.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.54,50,,60.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.31,75,,90.65,percent of total billed charges,75% of total billed charges for outpatient setting,105.76,70,,84.61,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,80,,96.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,19.4,12.84,,15.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,98.2,65,,78.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,35,,42.3,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.97,90,,108.78,percent of total billed charges,90% of total billed charges for outpatient setting,19.4,135.97,
UNIVERSAL PACK I / 88761,69169250,CDM,272,RC,,,Outpatient,,,132.18,132.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.53,70,,74.02,percent of total billed charges,70% of total billed charges for outpatient setting,112.19,84.88,,89.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.09,50,,52.87,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.14,75,,79.31,percent of total billed charges,75% of total billed charges for outpatient setting,92.53,70,,74.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.97,12.84,,13.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.74,80,,84.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.97,12.84,,13.58,percent of total billed charges,12.84% of total billed charges,16.97,12.84,,13.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,85.92,65,,68.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,35,,37.01,percent of total billed charges,35% of total Billed charges for Outpatient Setting,118.96,90,,95.17,percent of total billed charges,90% of total billed charges for outpatient setting,16.97,118.96,
UNLISTED CYTOPATHOLOGY PROCEDURE,900055,CDM,311,RC,88199,HCPCS,Outpatient,,,198.35,178.52,,71.24,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,168.36,84.88,,134.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.17,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,148.76,75,,119.01,percent of total billed charges,75% of total billed charges for outpatient setting,138.85,70,,111.08,percent of total billed charges,70% of total billed charges for outpatient setting,75.69,170,,,Fee Schedule,170% of Medicare OPPS rate,95.73,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,25.47,12.84,,20.376,percent of total billed charges,12.84% of total billed charges,77.92,175,,,Fee Schedule,175% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,158.68,80,,126.94,percent of total billed charges,80% of total billed charges for outpatient setting,62.34,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,55.66,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,25.47,12.84,,20.38,percent of total billed charges,12.84% of total billed charges,25.47,12.84,,20.38,percent of total billed charges,12.84% of total billed charges,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,,,,,Other,Not Separately reimbursable,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,44.52,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,23.6,100,,,Fee Schedule,100% of Custom Fee Schedule,178.52,90,,142.82,percent of total billed charges,90% of total billed charges for outpatient setting,23.6,178.52,
UNNA PASTE BOOT APPLICATION,5100171,CDM,510,RC,,,Outpatient,,,444.27,444.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.99,70,,248.79,percent of total billed charges,70% of total billed charges for outpatient setting,377.1,84.88,,301.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,222.14,50,,177.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.2,75,,266.56,percent of total billed charges,75% of total billed charges for outpatient setting,310.99,70,,248.79,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.04,12.84,,45.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.42,80,,284.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.04,12.84,,45.63,percent of total billed charges,12.84% of total billed charges,57.04,12.84,,45.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,288.78,65,,231.02,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.49,35,,124.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,399.84,90,,319.87,percent of total billed charges,90% of total billed charges for outpatient setting,57.04,399.84,
U-PAD 23X24 /  MSC281241,6150471,CDM,272,RC,,,Outpatient,,,0.82,0.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,70,,0.46,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,84.88,,0.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.41,50,,0.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.62,75,,0.5,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,70,,0.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,12.84,,0.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.66,80,,0.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,12.84,,0.09,percent of total billed charges,12.84% of total billed charges,0.11,12.84,,0.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.53,65,,0.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.29,35,,0.23,percent of total billed charges,35% of total Billed charges for Outpatient Setting,0.74,90,,0.59,percent of total billed charges,90% of total billed charges for outpatient setting,0.11,0.74,
UPPER EXT INFANT 2 VWS LEFT,2400526,CDM,320,RC,73092,HCPCS,Outpatient,,,328.23,246.17,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,164.12,50,,131.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.88,35,,91.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
UPPER EXT INFANT 2 VWS RIGHT,2400525,CDM,320,RC,73092,HCPCS,Outpatient,,,328.23,246.17,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,278.6,84.88,,222.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,246.17,75,,196.94,percent of total billed charges,75% of total billed charges for outpatient setting,229.76,70,,183.81,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,42.14,12.84,,33.712,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,262.58,80,,210.06,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,42.14,12.84,,33.71,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,108.12,100,,,Fee Schedule,100% of Custom Fee Schedule,295.41,90,,236.33,percent of total billed charges,90% of total billed charges for outpatient setting,42.14,295.41,
UPPER EXTREMITY PACK,69159029,CDM,272,RC,,,Outpatient,,,582.28,582.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.6,70,,326.08,percent of total billed charges,70% of total billed charges for outpatient setting,494.24,84.88,,395.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,291.14,50,,232.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,436.71,75,,349.37,percent of total billed charges,75% of total billed charges for outpatient setting,407.6,70,,326.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.76,12.84,,59.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.82,80,,372.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.76,12.84,,59.81,percent of total billed charges,12.84% of total billed charges,74.76,12.84,,59.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,378.48,65,,302.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.8,35,,163.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,524.05,90,,419.24,percent of total billed charges,90% of total billed charges for outpatient setting,74.76,524.05,
UREA NITROGEN URINE,201334,CDM,300,RC,84540,HCPCS,Outpatient,,,25.02,22.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,70,,14.01,percent of total billed charges,70% of total billed charges for outpatient setting,21.24,84.88,,16.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.15,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,18.77,75,,15.02,percent of total billed charges,75% of total billed charges for outpatient setting,17.51,70,,14.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.02,80,,16.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,100% of Custom Fee Schedule,22.52,90,,18.02,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,22.52,
URETERAL DILATOR SET 6-18FR PTFE /076600,69161609,CDM,272,RC,,,Outpatient,,,1132.22,1132.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792.55,70,,634.04,percent of total billed charges,70% of total billed charges for outpatient setting,961.03,84.88,,768.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,566.11,50,,452.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,849.17,75,,679.34,percent of total billed charges,75% of total billed charges for outpatient setting,792.55,70,,634.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.38,12.84,,116.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.78,80,,724.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.38,12.84,,116.3,percent of total billed charges,12.84% of total billed charges,145.38,12.84,,116.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,735.94,65,,588.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.28,35,,317.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1019,90,,815.2,percent of total billed charges,90% of total billed charges for outpatient setting,145.38,1019,
URETERAL DILATOR SET 6-18FR/ G17310,69162898,CDM,272,RC,,,Outpatient,,,999.2,999.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.44,70,,559.55,percent of total billed charges,70% of total billed charges for outpatient setting,848.12,84.88,,678.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.6,50,,399.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.4,75,,599.52,percent of total billed charges,75% of total billed charges for outpatient setting,699.44,70,,559.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.3,12.84,,102.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.36,80,,639.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.3,12.84,,102.64,percent of total billed charges,12.84% of total billed charges,128.3,12.84,,102.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.48,65,,519.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.72,35,,279.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.28,90,,719.42,percent of total billed charges,90% of total billed charges for outpatient setting,128.3,899.28,
URETEROSCOPE DISP AXIS II / AX20409,8209528,CDM,272,RC,C1747,HCPCS,Outpatient,,,2616.77,2616.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1831.74,70,,1465.39,percent of total billed charges,70% of total billed charges for outpatient setting,2221.11,84.88,,1776.89,percent of total billed charges,84.88% of total billed charges for outpatient setting,1308.39,50,,1046.71,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1962.58,75,,1570.06,percent of total billed charges,75% of total billed charges for outpatient setting,1831.74,70,,1465.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.99,12.84,,268.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2093.42,80,,1674.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.99,12.84,,268.79,percent of total billed charges,12.84% of total billed charges,335.99,12.84,,268.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1700.9,65,,1360.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.87,35,,732.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2355.09,90,,1884.07,percent of total billed charges,90% of total billed charges for outpatient setting,335.99,2355.09,
URETEROSCOPIC BIOPSY FORCEP 3FR FLEX,69162130,CDM,272,RC,,,Outpatient,,,1401.19,1401.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.83,70,,784.66,percent of total billed charges,70% of total billed charges for outpatient setting,1189.33,84.88,,951.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,700.6,50,,560.48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1050.89,75,,840.71,percent of total billed charges,75% of total billed charges for outpatient setting,980.83,70,,784.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.91,12.84,,143.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.95,80,,896.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.91,12.84,,143.93,percent of total billed charges,12.84% of total billed charges,179.91,12.84,,143.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,910.77,65,,728.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.42,35,,392.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1261.07,90,,1008.86,percent of total billed charges,90% of total billed charges for outpatient setting,179.91,1261.07,
URETHAL PRESSURE PROFILE,5100080,CDM,360,RC,,,Outpatient,,,1332.47,1332.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.73,70,,746.18,percent of total billed charges,70% of total billed charges for outpatient setting,1131,84.88,,904.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,666.24,50,,532.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,999.35,75,,799.48,percent of total billed charges,75% of total billed charges for outpatient setting,932.73,70,,746.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.09,12.84,,136.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.98,80,,852.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.09,12.84,,136.87,percent of total billed charges,12.84% of total billed charges,171.09,12.84,,136.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.36,35,,373.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1199.22,90,,959.38,percent of total billed charges,90% of total billed charges for outpatient setting,171.09,1199.22,
URIC ACID,200230,CDM,300,RC,84550,HCPCS,Outpatient,,,20.34,18.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,17.26,84.88,,13.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,15.26,75,,12.21,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,70,,11.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.27,80,,13.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.59,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of Custom Fee Schedule,18.31,90,,14.65,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,18.31,
URIMAR-T:TAB,3302764,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
URIN PROTEIN ELECTROPHORESIS,200975,CDM,300,RC,84165,HCPCS,Outpatient,,,48.33,43.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,41.02,84.88,,32.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.44,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,36.25,75,,29,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,70,,27.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,80,,30.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.36,100,,,Fee Schedule,100% of Custom Fee Schedule,43.5,90,,34.8,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,43.5,
URINAL W/ LID 1QT / H140-01,5150086,CDM,270,RC,,,Outpatient,,,3.06,3.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.14,70,,1.71,percent of total billed charges,70% of total billed charges for outpatient setting,2.6,84.88,,2.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.53,50,,1.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,75,,1.84,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,70,,1.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,80,,1.96,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,0.39,12.84,,0.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.99,65,,1.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.75,90,,2.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.39,2.75,
URINAL W/ LID 1QT CS/48 / DYND80235S,70000024,CDM,270,RC,,,Outpatient,,,3.12,3.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,2.65,84.88,,2.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.56,50,,1.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.34,75,,1.87,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,70,,1.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,80,,2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.03,65,,1.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.09,35,,0.87,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.81,90,,2.25,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.81,
URINALYSIS DIPSTICK ONLY,200318,CDM,307,RC,81003,HCPCS,Outpatient,,,10.13,9.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,8.6,84.88,,6.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,7.6,75,,6.08,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,70,,5.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,80,,6.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.28,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of Custom Fee Schedule,9.12,90,,7.3,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,9.12,
URINALYSIS W/ MICROSCOPY,200316,CDM,307,RC,81001,HCPCS,Outpatient,,,14.27,12.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,84.88,,9.69,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,10.7,75,,8.56,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,70,,7.99,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,80,,9.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,100% of Custom Fee Schedule,12.84,90,,10.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.17,12.84,
URINARY ANTISEP (UTA) CAP:,3302129,CDM,259,RC,,,Outpatient,,,12.54,12.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,70,,7.02,percent of total billed charges,70% of total billed charges for outpatient setting,10.64,84.88,,8.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.27,50,,5.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.41,75,,7.53,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,70,,7.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,80,,8.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,1.61,12.84,,1.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.15,65,,6.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,35,,3.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.29,90,,9.03,percent of total billed charges,90% of total billed charges for outpatient setting,1.61,11.29,
URINARY DRAINAGE BAG 2000CC / 154004,6150014,CDM,272,RC,,,Outpatient,,,20.07,20.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.05,70,,11.24,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,84.88,,13.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.04,50,,8.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.05,75,,12.04,percent of total billed charges,75% of total billed charges for outpatient setting,14.05,70,,11.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,80,,12.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,2.58,12.84,,2.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.05,65,,10.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,35,,5.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.06,90,,14.45,percent of total billed charges,90% of total billed charges for outpatient setting,2.58,18.06,
URINE AMYLASE,220056,CDM,300,RC,82150,HCPCS,Outpatient,,,29.16,26.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,24.75,84.88,,19.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.13,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,21.87,75,,17.5,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,70,,16.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.33,80,,18.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of Custom Fee Schedule,26.24,90,,20.99,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,26.24,
URINE CALCIUM 24 HR URINE,220052,CDM,301,RC,82340,HCPCS,Outpatient,,,27.14,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,70,,15.2,percent of total billed charges,70% of total billed charges for outpatient setting,23.04,84.88,,18.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,20.36,75,,16.29,percent of total billed charges,75% of total billed charges for outpatient setting,19,70,,15.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,80,,17.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,8.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.44,100,,,Fee Schedule,100% of Custom Fee Schedule,24.43,90,,19.54,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,24.43,
URINE CFP,200565,CDM,300,RC,84155,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
URINE CFP,201305,CDM,300,RC,84155,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
URINE CL,201115,CDM,300,RC,82436,HCPCS,Outpatient,,,25.88,23.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.12,70,,14.5,percent of total billed charges,70% of total billed charges for outpatient setting,21.97,84.88,,17.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.64,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,19.41,75,,15.53,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,70,,14.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,80,,16.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.34,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,100,,,Fee Schedule,100% of Custom Fee Schedule,23.29,90,,18.63,percent of total billed charges,90% of total billed charges for outpatient setting,5.75,23.29,
"URINE COLLECTOR, PEDI  /145501",5150014,CDM,270,RC,,,Outpatient,,,2.95,2.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.07,70,,1.66,percent of total billed charges,70% of total billed charges for outpatient setting,2.5,84.88,,2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.48,50,,1.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.21,75,,1.77,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,70,,1.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.304,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.36,80,,1.89,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,0.38,12.84,,0.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1.92,65,,1.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,35,,0.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.66,90,,2.13,percent of total billed charges,90% of total billed charges for outpatient setting,0.38,2.66,
URINE CREATININE  24 HR,220087,CDM,301,RC,82570,HCPCS,Outpatient,,,23.31,20.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,19.79,84.88,,15.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.89,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.48,75,,13.98,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,70,,13.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,80,,14.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.56,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.81,100,,,Fee Schedule,100% of Custom Fee Schedule,20.98,90,,16.78,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,20.98,
URINE DRAINAGE BAG 4000CC / 153509,6150013,CDM,272,RC,,,Outpatient,,,27.33,27.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.13,70,,15.3,percent of total billed charges,70% of total billed charges for outpatient setting,23.2,84.88,,18.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.67,50,,10.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,75,,16.4,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,70,,15.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,80,,17.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,3.51,12.84,,2.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.76,65,,14.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,35,,7.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.6,90,,19.68,percent of total billed charges,90% of total billed charges for outpatient setting,3.51,24.6,
URINE LEG BAG 32OZ / 145516,5150186,CDM,272,RC,,,Outpatient,,,18.18,18.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.73,70,,10.18,percent of total billed charges,70% of total billed charges for outpatient setting,15.43,84.88,,12.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.09,50,,7.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.64,75,,10.91,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,70,,10.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.54,80,,11.63,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.82,65,,9.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.36,35,,5.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.36,90,,13.09,percent of total billed charges,90% of total billed charges for outpatient setting,2.33,16.36,
URINE METER BAG CLSD SYSTEM // 153214,5150015,CDM,270,RC,,,Outpatient,,,52.33,52.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.63,70,,29.3,percent of total billed charges,70% of total billed charges for outpatient setting,44.42,84.88,,35.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.17,50,,20.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.25,75,,31.4,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,70,,29.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.72,12.84,,5.376,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.86,80,,33.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.72,12.84,,5.38,percent of total billed charges,12.84% of total billed charges,6.72,12.84,,5.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.01,65,,27.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.32,35,,14.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.1,90,,37.68,percent of total billed charges,90% of total billed charges for outpatient setting,6.72,47.1,
URINE NA,201090,CDM,300,RC,84300,HCPCS,Outpatient,,,22.77,20.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,19.33,84.88,,15.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.08,75,,13.66,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,80,,14.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,100,,,Fee Schedule,100% of Custom Fee Schedule,20.49,90,,16.39,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,20.49,
"URINE SODIUM, 24 HR",200631,CDM,300,RC,84300,HCPCS,Outpatient,,,22.77,20.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,19.33,84.88,,15.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.34,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,17.08,75,,13.66,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,70,,12.75,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.22,80,,14.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,100,,,Fee Schedule,100% of Custom Fee Schedule,20.49,90,,16.39,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,20.49,
"URINE TOTAL PROTEIN, 24 HR",220106,CDM,300,RC,84156,HCPCS,Outpatient,,,16.52,14.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,14.02,84.88,,11.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.39,75,,9.91,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,70,,9.25,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,80,,10.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of Custom Fee Schedule,14.87,90,,11.9,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,14.87,
UROGESIC BLUE : TAB,3302979,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
UROGRAM ANTEGRADE,2400755,CDM,320,RC,74425,HCPCS,Outpatient,,,1131.44,848.58,,527.98,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,960.37,84.88,,768.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,848.58,75,,678.86,percent of total billed charges,75% of total billed charges for outpatient setting,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,560.98,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,145.28,12.84,,116.224,percent of total billed charges,12.84% of total billed charges,577.48,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,905.15,80,,724.12,percent of total billed charges,80% of total billed charges for outpatient setting,461.98,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,1018.3,90,,814.64,percent of total billed charges,90% of total billed charges for outpatient setting,128,1018.3,
UROGRAM RETRO,2400750,CDM,320,RC,74420,HCPCS,Outpatient,,,1131.44,848.58,,527.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,960.37,84.88,,768.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,634.72,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,848.58,75,,678.86,percent of total billed charges,75% of total billed charges for outpatient setting,792.01,70,,633.61,percent of total billed charges,70% of total billed charges for outpatient setting,560.97,170,,,Fee Schedule,170% of Medicare OPPS rate,709.47,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,145.28,12.84,,116.224,percent of total billed charges,12.84% of total billed charges,577.47,175,,,Fee Schedule,175% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,905.15,80,,724.12,percent of total billed charges,80% of total billed charges for outpatient setting,461.97,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,412.48,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,145.28,12.84,,116.22,percent of total billed charges,12.84% of total billed charges,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,329.98,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,1018.3,90,,814.64,percent of total billed charges,90% of total billed charges for outpatient setting,128,1018.3,
UROGRAPHY INFUSION DRIP TECHNIQUE AND/OR,2400740,CDM,320,RC,74410,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UROGRAPHY WITH NEPHROTOMOGRAPHY,2400745,CDM,320,RC,74415,HCPCS,Outpatient,,,553.82,415.37,,256.1,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,470.08,84.88,,376.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,351.51,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,415.37,75,,332.3,percent of total billed charges,75% of total billed charges for outpatient setting,387.67,70,,310.14,percent of total billed charges,70% of total billed charges for outpatient setting,272.11,170,,,Fee Schedule,170% of Medicare OPPS rate,344.14,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,71.11,12.84,,56.888,percent of total billed charges,12.84% of total billed charges,280.11,175,,,Fee Schedule,175% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,443.06,80,,354.45,percent of total billed charges,80% of total billed charges for outpatient setting,224.09,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,200.07,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,71.11,12.84,,56.89,percent of total billed charges,12.84% of total billed charges,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.06,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,498.44,90,,398.75,percent of total billed charges,90% of total billed charges for outpatient setting,71.11,498.44,
UROLOGY DRAIN BAG / CMS-950P,70000728,CDM,272,RC,,,Outpatient,,,58.44,58.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.91,70,,32.73,percent of total billed charges,70% of total billed charges for outpatient setting,49.6,84.88,,39.68,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.22,50,,23.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.83,75,,35.06,percent of total billed charges,75% of total billed charges for outpatient setting,40.91,70,,32.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.75,80,,37.4,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,7.5,12.84,,6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.99,65,,30.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.45,35,,16.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.6,90,,42.08,percent of total billed charges,90% of total billed charges for outpatient setting,7.5,52.6,
UROLOGY DRAIN BAG SIEMENS / CF507505,69161579,CDM,272,RC,,,Outpatient,,,74.76,74.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.33,70,,41.86,percent of total billed charges,70% of total billed charges for outpatient setting,63.46,84.88,,50.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,37.38,50,,29.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.07,75,,44.86,percent of total billed charges,75% of total billed charges for outpatient setting,52.33,70,,41.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.81,80,,47.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,9.6,12.84,,7.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,48.59,65,,38.87,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.17,35,,20.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,67.28,90,,53.82,percent of total billed charges,90% of total billed charges for outpatient setting,9.6,67.28,
UROLOGY TIER 1 OR TIME,6100121,CDM,360,RC,,,Outpatient,,,5000,5000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3500,70,,2800,percent of total billed charges,70% of total billed charges for outpatient setting,4244,84.88,,3395.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,2500,50,,2000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750,75,,3000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4000,80,,3200,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,642,12.84,,513.6,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750,35,,1400,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4500,90,,3600,percent of total billed charges,90% of total billed charges for outpatient setting,642,4500,
UROLOGY TIER 2 OR TIME,6100122,CDM,360,RC,,,Outpatient,,,8000,8000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5600,70,,4480,percent of total billed charges,70% of total billed charges for outpatient setting,6790.4,84.88,,5432.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,4000,50,,3200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6000,75,,4800,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6400,80,,5120,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,1027.2,12.84,,821.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2800,35,,2240,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7200,90,,5760,percent of total billed charges,90% of total billed charges for outpatient setting,1027.2,7200,
UROLOGY TIER 3 OR TIME,6100123,CDM,360,RC,,,Outpatient,,,12000,12000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8400,70,,6720,percent of total billed charges,70% of total billed charges for outpatient setting,10185.6,84.88,,8148.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,6000,50,,4800,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9000,75,,7200,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9600,80,,7680,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,1540.8,12.84,,1232.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,35,,3360,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10800,90,,8640,percent of total billed charges,90% of total billed charges for outpatient setting,1540.8,10800,
UROLOGY TIER 4 OR TIME,6100124,CDM,360,RC,,,Outpatient,,,18000,18000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12600,70,,10080,percent of total billed charges,70% of total billed charges for outpatient setting,15278.4,84.88,,12222.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,9000,50,,7200,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13500,75,,10800,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14400,80,,11520,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,2311.2,12.84,,1848.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6300,35,,5040,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16200,90,,12960,percent of total billed charges,90% of total billed charges for outpatient setting,2000,16200,
UROLOGY TIER 5 OR TIME,6100125,CDM,360,RC,,,Outpatient,,,25000,25000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17500,70,,14000,percent of total billed charges,70% of total billed charges for outpatient setting,21220,84.88,,16976,percent of total billed charges,84.88% of total billed charges for outpatient setting,12500,50,,10000,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18750,75,,15000,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20000,80,,16000,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,3210,12.84,,2568,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8750,35,,7000,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22500,90,,18000,percent of total billed charges,90% of total billed charges for outpatient setting,2000,22500,
UROLOGY TRAY HEYMAN / 123400,69161581,CDM,272,RC,,,Outpatient,,,1462.6,1462.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.82,70,,819.06,percent of total billed charges,70% of total billed charges for outpatient setting,1241.45,84.88,,993.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,731.3,50,,585.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1096.95,75,,877.56,percent of total billed charges,75% of total billed charges for outpatient setting,1023.82,70,,819.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.8,12.84,,150.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170.08,80,,936.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.8,12.84,,150.24,percent of total billed charges,12.84% of total billed charges,187.8,12.84,,150.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,950.69,65,,760.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.91,35,,409.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1316.34,90,,1053.07,percent of total billed charges,90% of total billed charges for outpatient setting,187.8,1316.34,
UROLOK II ADAPTOR / M0067301401,69161079,CDM,272,RC,,,Outpatient,,,111.74,111.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.22,70,,62.58,percent of total billed charges,70% of total billed charges for outpatient setting,94.84,84.88,,75.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.87,50,,44.7,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.81,75,,67.05,percent of total billed charges,75% of total billed charges for outpatient setting,78.22,70,,62.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.35,12.84,,11.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.39,80,,71.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.35,12.84,,11.48,percent of total billed charges,12.84% of total billed charges,14.35,12.84,,11.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,72.63,65,,58.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.11,35,,31.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,100.57,90,,80.46,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,100.57,
URSODIOL (ACTIGALL) CAP : 300MG,3302130,CDM,259,RC,,,Outpatient,,,6.95,6.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.87,70,,3.9,percent of total billed charges,70% of total billed charges for outpatient setting,5.9,84.88,,4.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.48,50,,2.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.21,75,,4.17,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,70,,3.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,12.84,,0.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,80,,4.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.89,12.84,,0.71,percent of total billed charges,12.84% of total billed charges,0.89,12.84,,0.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4.52,65,,3.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,35,,1.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,6.26,90,,5.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.89,6.26,
URSODIOL (ACTIGALL) CAP : 300MG,3302131,CDM,259,RC,,,Outpatient,,,9.33,9.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,70,,5.22,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,84.88,,6.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.67,50,,3.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7,75,,5.6,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,70,,5.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.46,80,,5.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,1.2,12.84,,0.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.06,65,,4.85,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.27,35,,2.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.4,90,,6.72,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,8.4,
US ABD COMP,2600140,CDM,402,RC,76700,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ABD RUQ,2600145,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
"US ABD, LIMITED",2600152,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ADB SOFT TISSUE,2600167,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US AORTA SCREENING FOR AAA,2600157,CDM,402,RC,76706,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,91.73,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ART DOPPLER BILAT LOWER EXT,2600055,CDM,921,RC,93925,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ART DOPPLER BILAT UPPER EXT,2600065,CDM,921,RC,93930,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ART DOPPLER UNI LOWER EXT,2600380,CDM,921,RC,93926,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US ART DOPPLER UNI UPPER EXT,2600070,CDM,921,RC,93931,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US AXILLA BILATERAL,2600159,CDM,402,RC,76882,HCPCS,Outpatient,,,954,954,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,809.76,84.88,,647.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,477,50,,381.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.5,75,,572.4,percent of total billed charges,75% of total billed charges for outpatient setting,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.2,80,,610.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.9,35,,267.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,858.6,90,,686.88,percent of total billed charges,90% of total billed charges for outpatient setting,122.49,858.6,
US AXILLA UNILATERAL,2600158,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US BLADDER,2600166,CDM,402,RC,76857,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US BREAST ASP EACH ADDL,2600137,CDM,360,RC,,,Outpatient,,,374.64,374.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.25,70,,209.8,percent of total billed charges,70% of total billed charges for outpatient setting,317.99,84.88,,254.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,187.32,50,,149.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.98,75,,224.78,percent of total billed charges,75% of total billed charges for outpatient setting,262.25,70,,209.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.1,12.84,,38.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.71,80,,239.77,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.1,12.84,,38.48,percent of total billed charges,12.84% of total billed charges,48.1,12.84,,38.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.12,35,,104.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,337.18,90,,269.74,percent of total billed charges,90% of total billed charges for outpatient setting,48.1,337.18,
US BREAST BILATERAL COMPLETE,2600128,CDM,402,RC,76641,HCPCS,Outpatient,,,954,954,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,809.76,84.88,,647.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,477,50,,381.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.5,75,,572.4,percent of total billed charges,75% of total billed charges for outpatient setting,667.8,70,,534.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.992,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.2,80,,610.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,122.49,12.84,,97.99,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.9,35,,267.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,858.6,90,,686.88,percent of total billed charges,90% of total billed charges for outpatient setting,122.49,858.6,
US BREAST BILATERAL LIMITED,2600132,CDM,402,RC,76642,HCPCS,Outpatient,,,636,636,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,318,50,,254.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.6,35,,178.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US BREAST CORE BX,2600138,CDM,360,RC,,,Outpatient,,,1566.97,1566.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.88,70,,877.5,percent of total billed charges,70% of total billed charges for outpatient setting,1330.04,84.88,,1064.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,783.49,50,,626.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1175.23,75,,940.18,percent of total billed charges,75% of total billed charges for outpatient setting,1096.88,70,,877.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.2,12.84,,160.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1253.58,80,,1002.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.2,12.84,,160.96,percent of total billed charges,12.84% of total billed charges,201.2,12.84,,160.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.44,35,,438.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1410.27,90,,1128.22,percent of total billed charges,90% of total billed charges for outpatient setting,201.2,1410.27,
US BREAST CYST ASP,2600136,CDM,360,RC,,,Outpatient,,,960.32,960.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,815.12,84.88,,652.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,480.16,50,,384.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,720.24,75,,576.19,percent of total billed charges,75% of total billed charges for outpatient setting,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.26,80,,614.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.11,35,,268.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,864.29,90,,691.43,percent of total billed charges,90% of total billed charges for outpatient setting,123.31,864.29,
US BREAST NDLE LOC,2600139,CDM,402,RC,19285,HCPCS,Outpatient,,,997.5,997.5,,892.21,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,698.25,70,,558.6,percent of total billed charges,70% of total billed charges for outpatient setting,846.68,84.88,,677.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,796.72,50,,637.38,percent of total billed charges,50% of total Billed charges for outpatient setting,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,748.13,75,,598.5,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,70,,558.6,percent of total billed charges,70% of total billed charges for outpatient setting,947.98,170,,,Fee Schedule,170% of Medicare OPPS rate,1198.91,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,128.08,12.84,,102.464,percent of total billed charges,12.84% of total billed charges,975.86,175,,,Fee Schedule,175% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,798,80,,638.4,percent of total billed charges,80% of total billed charges for outpatient setting,780.68,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,697.04,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,128.08,12.84,,102.46,percent of total billed charges,12.84% of total billed charges,128.08,12.84,,102.46,percent of total billed charges,12.84% of total billed charges,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,557.63,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,116.88,100,,,Fee Schedule,100% of Custom Fee Schedule,897.75,90,,718.2,percent of total billed charges,90% of total billed charges for outpatient setting,116.88,1198.91,
US BREAST NDLE LOC EA ADDL,2600141,CDM,360,RC,,,Outpatient,,,381.85,381.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.3,70,,213.84,percent of total billed charges,70% of total billed charges for outpatient setting,324.11,84.88,,259.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,190.93,50,,152.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.39,75,,229.11,percent of total billed charges,75% of total billed charges for outpatient setting,267.3,70,,213.84,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.03,12.84,,39.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.48,80,,244.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.03,12.84,,39.22,percent of total billed charges,12.84% of total billed charges,49.03,12.84,,39.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.65,35,,106.92,percent of total billed charges,35% of total Billed charges for Outpatient Setting,343.67,90,,274.94,percent of total billed charges,90% of total billed charges for outpatient setting,49.03,343.67,
US BREAST UNILATERAL COMPLETE,2600133,CDM,402,RC,76641,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,105.65,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US BREAST UNILATERAL LIMITED,2600134,CDM,402,RC,76642,HCPCS,Outpatient,,,636,636,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,87.38,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,72.48,572.4,
US BUTTOCK,2600216,CDM,402,RC,76857,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US CARD REFLUX VENOUS STUDY BILAT LOW EX,2600078,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US CAROTID DOPPLER,2600040,CDM,921,RC,93880,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US CHEST,2600147,CDM,402,RC,76604,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US DISK IMPORT,2600121,CDM,402,RC,,,Outpatient,,,636,636,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,318,50,,254.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.6,35,,178.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US DUPLEX SCAN ABD/PELVIC/SCROTAL /RETR,2600044,CDM,921,RC,93975,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GASTROINTESTINAL ENDOSCOPIC,2600305,CDM,402,RC,76975,HCPCS,Outpatient,,,717.13,717.13,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
US GROIN  (VASCULAR) BILATERAL,2600264,CDM,921,RC,93925,HCPCS,Outpatient,,,713.49,713.49,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,605.61,84.88,,484.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,535.12,75,,428.1,percent of total billed charges,75% of total billed charges for outpatient setting,499.44,70,,399.55,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,91.61,12.84,,73.288,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,570.79,80,,456.63,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,91.61,12.84,,73.29,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,642.14,90,,513.71,percent of total billed charges,90% of total billed charges for outpatient setting,91.61,642.14,
US GROIN (NONVASCULAR),2600262,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
"US GROIN (NONVASCULAR), BILATERAL",2600263,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,318,50,,254.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,452,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.6,35,,178.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GROIN (VASCULAR),2600260,CDM,921,RC,93926,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GUIDE CHRONIC VILLUS,2600275,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GUIDE FOR ASPIRATE OVA,2600285,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GUIDE FOR ENDOMYCARDIAL B,2600255,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GUIDE FOR INTERSTITIAL RAD,2600295,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US GUIDE FOR PLACEMENT OF RAD,2600290,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US LOWER BACK LTD,2600217,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PAROTID,2600129,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PAROTID BX,2600156,CDM,360,RC,,,Outpatient,,,960.32,960.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,815.12,84.88,,652.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,480.16,50,,384.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,720.24,75,,576.19,percent of total billed charges,75% of total billed charges for outpatient setting,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.26,80,,614.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.11,35,,268.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,864.29,90,,691.43,percent of total billed charges,90% of total billed charges for outpatient setting,123.31,864.29,
US PELVIC,2600210,CDM,402,RC,76856,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PELVIC LTD,2600215,CDM,402,RC,76857,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PREG COMP,2600170,CDM,402,RC,76805,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PREG LTD,2600180,CDM,402,RC,76815,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PROSTATE,2600225,CDM,402,RC,76872,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US PROSTATE BX SC,2600143,CDM,360,RC,,,Outpatient,,,1843.88,1843.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290.72,70,,1032.58,percent of total billed charges,70% of total billed charges for outpatient setting,1565.09,84.88,,1252.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,921.94,50,,737.55,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1382.91,75,,1106.33,percent of total billed charges,75% of total billed charges for outpatient setting,1290.72,70,,1032.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.75,12.84,,189.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1475.1,80,,1180.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.75,12.84,,189.4,percent of total billed charges,12.84% of total billed charges,236.75,12.84,,189.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.36,35,,516.29,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1659.49,90,,1327.59,percent of total billed charges,90% of total billed charges for outpatient setting,236.75,1659.49,
US PYLORIC STENOSIS,26000147,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US RAD REFLUX VENOUS STUDY BILAT LOW EXT,2600079,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US RENAL,2600150,CDM,402,RC,76770,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US RETRO LTD,2600155,CDM,402,RC,76775,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US RETROPERITONEAL (AORTA/KIDNEY) COMPLE,2600151,CDM,402,RC,76770,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SEGMENTAL PRESSURE W/WO EXERCISE,2600050,CDM,921,RC,93924,HCPCS,Outpatient,,,636,636,,379.45,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,403.16,170,,,Fee Schedule,170% of Medicare OPPS rate,509.88,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,415.01,175,,,Fee Schedule,175% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,332.01,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,296.44,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,237.15,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SEGMENTAL PRESSURES,2600045,CDM,921,RC,93923,HCPCS,Outpatient,,,636,636,,200.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,189.59,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,212.68,170,,,Fee Schedule,170% of Medicare OPPS rate,268.98,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,218.94,175,,,Fee Schedule,175% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,175.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,156.38,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,125.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,155.91,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SOFT TISSUE CHEST,2600238,CDM,402,RC,76604,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SOFT TISSUE HEAD & NECK,2600237,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SOFT TISSUE NON-VASC EXTREMITY,2600235,CDM,402,RC,76882,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,107.12,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US SPLEEN,2600146,CDM,402,RC,76705,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US TESTICULAR,2600220,CDM,402,RC,76870,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US THYROID,2600130,CDM,402,RC,76536,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US THYROID BX,2600144,CDM,360,RC,,,Outpatient,,,960.32,960.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,815.12,84.88,,652.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,480.16,50,,384.13,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,720.24,75,,576.19,percent of total billed charges,75% of total billed charges for outpatient setting,672.22,70,,537.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.26,80,,614.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,123.31,12.84,,98.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.11,35,,268.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,864.29,90,,691.43,percent of total billed charges,90% of total billed charges for outpatient setting,123.31,864.29,
US TRANS VAG,2600200,CDM,402,RC,76830,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US TRANSRECTAL FOR MARKER PLACEMENT,2600191,CDM,402,RC,76872,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US UPPER BACK LTD,2600218,CDM,402,RC,76604,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US VEN DOPPLER BILAT UPPER OR LOWER EXT,2600075,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US VEN DOPPLER UNI UPPER OR LOWER EXT,2600080,CDM,921,RC,93971,HCPCS,Outpatient,,,561.52,561.52,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,393.06,70,,314.45,percent of total billed charges,70% of total billed charges for outpatient setting,476.62,84.88,,381.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,421.14,75,,336.91,percent of total billed charges,75% of total billed charges for outpatient setting,393.06,70,,314.45,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,449.22,80,,359.38,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,72.1,12.84,,57.68,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,505.37,90,,404.3,percent of total billed charges,90% of total billed charges for outpatient setting,72.1,505.37,
US VEN DOPPLER UNI UPPER OR LOWER EXT,2600395,CDM,921,RC,93971,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US VESSEL MAPPING FOR HEMODIALYSIS ACCES,2600076,CDM,921,RC,93985,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,324.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,256.31,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**ART DOPPLER BILAT UPPER EXT,2610065,CDM,921,RC,93930,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**ART DOPPLER UNILAT LOWER EXT,2610060,CDM,402,RC,93926,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,452,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**ART DOPPLER UNILAT UPPER EXT,2610070,CDM,921,RC,93931,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**CAROTID DOPPLER,2610040,CDM,921,RC,93880,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**HEMODIALYSIS ACCESS GRAFT,2610041,CDM,921,RC,93990,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.75,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.95,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**VEN DOPPLER BILAT UPPER OR LOWER EXT,2610075,CDM,921,RC,93970,HCPCS,Outpatient,,,636,636,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,227.02,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
US**VEN DOPPLR UNILAT UPPER OR LOWER EXT,2610395,CDM,921,RC,93971,HCPCS,Outpatient,,,636,636,,156.09,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,539.84,84.88,,431.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.19,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,477,75,,381.6,percent of total billed charges,75% of total billed charges for outpatient setting,445.2,70,,356.16,percent of total billed charges,70% of total billed charges for outpatient setting,165.85,170,,,Fee Schedule,170% of Medicare OPPS rate,209.74,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,81.66,12.84,,65.328,percent of total billed charges,12.84% of total billed charges,170.73,175,,,Fee Schedule,175% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,508.8,80,,407.04,percent of total billed charges,80% of total billed charges for outpatient setting,136.58,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,121.94,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,81.66,12.84,,65.33,percent of total billed charges,12.84% of total billed charges,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,193,100,,,Case rate,pays based on fixed rate ,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,97.56,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,160.08,100,,,Fee Schedule,100% of Custom Fee Schedule,572.4,90,,457.92,percent of total billed charges,90% of total billed charges for outpatient setting,81.66,572.4,
USE ITEM#202356,200260,CDM,305,RC,85576,HCPCS,Outpatient,,,112.1,100.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.47,70,,62.78,percent of total billed charges,70% of total billed charges for outpatient setting,95.15,84.88,,76.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,84.08,75,,67.26,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,70,,62.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.68,80,,71.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.74,100,,,Fee Schedule,100% of Custom Fee Schedule,100.89,90,,80.71,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100.89,
USTEKINUMAB (STELARA) 5MG/ML 26ML VIAL,3313726,CDM,636,RC,J3358,HCPCS,Outpatient,,,6168.12,6168.12,,19.77,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4317.68,70,,3454.14,percent of total billed charges,70% of total billed charges for outpatient setting,5235.5,84.88,,4188.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.82,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4626.09,75,,3700.87,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,21.01,170,,,Fee Schedule,170% of Medicare OPPS rate,26.57,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,791.99,12.84,,633.592,percent of total billed charges,12.84% of total billed charges,21.63,175,,,Fee Schedule,175% of Medicare OPPS rate,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4934.5,80,,3947.6,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,15.45,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,791.99,12.84,,633.59,percent of total billed charges,12.84% of total billed charges,791.99,12.84,,633.59,percent of total billed charges,12.84% of total billed charges,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4009.28,65,,3207.42,percent of total billed charges,65% of total billed charges for outpatient setting,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,12.36,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,13.53,100,,,Fee Schedule,100% of Custom Fee Schedule,5551.31,90,,4441.05,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,5551.31,
UTERINE MANIPULATOR  HUMI/ 6003,6150567,CDM,272,RC,,,Outpatient,,,148.05,148.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.64,70,,82.91,percent of total billed charges,70% of total billed charges for outpatient setting,125.66,84.88,,100.53,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.03,50,,59.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.04,75,,88.83,percent of total billed charges,75% of total billed charges for outpatient setting,103.64,70,,82.91,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,12.84,,15.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.44,80,,94.75,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,12.84,,15.21,percent of total billed charges,12.84% of total billed charges,19.01,12.84,,15.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,96.23,65,,76.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.82,35,,41.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,133.25,90,,106.6,percent of total billed charges,90% of total billed charges for outpatient setting,19.01,133.25,
UTRONA-C TAB,3303358,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VACCINE COVID-19 MODERNA,5000010,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,0.01,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,84.88,,0.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,75,,0.01,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,80,,0.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,65,,0.01,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,0.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,0.01,
VACURETTE 10MM CURVED / 21553,6150755,CDM,272,RC,,,Outpatient,,,28.16,28.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,23.9,84.88,,19.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.08,50,,11.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.12,75,,16.9,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.53,80,,18.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.3,65,,14.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.34,90,,20.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.34,
VACURETTE 11MM CURVED,6150756,CDM,272,RC,,,Outpatient,,,43.55,43.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.49,70,,24.39,percent of total billed charges,70% of total billed charges for outpatient setting,36.97,84.88,,29.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.78,50,,17.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.66,75,,26.13,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,70,,24.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.84,80,,27.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.31,65,,22.65,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,35,,12.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.2,90,,31.36,percent of total billed charges,90% of total billed charges for outpatient setting,5.59,39.2,
VACURETTE 7MM CURVED / 022107-10,6150752,CDM,272,RC,,,Outpatient,,,28.16,28.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,23.9,84.88,,19.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.08,50,,11.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.12,75,,16.9,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.53,80,,18.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.3,65,,14.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.34,90,,20.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.34,
VACURETTE 8MM CURVED / 022108-10,6150753,CDM,272,RC,,,Outpatient,,,28.16,28.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,23.9,84.88,,19.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.08,50,,11.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.12,75,,16.9,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.53,80,,18.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.3,65,,14.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.34,90,,20.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.34,
VACURETTE 9MM CURVED / 21552,6150754,CDM,272,RC,,,Outpatient,,,28.16,28.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,23.9,84.88,,19.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.08,50,,11.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.12,75,,16.9,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,70,,15.77,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.53,80,,18.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,3.62,12.84,,2.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.3,65,,14.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,35,,7.89,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.34,90,,20.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.62,25.34,
VALIUM TAB : 2MG,3302560,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VALIUM TAB : 5MG,3302561,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VALPROATE (DEPAKENE) SYRUP 250MG/5ML:5ML,3302132,CDM,259,RC,,,Outpatient,,,582.84,582.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.99,70,,326.39,percent of total billed charges,70% of total billed charges for outpatient setting,494.71,84.88,,395.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,291.42,50,,233.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437.13,75,,349.7,percent of total billed charges,75% of total billed charges for outpatient setting,407.99,70,,326.39,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.84,12.84,,59.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.27,80,,373.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.84,12.84,,59.87,percent of total billed charges,12.84% of total billed charges,74.84,12.84,,59.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,378.85,65,,303.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.99,35,,163.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,524.56,90,,419.65,percent of total billed charges,90% of total billed charges for outpatient setting,74.84,524.56,
VALPROATE SODIUM 100MG/ML 5 ML INJ,3303276,CDM,250,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
VALPROIC ACID,220031,CDM,300,RC,80164,HCPCS,Outpatient,,,60.93,54.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,51.72,84.88,,41.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.7,75,,36.56,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,80,,38.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.84,90,,43.87,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,54.84,
VALSARTAN (DIOVAN) 160 MG TAB,3302817,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VALSARTAN (DIOVAN) TAB : 80MG U/D,3302134,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VALSARTAN (genericDIOVAN ) 80MG TAB,3302133,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
VALTREX 500MG: TAB,3302839,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VALVE AHMED GLAUCOMA / FP7,69169192,CDM,278,RC,C1783,HCPCS,Outpatient,,,2649.68,2649.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.81,60,,1271.85,percent of total billed charges,60% of total Billed charges for outpatient setting,2249.05,84.88,,1799.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.26,75,,1589.81,percent of total billed charges,75% of total billed charges for outpatient setting,1324.84,50,,1059.87,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.74,80,,1695.79,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,340.22,12.84,,272.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2782.16,105,,2225.73,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.39,35,,741.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1589.81,60,,1271.85,percent of total billed charges,60% of total billed charges for outpatient setting,340.22,2782.16,
VANCOMYCIN (VANCOCIN) 1GM/NS 150 ML:,3302135,CDM,250,RC,,,Outpatient,,,58.98,58.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.29,70,,33.03,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,84.88,,40.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.49,50,,23.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.24,75,,35.39,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,70,,33.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.57,12.84,,6.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.18,80,,37.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.57,12.84,,6.06,percent of total billed charges,12.84% of total billed charges,7.57,12.84,,6.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.34,65,,30.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,35,,16.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,53.08,90,,42.46,percent of total billed charges,90% of total billed charges for outpatient setting,7.57,53.08,
VANCOMYCIN (VANCOCIN) INJ : 1GM,3302136,CDM,250,RC,,,Outpatient,,,43.82,43.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,37.19,84.88,,29.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.91,50,,17.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.87,75,,26.3,percent of total billed charges,75% of total billed charges for outpatient setting,30.67,70,,24.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,80,,28.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,5.63,12.84,,4.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.48,65,,22.78,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.34,35,,12.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.44,90,,31.55,percent of total billed charges,90% of total billed charges for outpatient setting,5.63,39.44,
VANCOMYCIN 1.5GMS/300MLS PREMIX,3313015,CDM,636,RC,J3370,HCPCS,Outpatient,,,138.23,138.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.76,70,,77.41,percent of total billed charges,70% of total billed charges for outpatient setting,117.33,84.88,,93.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,103.67,75,,82.94,percent of total billed charges,75% of total billed charges for outpatient setting,96.76,70,,77.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.58,80,,88.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,17.75,12.84,,14.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,89.85,65,,71.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of Custom Fee Schedule,124.41,90,,99.53,percent of total billed charges,90% of total billed charges for outpatient setting,3.01,124.41,
VANCOMYCIN 1GM INJ,3302637,CDM,636,RC,J3370,HCPCS,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of Custom Fee Schedule,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,3.56,
VANCOMYCIN 1GM/200MLS PREMIX,3313303,CDM,636,RC,J3370,HCPCS,Outpatient,,,93.2,93.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.24,70,,52.19,percent of total billed charges,70% of total billed charges for outpatient setting,79.11,84.88,,63.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,69.9,75,,55.92,percent of total billed charges,75% of total billed charges for outpatient setting,65.24,70,,52.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,12.84,,9.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.56,80,,59.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,12.84,,9.58,percent of total billed charges,12.84% of total billed charges,11.97,12.84,,9.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,60.58,65,,48.46,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of Custom Fee Schedule,83.88,90,,67.1,percent of total billed charges,90% of total billed charges for outpatient setting,3.01,83.88,
VANCOMYCIN 500 MG INJ,3302137,CDM,250,RC,J3370,HCPCS,Outpatient,,,33.05,33.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.14,70,,18.51,percent of total billed charges,70% of total billed charges for outpatient setting,28.05,84.88,,22.44,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.01,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,24.79,75,,19.83,percent of total billed charges,75% of total billed charges for outpatient setting,23.14,70,,18.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.44,80,,21.15,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,4.24,12.84,,3.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,21.48,65,,17.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.56,100,,,Fee Schedule,100% of Custom Fee Schedule,29.75,90,,23.8,percent of total billed charges,90% of total billed charges for outpatient setting,3.01,29.75,
VANCOMYCIN PEAK,220043,CDM,300,RC,80202,HCPCS,Outpatient,,,60.93,54.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,51.72,84.88,,41.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.7,75,,36.56,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,80,,38.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.84,90,,43.87,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,54.84,
VANCOMYCIN QUANT,220044,CDM,300,RC,80202,HCPCS,Outpatient,,,60.93,54.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,51.72,84.88,,41.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.7,75,,36.56,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,80,,38.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.84,90,,43.87,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,54.84,
VANCOMYCIN TROUGH,220045,CDM,300,RC,80202,HCPCS,Outpatient,,,60.93,54.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,51.72,84.88,,41.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,45.7,75,,36.56,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,70,,34.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.74,80,,38.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,19.78,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,100,,,Fee Schedule,100% of Custom Fee Schedule,54.84,90,,43.87,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,54.84,
VANCOMYCIN: 250 MG CAPSULE,3303144,CDM,259,RC,,,Outpatient,,,70.39,70.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.27,70,,39.42,percent of total billed charges,70% of total billed charges for outpatient setting,59.75,84.88,,47.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,35.2,50,,28.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.79,75,,42.23,percent of total billed charges,75% of total billed charges for outpatient setting,49.27,70,,39.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,12.84,,7.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.31,80,,45.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.04,12.84,,7.23,percent of total billed charges,12.84% of total billed charges,9.04,12.84,,7.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,45.75,65,,36.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.64,35,,19.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,63.35,90,,50.68,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,63.35,
VARIBAR THIN LIQUID SUSP / 900001,70000430,CDM,270,RC,,,Outpatient,,,43.47,43.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,36.9,84.88,,29.52,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.74,50,,17.39,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.6,75,,26.08,percent of total billed charges,75% of total billed charges for outpatient setting,30.43,70,,24.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,12.84,,4.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.78,80,,27.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.58,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,5.58,12.84,,4.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.26,65,,22.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.21,35,,12.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.12,90,,31.3,percent of total billed charges,90% of total billed charges for outpatient setting,5.58,39.12,
VARICELLA (VARIVAX) 0.5 ML SDV :,3302138,CDM,250,RC,,,Outpatient,,,197.75,197.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.43,70,,110.74,percent of total billed charges,70% of total billed charges for outpatient setting,167.85,84.88,,134.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,98.88,50,,79.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.31,75,,118.65,percent of total billed charges,75% of total billed charges for outpatient setting,138.43,70,,110.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,12.84,,20.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.2,80,,126.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,12.84,,20.31,percent of total billed charges,12.84% of total billed charges,25.39,12.84,,20.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128.54,65,,102.83,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.21,35,,55.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,177.98,90,,142.38,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,177.98,
VARICELLA-ZOSTER VIRUS AB IgG,220730,CDM,302,RC,86787,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
VARICELLA-ZOSTER VIRUS AB IGM,220735,CDM,302,RC,86787,HCPCS,Outpatient,,,57.96,52.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,84.88,,39.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,22.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,43.47,75,,34.78,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,70,,32.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.37,80,,37.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,18.81,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.27,100,,,Fee Schedule,100% of Custom Fee Schedule,52.16,90,,41.73,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,52.16,
VASELINE GAUZE 3X9 STERILE / 8884413605,6150183,CDM,272,RC,,,Outpatient,,,4.05,4.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.84,70,,2.27,percent of total billed charges,70% of total billed charges for outpatient setting,3.44,84.88,,2.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.03,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.04,75,,2.43,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,70,,2.27,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,80,,2.59,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,35,,1.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.65,90,,2.92,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.65,
VASOGRAPHY VESTCULOGRAPHY OR EPIDIDYMOGR,2400765,CDM,320,RC,74440,HCPCS,Outpatient,,,717.13,537.85,,329.9,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,608.7,84.88,,486.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,323.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,537.85,75,,430.28,percent of total billed charges,75% of total billed charges for outpatient setting,501.99,70,,401.59,percent of total billed charges,70% of total billed charges for outpatient setting,350.52,170,,,Fee Schedule,170% of Medicare OPPS rate,443.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,92.08,12.84,,73.664,percent of total billed charges,12.84% of total billed charges,360.83,175,,,Fee Schedule,175% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,573.7,80,,458.96,percent of total billed charges,80% of total billed charges for outpatient setting,288.67,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,257.74,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,92.08,12.84,,73.66,percent of total billed charges,12.84% of total billed charges,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,206.19,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,306.44,100,,,Fee Schedule,100% of Custom Fee Schedule,645.42,90,,516.34,percent of total billed charges,90% of total billed charges for outpatient setting,92.08,645.42,
VASOPRESSIN 20U/ML INJ 1 ML,3302140,CDM,250,RC,,,Outpatient,,,146.66,146.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.66,70,,82.13,percent of total billed charges,70% of total billed charges for outpatient setting,124.49,84.88,,99.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.33,50,,58.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110,75,,88,percent of total billed charges,75% of total billed charges for outpatient setting,102.66,70,,82.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.83,12.84,,15.064,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.33,80,,93.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.83,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,18.83,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.33,65,,76.26,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.33,35,,41.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.99,90,,105.59,percent of total billed charges,90% of total billed charges for outpatient setting,18.83,131.99,
VASOPRESSIN 20U/ML MDV : 1 ML,3302139,CDM,250,RC,,,Outpatient,,,14.55,14.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,70,,8.15,percent of total billed charges,70% of total billed charges for outpatient setting,12.35,84.88,,9.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.28,50,,5.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.91,75,,8.73,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,70,,8.15,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.64,80,,9.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,1.87,12.84,,1.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.46,65,,7.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,35,,4.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.1,90,,10.48,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,13.1,
"VDRL, CSF",200158,CDM,302,RC,86592,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
"VDRL, CSF",220084,CDM,302,RC,86592,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
VECURONIUM BROMIDE INJ 10 MG,3302142,CDM,250,RC,,,Outpatient,,,53.51,53.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.46,70,,29.97,percent of total billed charges,70% of total billed charges for outpatient setting,45.42,84.88,,36.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.76,50,,21.41,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.13,75,,32.1,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,70,,29.97,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.87,12.84,,5.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.81,80,,34.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.87,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,6.87,12.84,,5.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.78,65,,27.82,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,35,,14.98,percent of total billed charges,35% of total Billed charges for Outpatient Setting,48.16,90,,38.53,percent of total billed charges,90% of total billed charges for outpatient setting,6.87,48.16,
VECURONIUM BROMIDE INJ: 10 MG,3302141,CDM,250,RC,,,Outpatient,,,373.77,373.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.64,70,,209.31,percent of total billed charges,70% of total billed charges for outpatient setting,317.26,84.88,,253.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,186.89,50,,149.51,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.33,75,,224.26,percent of total billed charges,75% of total billed charges for outpatient setting,261.64,70,,209.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.99,12.84,,38.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.02,80,,239.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.99,12.84,,38.39,percent of total billed charges,12.84% of total billed charges,47.99,12.84,,38.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,242.95,65,,194.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.82,35,,104.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,336.39,90,,269.11,percent of total billed charges,90% of total billed charges for outpatient setting,47.99,336.39,
VECURONIUM BROMIDE INJ: 10 MG,3302143,CDM,250,RC,,,Outpatient,,,438.06,438.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.64,70,,245.31,percent of total billed charges,70% of total billed charges for outpatient setting,371.83,84.88,,297.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,219.03,50,,175.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.55,75,,262.84,percent of total billed charges,75% of total billed charges for outpatient setting,306.64,70,,245.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,12.84,,45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.45,80,,280.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,12.84,,45,percent of total billed charges,12.84% of total billed charges,56.25,12.84,,45,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,284.74,65,,227.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.32,35,,122.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,394.25,90,,315.4,percent of total billed charges,90% of total billed charges for outpatient setting,56.25,394.25,
VENIPUNCTURE,210099,CDM,360,RC,36415,HCPCS,Outpatient,,,5.57,5.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,70,,3.12,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,84.88,,3.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.18,75,,3.34,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,70,,3.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.576,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.46,80,,3.57,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,0.72,12.84,,0.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,100,,,Fee Schedule,100% of Custom Fee Schedule,5.01,90,,4.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,5.01,
VENIPUNCTURE,200376,CDM,300,RC,36415,HCPCS,Outpatient,,,38.57,34.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,70,,21.6,percent of total billed charges,70% of total billed charges for outpatient setting,32.74,84.88,,26.19,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,75,,23.14,percent of total billed charges,75% of total billed charges for outpatient setting,27,70,,21.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.86,80,,24.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.17,100,,,Fee Schedule,100% of Custom Fee Schedule,34.71,90,,27.77,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,34.71,
VENLAFAXINE (EFFEXOR) TAB: 25 MG,3302144,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VENLAFAXINE (EFFEXOR) TAB: 75 MG,3302145,CDM,259,RC,,,Outpatient,,,4.18,4.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,70,,2.34,percent of total billed charges,70% of total billed charges for outpatient setting,3.55,84.88,,2.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.09,50,,1.67,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.14,75,,2.51,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,70,,2.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,80,,2.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,0.54,12.84,,0.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.72,65,,2.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.46,35,,1.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.76,90,,3.01,percent of total billed charges,90% of total billed charges for outpatient setting,0.54,3.76,
VENLAFAXINE XR (EFFEXOR) 37.5 MG CAP,3302861,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
VENLAFAXINE XR (EFFEXOR) CAP: 75MG,3302146,CDM,259,RC,,,Outpatient,,,7.95,7.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,84.88,,5.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,3.98,50,,3.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.96,75,,4.77,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,70,,4.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.36,80,,5.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.02,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.17,65,,4.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,35,,2.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.16,90,,5.73,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,7.16,
VENOFER (IRON SUCROSE) 20MG ML 1MG UNIT,3303295,CDM,636,RC,J1756,HCPCS,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.22,100,,,Fee Schedule,100% of Custom Fee Schedule,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.22,2.92,
VENOFER: IRON SUCROSE 1MG/UNIT (WASTAGE),3305391,CDM,636,RC,J1756,HCPCS,Outpatient,,,1.33,1.33,JW,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,70,,0.74,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,84.88,,0.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,0.67,50,,0.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1,75,,0.8,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,70,,0.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,12.84,,0.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,80,,0.85,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,0.17,12.84,,0.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,0.86,65,,0.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,35,,0.38,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1.2,90,,0.96,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,1.2,
"VENOGRAPHY, BILATERAL EXT",2200712,CDM,320,RC,75822,HCPCS,Outpatient,,,3269.67,2452.25,,2016.17,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.77,70,,1831.02,percent of total billed charges,70% of total billed charges for outpatient setting,2775.3,84.88,,2220.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,1367.11,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2452.25,75,,1961.8,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,2142.19,170,,,Fee Schedule,170% of Medicare OPPS rate,2709.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,419.83,12.84,,335.864,percent of total billed charges,12.84% of total billed charges,2205.19,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2615.74,80,,2092.59,percent of total billed charges,80% of total billed charges for outpatient setting,1764.15,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1575.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.1,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,878.73,100,,,Fee Schedule,100% of Custom Fee Schedule,2942.7,90,,2354.16,percent of total billed charges,90% of total billed charges for outpatient setting,128,2942.7,
"VENOGRAPHY, CAVAL, INF W SERIALOGRAPHY",2200710,CDM,320,RC,75825,HCPCS,Outpatient,,,6654.15,4990.61,,4104.4,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4657.91,70,,3726.33,percent of total billed charges,70% of total billed charges for outpatient setting,5648.04,84.88,,4518.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,3466.9,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,4990.61,75,,3992.49,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,4360.92,170,,,Fee Schedule,170% of Medicare OPPS rate,5515.29,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,854.39,12.84,,683.512,percent of total billed charges,12.84% of total billed charges,4489.19,175,,,Fee Schedule,175% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,5323.32,80,,4258.66,percent of total billed charges,80% of total billed charges for outpatient setting,3591.35,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,3206.56,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,854.39,12.84,,683.51,percent of total billed charges,12.84% of total billed charges,854.39,12.84,,683.51,percent of total billed charges,12.84% of total billed charges,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2565.25,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,3064.89,100,,,Fee Schedule,100% of Custom Fee Schedule,5988.74,90,,4790.99,percent of total billed charges,90% of total billed charges for outpatient setting,128,5988.74,
"VENOGRAPHY, CAVAL, SUP W SERIALOGRAPHY",2200711,CDM,320,RC,75827,HCPCS,Outpatient,,,3269.67,2452.25,,2016.18,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.77,70,,1831.02,percent of total billed charges,70% of total billed charges for outpatient setting,2775.3,84.88,,2220.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,851.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2452.25,75,,1961.8,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,2142.19,170,,,Fee Schedule,170% of Medicare OPPS rate,2709.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,419.83,12.84,,335.864,percent of total billed charges,12.84% of total billed charges,2205.2,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2615.74,80,,2092.59,percent of total billed charges,80% of total billed charges for outpatient setting,1764.16,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1575.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,983.72,100,,,Fee Schedule,100% of Custom Fee Schedule,2942.7,90,,2354.16,percent of total billed charges,90% of total billed charges for outpatient setting,128,2942.7,
"VENOGRAPHY, UNILATERAL EXT",2200713,CDM,320,RC,75820,HCPCS,Outpatient,,,3269.67,2452.25,,2016.18,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2288.77,70,,1831.02,percent of total billed charges,70% of total billed charges for outpatient setting,2775.3,84.88,,2220.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,851.96,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2452.25,75,,1961.8,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,2142.19,170,,,Fee Schedule,170% of Medicare OPPS rate,2709.24,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,419.83,12.84,,335.864,percent of total billed charges,12.84% of total billed charges,2205.2,175,,,Fee Schedule,175% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,2615.74,80,,2092.59,percent of total billed charges,80% of total billed charges for outpatient setting,1764.16,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,1575.14,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,419.83,12.84,,335.86,percent of total billed charges,12.84% of total billed charges,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,1260.11,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,983.72,100,,,Fee Schedule,100% of Custom Fee Schedule,2942.7,90,,2354.16,percent of total billed charges,90% of total billed charges for outpatient setting,128,2942.7,
VENOUS GRAFTS,2200680,CDM,481,RC,,,Outpatient,,,2045.47,2045.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.83,70,,1145.46,percent of total billed charges,70% of total billed charges for outpatient setting,1736.19,84.88,,1388.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,1022.74,50,,818.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1534.1,75,,1227.28,percent of total billed charges,75% of total billed charges for outpatient setting,1431.83,70,,1145.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.64,12.84,,210.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.38,80,,1309.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.64,12.84,,210.11,percent of total billed charges,12.84% of total billed charges,262.64,12.84,,210.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.91,35,,572.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1840.92,90,,1472.74,percent of total billed charges,90% of total billed charges for outpatient setting,262.64,1840.92,
VENT TUBE POPE 1.14MM  1035004,69161084,CDM,278,RC,,,Outpatient,,,162.63,162.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.58,60,,78.06,percent of total billed charges,60% of total Billed charges for outpatient setting,138.04,84.88,,110.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.32,50,,65.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.97,75,,97.58,percent of total billed charges,75% of total billed charges for outpatient setting,81.32,50,,65.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.88,12.84,,16.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.1,80,,104.08,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.88,12.84,,16.7,percent of total billed charges,12.84% of total billed charges,20.88,12.84,,16.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.63,65,,130.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.92,35,,45.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.58,60,,78.06,percent of total billed charges,60% of total billed charges for outpatient setting,20.88,162.63,
VENTILATOR ADAPTER JET / 600101,69160719,CDM,272,RC,,,Outpatient,,,310.41,310.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.29,70,,173.83,percent of total billed charges,70% of total billed charges for outpatient setting,263.48,84.88,,210.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,155.21,50,,124.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.81,75,,186.25,percent of total billed charges,75% of total billed charges for outpatient setting,217.29,70,,173.83,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.86,12.84,,31.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.33,80,,198.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.86,12.84,,31.89,percent of total billed charges,12.84% of total billed charges,39.86,12.84,,31.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,201.77,65,,161.42,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.64,35,,86.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,279.37,90,,223.5,percent of total billed charges,90% of total billed charges for outpatient setting,39.86,279.37,
VENTRALIGHT ST MESH 6X10IN / 5954610,69161167,CDM,278,RC,,,Outpatient,,,33406.12,33406.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20043.67,60,,16034.94,percent of total billed charges,60% of total Billed charges for outpatient setting,28355.11,84.88,,22684.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,16703.06,50,,13362.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25054.59,75,,20043.67,percent of total billed charges,75% of total billed charges for outpatient setting,16703.06,50,,13362.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26724.9,80,,21379.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35076.43,105,,28061.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11692.14,35,,9353.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20043.67,60,,16034.94,percent of total billed charges,60% of total billed charges for outpatient setting,4289.35,35076.43,
VENTRALIGHT ST MESH 6X8IN / 5954680,69161067,CDM,278,RC,,,Outpatient,,,33406.12,33406.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20043.67,60,,16034.94,percent of total billed charges,60% of total Billed charges for outpatient setting,28355.11,84.88,,22684.09,percent of total billed charges,84.88% of total billed charges for outpatient setting,16703.06,50,,13362.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25054.59,75,,20043.67,percent of total billed charges,75% of total billed charges for outpatient setting,16703.06,50,,13362.45,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26724.9,80,,21379.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,4289.35,12.84,,3431.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,35076.43,105,,28061.14,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11692.14,35,,9353.71,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20043.67,60,,16034.94,percent of total billed charges,60% of total billed charges for outpatient setting,4289.35,35076.43,
VENTRALIGHT ST MESH 7X9IN / 5954790,69161578,CDM,278,RC,,,Outpatient,,,3356.8,3356.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2014.08,60,,1611.26,percent of total billed charges,60% of total Billed charges for outpatient setting,2849.25,84.88,,2279.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,1678.4,50,,1342.72,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2517.6,75,,2014.08,percent of total billed charges,75% of total billed charges for outpatient setting,1678.4,50,,1342.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.01,12.84,,344.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2685.44,80,,2148.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.01,12.84,,344.81,percent of total billed charges,12.84% of total billed charges,431.01,12.84,,344.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3524.64,105,,2819.71,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.88,35,,939.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2014.08,60,,1611.26,percent of total billed charges,60% of total billed charges for outpatient setting,431.01,3524.64,
VENTRALIGHT ST MESH W/ECHO 6X8  HUVHO791,69161258,CDM,278,RC,,,Outpatient,,,2480,2480,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488,60,,1190.4,percent of total billed charges,60% of total Billed charges for outpatient setting,2105.02,84.88,,1684.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1240,50,,992,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1860,75,,1488,percent of total billed charges,75% of total billed charges for outpatient setting,1240,50,,992,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.43,12.84,,254.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984,80,,1587.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.43,12.84,,254.74,percent of total billed charges,12.84% of total billed charges,318.43,12.84,,254.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2604,105,,2083.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868,35,,694.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1488,60,,1190.4,percent of total billed charges,60% of total billed charges for outpatient setting,318.43,2604,
VERAPAMIL HCL 120MG TAB,3302149,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VERAPAMIL HCL 80MG TAB,3314223,CDM,259,RC,,,Outpatient,,,3.09,3.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,84.88,,2.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.55,50,,1.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,75,,1.86,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,70,,1.73,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,80,,1.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,0.4,12.84,,0.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.01,65,,1.61,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,35,,0.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.78,90,,2.22,percent of total billed charges,90% of total billed charges for outpatient setting,0.4,2.78,
VERAPAMIL HCL AMP 2.5 MG/ML 2ML,3302147,CDM,250,RC,,,Outpatient,,,150.22,150.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.15,70,,84.12,percent of total billed charges,70% of total billed charges for outpatient setting,127.51,84.88,,102.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,75.11,50,,60.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.67,75,,90.14,percent of total billed charges,75% of total billed charges for outpatient setting,105.15,70,,84.12,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.29,12.84,,15.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.18,80,,96.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.29,12.84,,15.43,percent of total billed charges,12.84% of total billed charges,19.29,12.84,,15.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.64,65,,78.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.58,35,,42.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,135.2,90,,108.16,percent of total billed charges,90% of total billed charges for outpatient setting,19.29,135.2,
VERAPAMIL HCL TAB: 180 MG,3302151,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VERAPAMIL HCL TAB: 240 MG,3302150,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VERAPAMIL HCL TAB: 40 MG,3302148,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VERAPAMIL SR : 180  MG,3303322,CDM,259,RC,,,Outpatient,,,5.37,5.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,70,,3.01,percent of total billed charges,70% of total billed charges for outpatient setting,4.56,84.88,,3.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.69,50,,2.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.03,75,,3.22,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,70,,3.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,80,,3.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.49,65,,2.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,35,,1.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.83,90,,3.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.69,4.83,
VERAPAMIL SR : 240 MG,3302152,CDM,259,RC,,,Outpatient,,,5.37,5.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,70,,3.01,percent of total billed charges,70% of total billed charges for outpatient setting,4.56,84.88,,3.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.69,50,,2.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.03,75,,3.22,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,70,,3.01,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,80,,3.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,0.69,12.84,,0.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.49,65,,2.79,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,35,,1.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.83,90,,3.86,percent of total billed charges,90% of total billed charges for outpatient setting,0.69,4.83,
VERELAN PM: 100 MG,3303100,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VESICARE 5 MG: SOLIFENACIN,3303234,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
VES-O-LOK MED/LG CLIPS GREEN / 51114V,7703718,CDM,272,RC,,,Outpatient,,,146.6,146.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.62,70,,82.1,percent of total billed charges,70% of total billed charges for outpatient setting,124.43,84.88,,99.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.3,50,,58.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.95,75,,87.96,percent of total billed charges,75% of total billed charges for outpatient setting,102.62,70,,82.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.82,12.84,,15.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.28,80,,93.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.82,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,18.82,12.84,,15.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.29,65,,76.23,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.31,35,,41.05,percent of total billed charges,35% of total Billed charges for Outpatient Setting,131.94,90,,105.55,percent of total billed charges,90% of total billed charges for outpatient setting,18.82,131.94,
VESSEL CANNULA 30004,6152560,CDM,272,RC,,,Outpatient,,,43.53,43.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.47,70,,24.38,percent of total billed charges,70% of total billed charges for outpatient setting,36.95,84.88,,29.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.77,50,,17.42,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.65,75,,26.12,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,70,,24.38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.82,80,,27.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,5.59,12.84,,4.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,28.29,65,,22.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,35,,12.19,percent of total billed charges,35% of total Billed charges for Outpatient Setting,39.18,90,,31.34,percent of total billed charges,90% of total billed charges for outpatient setting,5.59,39.18,
VESSEL LOOPS BLUE MINI,6150872,CDM,270,RC,,,Outpatient,,,30.73,30.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.51,70,,17.21,percent of total billed charges,70% of total billed charges for outpatient setting,26.08,84.88,,20.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.37,50,,12.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.05,75,,18.44,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,70,,17.21,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,80,,19.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,3.95,12.84,,3.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,19.97,65,,15.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,35,,8.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,27.66,90,,22.13,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,27.66,
VESSEL LOOPS RED MINI / 30-712,6150874,CDM,270,RC,,,Outpatient,,,9.54,9.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,84.88,,6.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.77,50,,3.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.16,75,,5.73,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,70,,5.34,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.63,80,,6.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,1.22,12.84,,0.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,6.2,65,,4.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,35,,2.67,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.59,90,,6.87,percent of total billed charges,90% of total billed charges for outpatient setting,1.22,8.59,
VG2 4X6 CERVICAL LORDOTIC / VG2C-T46P,69161761,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VG2 5X7 CERVICAL LORDOTIC VG2C-T57P,69161762,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VG2 6X8 CERVICAL LORDOTIC VG2C-T68P,69161763,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VG2 7X9 CERVICAL LORDOTIC VG2C-T79P,69161764,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VG2 8X10 CERVICAL LORDOTIC VG2C-T810P,69161765,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VG2 9X11 CERVICAL LORDOTIC VG2C-T911P,69161766,CDM,278,RC,,,Outpatient,,,2698,2698,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618.8,60,,1295.04,percent of total billed charges,60% of total Billed charges for outpatient setting,2290.06,84.88,,1832.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2023.5,75,,1618.8,percent of total billed charges,75% of total billed charges for outpatient setting,1349,50,,1079.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.136,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2158.4,80,,1726.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,346.42,12.84,,277.14,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2832.9,105,,2266.32,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.3,35,,755.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1618.8,60,,1295.04,percent of total billed charges,60% of total billed charges for outpatient setting,346.42,2832.9,
VIAFLEX EMPTY 2000 ML: BAG,3303177,CDM,250,RC,,,Outpatient,,,87.92,87.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.54,70,,49.23,percent of total billed charges,70% of total billed charges for outpatient setting,74.63,84.88,,59.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,43.96,50,,35.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.94,75,,52.75,percent of total billed charges,75% of total billed charges for outpatient setting,61.54,70,,49.23,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.29,12.84,,9.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.34,80,,56.27,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.29,12.84,,9.03,percent of total billed charges,12.84% of total billed charges,11.29,12.84,,9.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,57.15,65,,45.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.77,35,,24.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,79.13,90,,63.3,percent of total billed charges,90% of total billed charges for outpatient setting,11.29,79.13,
VICOPROFEN(HYDROCODONE/IBUP):7.5MG/200MG,3302708,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
VIGAMOX 0.5% OPTH SOLN 3MLS,3302918,CDM,272,RC,,,Outpatient,,,709.76,709.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.83,70,,397.46,percent of total billed charges,70% of total billed charges for outpatient setting,602.44,84.88,,481.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,354.88,50,,283.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,532.32,75,,425.86,percent of total billed charges,75% of total billed charges for outpatient setting,496.83,70,,397.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.13,12.84,,72.904,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.81,80,,454.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.13,12.84,,72.9,percent of total billed charges,12.84% of total billed charges,91.13,12.84,,72.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,461.34,65,,369.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.42,35,,198.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,638.78,90,,511.02,percent of total billed charges,90% of total billed charges for outpatient setting,91.13,638.78,
VIRAL CULTURE,220085,CDM,310,RC,87252,HCPCS,Outpatient,,,117.32,105.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.12,70,,65.7,percent of total billed charges,70% of total billed charges for outpatient setting,99.58,84.88,,79.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.76,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,87.99,75,,70.39,percent of total billed charges,75% of total billed charges for outpatient setting,82.12,70,,65.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.86,80,,75.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,38.06,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.43,100,,,Fee Schedule,100% of Custom Fee Schedule,105.59,90,,84.47,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,105.59,
VISCOAT SYRINGE 0.5MG/ML:,3302548,CDM,259,RC,,,Outpatient,,,396.98,396.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.89,70,,222.31,percent of total billed charges,70% of total billed charges for outpatient setting,336.96,84.88,,269.57,percent of total billed charges,84.88% of total billed charges for outpatient setting,198.49,50,,158.79,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.74,75,,238.19,percent of total billed charges,75% of total billed charges for outpatient setting,277.89,70,,222.31,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,12.84,,40.776,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.58,80,,254.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.97,12.84,,40.78,percent of total billed charges,12.84% of total billed charges,50.97,12.84,,40.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,258.04,65,,206.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.94,35,,111.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,357.28,90,,285.82,percent of total billed charges,90% of total billed charges for outpatient setting,50.97,357.28,
VISIONAIRE ADPT GD LGNP KIT V0200109,69169284,CDM,272,RC,,,Outpatient,,,2021.25,2021.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1414.88,70,,1131.9,percent of total billed charges,70% of total billed charges for outpatient setting,1715.64,84.88,,1372.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,1010.63,50,,808.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1515.94,75,,1212.75,percent of total billed charges,75% of total billed charges for outpatient setting,1414.88,70,,1131.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.53,12.84,,207.624,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617,80,,1293.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.53,12.84,,207.62,percent of total billed charges,12.84% of total billed charges,259.53,12.84,,207.62,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1313.81,65,,1051.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.44,35,,565.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1819.13,90,,1455.3,percent of total billed charges,90% of total billed charges for outpatient setting,259.53,1819.13,
VISIONAIRE LGNP KIT LT SZ F4/T2 / V02000,69162203,CDM,272,RC,,,Outpatient,,,1730.4,1730.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,1468.76,84.88,,1175.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,865.2,50,,692.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.8,75,,1038.24,percent of total billed charges,75% of total billed charges for outpatient setting,1211.28,70,,969.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.744,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.32,80,,1107.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,222.18,12.84,,177.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1124.76,65,,899.81,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,35,,484.51,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1557.36,90,,1245.89,percent of total billed charges,90% of total billed charges for outpatient setting,222.18,1557.36,
VISIONAIRE LGNP KIT RT SZ F6/ V0200020,69162751,CDM,272,RC,,,Outpatient,,,865.2,865.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,734.38,84.88,,587.5,percent of total billed charges,84.88% of total billed charges for outpatient setting,432.6,50,,346.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.9,75,,519.12,percent of total billed charges,75% of total billed charges for outpatient setting,605.64,70,,484.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.872,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.16,80,,553.73,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,111.09,12.84,,88.87,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,562.38,65,,449.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,35,,242.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,778.68,90,,622.94,percent of total billed charges,90% of total billed charges for outpatient setting,111.09,778.68,
VISIONAIRE PMCP LT. KIT SZ F7/T8,69161131,CDM,278,RC,,,Outpatient,,,1892.63,1892.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,60,,908.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1606.46,84.88,,1285.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1419.47,75,,1135.58,percent of total billed charges,75% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.1,80,,1211.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1892.63,65,,1514.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.42,35,,529.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1135.58,60,,908.46,percent of total billed charges,60% of total billed charges for outpatient setting,243.01,1892.63,
VISIONAIRE PMCP RT. KIT SZ F5/T4,69161107,CDM,278,RC,,,Outpatient,,,1892.63,1892.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.58,60,,908.46,percent of total billed charges,60% of total Billed charges for outpatient setting,1606.46,84.88,,1285.17,percent of total billed charges,84.88% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1419.47,75,,1135.58,percent of total billed charges,75% of total billed charges for outpatient setting,946.32,50,,757.06,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1514.1,80,,1211.28,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,243.01,12.84,,194.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1892.63,65,,1514.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.42,35,,529.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1135.58,60,,908.46,percent of total billed charges,60% of total billed charges for outpatient setting,243.01,1892.63,
VISTARIL(HYDROXYZINE PAM.) SUSP:25MG/5ML,3302690,CDM,259,RC,,,Outpatient,,,9.07,9.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.35,70,,5.08,percent of total billed charges,70% of total billed charges for outpatient setting,7.7,84.88,,6.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.54,50,,3.63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.8,75,,5.44,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,70,,5.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,12.84,,0.928,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.26,80,,5.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,12.84,,0.93,percent of total billed charges,12.84% of total billed charges,1.16,12.84,,0.93,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.9,65,,4.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.17,35,,2.54,percent of total billed charges,35% of total Billed charges for Outpatient Setting,8.16,90,,6.53,percent of total billed charges,90% of total billed charges for outpatient setting,1.16,8.16,
"VIT D-1,25 DIHYDROXY",201105,CDM,300,RC,82652,HCPCS,Outpatient,,,173.25,155.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.28,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,147.05,84.88,,117.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,129.94,75,,103.95,percent of total billed charges,75% of total billed charges for outpatient setting,121.28,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.6,80,,110.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,56.2,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,100% of Custom Fee Schedule,155.93,90,,124.74,percent of total billed charges,90% of total billed charges for outpatient setting,20.52,155.93,
VIT D3 50000 UNITS,3302160,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITA A/D (A&D) OINT : 60GM,3302154,CDM,259,RC,,,Outpatient,,,5.46,5.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,84.88,,3.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.73,50,,2.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.1,75,,3.28,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,70,,3.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,80,,3.5,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,0.7,12.84,,0.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.55,65,,2.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,35,,1.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.91,90,,3.93,percent of total billed charges,90% of total billed charges for outpatient setting,0.7,4.91,
VITA A/D OINT : 60GM,3302153,CDM,259,RC,,,Outpatient,,,4.85,4.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,84.88,,3.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.43,50,,1.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.64,75,,2.91,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,70,,2.72,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.88,80,,3.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.15,65,,2.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.7,35,,1.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.37,90,,3.5,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.37,
VITA B COMP (NEPHROCAPS) CAP: 1 MG,3302155,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITA B1 (THIAMINE) MDV: 100 MG/ML  2ML,3302156,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITA B1 (THIAMINE) SDV: 100 MG   1 ML,3302157,CDM,250,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITA B12 (CYANOCOBALAMN) MDV 1000MCG,3302158,CDM,250,RC,,,Outpatient,,,4.77,4.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,70,,2.67,percent of total billed charges,70% of total billed charges for outpatient setting,4.05,84.88,,3.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.39,50,,1.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.58,75,,2.86,percent of total billed charges,75% of total billed charges for outpatient setting,3.34,70,,2.67,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.488,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.82,80,,3.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,0.61,12.84,,0.49,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.1,65,,2.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,35,,1.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.29,90,,3.43,percent of total billed charges,90% of total billed charges for outpatient setting,0.61,4.29,
VITA B12 (CYANOCOBALAMN)SDV 1000MCG:1ML,3302159,CDM,250,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN A,220496,CDM,300,RC,84590,HCPCS,Outpatient,,,52.25,47.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.58,70,,29.26,percent of total billed charges,70% of total billed charges for outpatient setting,44.35,84.88,,35.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,39.19,75,,31.35,percent of total billed charges,75% of total billed charges for outpatient setting,36.58,70,,29.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.8,80,,33.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.93,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,100,,,Fee Schedule,100% of Custom Fee Schedule,47.03,90,,37.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,47.03,
"VITAMIN A CAP: 25,000 UNITS",3303096,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITAMIN B COMP W-C (THERA) : U/D,3302161,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITAMIN B-1 (THIAMINE) TAB 100MG,3302072,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITAMIN B1 (THIAMINE) TAB: 100 MG U/D,3302162,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN B1 THIAMINE WHOLE BLOOD,220356,CDM,301,RC,84425,HCPCS,Outpatient,,,95.54,85.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.88,70,,53.5,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,84.88,,64.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.66,75,,57.33,percent of total billed charges,75% of total billed charges for outpatient setting,66.88,70,,53.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.43,80,,61.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.25,100,,,Fee Schedule,100% of Custom Fee Schedule,85.99,90,,68.79,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,85.99,
VITAMIN B12,220373,CDM,301,RC,82607,HCPCS,Outpatient,,,67.86,61.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,84.88,,46.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.88,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,50.9,75,,40.72,percent of total billed charges,75% of total billed charges for outpatient setting,47.5,70,,38,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.29,80,,43.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,100,,,Fee Schedule,100% of Custom Fee Schedule,61.07,90,,48.86,percent of total billed charges,90% of total billed charges for outpatient setting,15.08,61.07,
VITAMIN B2 RIBOFLAVIN,220379,CDM,300,RC,84425,HCPCS,Outpatient,,,95.54,85.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.88,70,,53.5,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,84.88,,64.87,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.45,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,71.66,75,,57.33,percent of total billed charges,75% of total billed charges for outpatient setting,66.88,70,,53.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.43,80,,61.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,31.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.25,100,,,Fee Schedule,100% of Custom Fee Schedule,85.99,90,,68.79,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,85.99,
VITAMIN B6 (PYRIDOXINE) 100MG/ML 1ML INJ,3313954,CDM,250,RC,,,Outpatient,,,56.14,56.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.3,70,,31.44,percent of total billed charges,70% of total billed charges for outpatient setting,47.65,84.88,,38.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.07,50,,22.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.11,75,,33.69,percent of total billed charges,75% of total billed charges for outpatient setting,39.3,70,,31.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.91,80,,35.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,7.21,12.84,,5.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,36.49,65,,29.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.65,35,,15.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,50.53,90,,40.42,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,50.53,
VITAMIN B6 (PYRIDOXINE) TAB: 50 MG U/D,3302163,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
"VITAMIN B6, PLASMA",220718,CDM,301,RC,84207,HCPCS,Outpatient,,,126.45,113.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.52,70,,70.82,percent of total billed charges,70% of total billed charges for outpatient setting,107.33,84.88,,85.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.25,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,94.84,75,,75.87,percent of total billed charges,75% of total billed charges for outpatient setting,88.52,70,,70.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.16,80,,80.93,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,41.02,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.81,100,,,Fee Schedule,100% of Custom Fee Schedule,113.81,90,,91.05,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,113.81,
VITAMIN C,220380,CDM,300,RC,82180,HCPCS,Outpatient,,,44.51,40.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,37.78,84.88,,30.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,16.97,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,33.38,75,,26.7,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,70,,24.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.61,80,,28.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,14.43,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,100,,,Fee Schedule,100% of Custom Fee Schedule,40.06,90,,32.05,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,40.06,
VITAMIN C (ASCORBIC ACID) 500MG TAB,3302782,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
VITAMIN C TAB: 500 MG,3302164,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN C TAB: 500 MG,3302165,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN C TAB: 500 MG,3302166,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN C TAB: 500 MG,3302167,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN D 25-HYDROXY,201731,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
VITAMIN D 3 1000 INTERNATIONAL UNIT TAB,3303285,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
VITAMIN D 3 5000  INTERNATIONAL UNIT TAB,3314186,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
VITAMIN D 400 UNIT TAB,3302168,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
"VITAMIN D-1,25 DIHYDROXY",220662,CDM,301,RC,82652,HCPCS,Outpatient,,,173.25,155.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.28,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,147.05,84.88,,117.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.1,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,129.94,75,,103.95,percent of total billed charges,75% of total billed charges for outpatient setting,121.28,70,,97.02,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.6,80,,110.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,56.2,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,100% of Custom Fee Schedule,155.93,90,,124.74,percent of total billed charges,90% of total billed charges for outpatient setting,20.52,155.93,
VITAMIN D2 AND D3,220656,CDM,301,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
VITAMIN D-25 HYDROXY,200455,CDM,300,RC,82306,HCPCS,Outpatient,,,133.2,119.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,113.06,84.88,,90.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,50.83,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,99.9,75,,79.92,percent of total billed charges,75% of total billed charges for outpatient setting,93.24,70,,74.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,80,,85.25,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,43.22,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of Custom Fee Schedule,119.88,90,,95.9,percent of total billed charges,90% of total billed charges for outpatient setting,29.6,119.88,
VITAMIN E,220688,CDM,301,RC,84446,HCPCS,Outpatient,,,63.81,57.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,54.16,84.88,,43.33,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,47.86,75,,38.29,percent of total billed charges,75% of total billed charges for outpatient setting,44.67,70,,35.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.05,80,,40.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.7,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,100,,,Fee Schedule,100% of Custom Fee Schedule,57.43,90,,45.94,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,57.43,
VITAMIN E 800 UNITS: CAP,3302803,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VITAMIN E CAP: 400 INTERNATIONAL UNITS,3302170,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
VITAMIN E CAP: 400 IU,3302169,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITAMIN K1,220290,CDM,300,RC,84597,HCPCS,Outpatient,,,61.74,55.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.22,70,,34.58,percent of total billed charges,70% of total billed charges for outpatient setting,52.4,84.88,,41.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,23.56,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,46.31,75,,37.05,percent of total billed charges,75% of total billed charges for outpatient setting,43.22,70,,34.58,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.39,80,,39.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,20.01,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,100,,,Fee Schedule,100% of Custom Fee Schedule,55.57,90,,44.46,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,55.57,
VITAMINS (OSTEO BI FLEX) MAX STRGTH:,3302171,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
VITOSS 1.25CC (BONE GRAFT) / 2102-2201,69162613,CDM,278,RC,C1713,HCPCS,Outpatient,,,2165.87,2165.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1299.52,60,,1039.62,percent of total billed charges,60% of total Billed charges for outpatient setting,1838.39,84.88,,1470.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624.4,75,,1299.52,percent of total billed charges,75% of total billed charges for outpatient setting,1082.94,50,,866.35,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.1,12.84,,222.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1732.7,80,,1386.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.1,12.84,,222.48,percent of total billed charges,12.84% of total billed charges,278.1,12.84,,222.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2274.16,105,,1819.33,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.05,35,,606.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1299.52,60,,1039.62,percent of total billed charges,60% of total billed charges for outpatient setting,278.1,2274.16,
VITOSS 15CC BONE GRAFT / 2102-0020,69162496,CDM,278,RC,C1713,HCPCS,Outpatient,,,2102.9,2102.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.74,60,,1009.39,percent of total billed charges,60% of total Billed charges for outpatient setting,1784.94,84.88,,1427.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1577.18,75,,1261.74,percent of total billed charges,75% of total billed charges for outpatient setting,1051.45,50,,841.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.01,12.84,,216.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1682.32,80,,1345.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.01,12.84,,216.01,percent of total billed charges,12.84% of total billed charges,270.01,12.84,,216.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2208.05,105,,1766.44,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,736.02,35,,588.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1261.74,60,,1009.39,percent of total billed charges,60% of total billed charges for outpatient setting,270.01,2208.05,
VITOSS 2.5CC (BONE GRAFT)/2102-2202,69162260,CDM,278,RC,,,Outpatient,,,2120.68,2120.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1272.41,60,,1017.93,percent of total billed charges,60% of total Billed charges for outpatient setting,1800.03,84.88,,1440.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,1060.34,50,,848.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1590.51,75,,1272.41,percent of total billed charges,75% of total billed charges for outpatient setting,1060.34,50,,848.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1696.54,80,,1357.23,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,272.3,12.84,,217.84,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2226.71,105,,1781.37,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.24,35,,593.79,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1272.41,60,,1017.93,percent of total billed charges,60% of total billed charges for outpatient setting,272.3,2226.71,
VITOSS 5CC (BONE GRAFT) / 2102-2205,69161694,CDM,278,RC,C1763,HCPCS,Outpatient,,,3977.14,3977.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2386.28,60,,1909.02,percent of total billed charges,60% of total Billed charges for outpatient setting,3375.8,84.88,,2700.64,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2982.86,75,,2386.29,percent of total billed charges,75% of total billed charges for outpatient setting,1988.57,50,,1590.86,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.66,12.84,,408.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3181.71,80,,2545.37,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.66,12.84,,408.53,percent of total billed charges,12.84% of total billed charges,510.66,12.84,,408.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4176,105,,3340.8,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392,35,,1113.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2386.28,60,,1909.02,percent of total billed charges,60% of total billed charges for outpatient setting,510.66,4176,
VIVELLE 0.05 : DOT,3302995,CDM,259,RC,,,Outpatient,,,124.69,124.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.28,70,,69.82,percent of total billed charges,70% of total billed charges for outpatient setting,105.84,84.88,,84.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,62.35,50,,49.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.52,75,,74.82,percent of total billed charges,75% of total billed charges for outpatient setting,87.28,70,,69.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.01,12.84,,12.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.75,80,,79.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.01,12.84,,12.81,percent of total billed charges,12.84% of total billed charges,16.01,12.84,,12.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,81.05,65,,64.84,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,35,,34.91,percent of total billed charges,35% of total Billed charges for Outpatient Setting,112.22,90,,89.78,percent of total billed charges,90% of total billed charges for outpatient setting,16.01,112.22,
VIVELLE DOT 0.025MG /DAY,3305307,CDM,259,RC,,,Outpatient,,,42.14,42.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.5,70,,23.6,percent of total billed charges,70% of total billed charges for outpatient setting,35.77,84.88,,28.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,21.07,50,,16.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.61,75,,25.29,percent of total billed charges,75% of total billed charges for outpatient setting,29.5,70,,23.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.41,12.84,,4.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.71,80,,26.97,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.41,12.84,,4.33,percent of total billed charges,12.84% of total billed charges,5.41,12.84,,4.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,27.39,65,,21.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,35,,11.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.93,90,,30.34,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,37.93,
V-LOC 0 / GS-21 NON ABSB / VLOCN0326,69161853,CDM,272,RC,,,Outpatient,,,115.96,115.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.17,70,,64.94,percent of total billed charges,70% of total billed charges for outpatient setting,98.43,84.88,,78.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.98,50,,46.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.97,75,,69.58,percent of total billed charges,75% of total billed charges for outpatient setting,81.17,70,,64.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,12.84,,11.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.77,80,,74.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,12.84,,11.91,percent of total billed charges,12.84% of total billed charges,14.89,12.84,,11.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,65,,60.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,35,,32.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.36,90,,83.49,percent of total billed charges,90% of total billed charges for outpatient setting,14.89,104.36,
V-LOC 0 GS-21 9IN / VLOCL0346,69162890,CDM,272,RC,,,Outpatient,,,135.85,135.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.1,70,,76.08,percent of total billed charges,70% of total billed charges for outpatient setting,115.31,84.88,,92.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.93,50,,54.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.89,75,,81.51,percent of total billed charges,75% of total billed charges for outpatient setting,95.1,70,,76.08,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,12.84,,13.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.68,80,,86.94,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.44,12.84,,13.95,percent of total billed charges,12.84% of total billed charges,17.44,12.84,,13.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,88.3,65,,70.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.55,35,,38.04,percent of total billed charges,35% of total Billed charges for Outpatient Setting,122.27,90,,97.82,percent of total billed charges,90% of total billed charges for outpatient setting,17.44,122.27,
V-LOC 1 / GS-21 NON ABSB / VLOCN0327,69161854,CDM,272,RC,,,Outpatient,,,115.96,115.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.17,70,,64.94,percent of total billed charges,70% of total billed charges for outpatient setting,98.43,84.88,,78.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.98,50,,46.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.97,75,,69.58,percent of total billed charges,75% of total billed charges for outpatient setting,81.17,70,,64.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,12.84,,11.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.77,80,,74.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,12.84,,11.91,percent of total billed charges,12.84% of total billed charges,14.89,12.84,,11.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,65,,60.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,35,,32.47,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.36,90,,83.49,percent of total billed charges,90% of total billed charges for outpatient setting,14.89,104.36,
V-LOC 180 2-0 V-20 12IN / VLOCL0615,69162116,CDM,272,RC,,,Outpatient,,,147.6,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,84.88,,100.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.8,50,,59.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,75,,88.56,percent of total billed charges,75% of total billed charges for outpatient setting,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,80,,94.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.94,65,,76.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.66,35,,41.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.84,90,,106.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.95,132.84,
V-LOC 180/ 3-0  GS-21   18   VLOCL0324,69162367,CDM,272,RC,,,Outpatient,,,114.15,114.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.91,70,,63.93,percent of total billed charges,70% of total billed charges for outpatient setting,96.89,84.88,,77.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,57.08,50,,45.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.61,75,,68.49,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,70,,63.93,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,12.84,,11.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.32,80,,73.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,12.84,,11.73,percent of total billed charges,12.84% of total billed charges,14.66,12.84,,11.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,74.2,65,,59.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.95,35,,31.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.74,90,,82.19,percent of total billed charges,90% of total billed charges for outpatient setting,14.66,102.74,
V-LOC 180-0 GS-21 12IN / VLOCL0316,69161383,CDM,272,RC,,,Outpatient,,,147.6,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,84.88,,100.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.8,50,,59.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,75,,88.56,percent of total billed charges,75% of total billed charges for outpatient setting,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,80,,94.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.94,65,,76.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.66,35,,41.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.84,90,,106.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.95,132.84,
V-LOC 2-0 GS-22 6IN / VLOCM2105,69162040,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC 2-0 GS-22 9IN  PBT/ VLOCN2145,69169316,CDM,272,RC,,,Outpatient,,,116.36,116.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.45,70,,65.16,percent of total billed charges,70% of total billed charges for outpatient setting,98.77,84.88,,79.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.18,50,,46.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.27,75,,69.82,percent of total billed charges,75% of total billed charges for outpatient setting,81.45,70,,65.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.94,12.84,,11.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.09,80,,74.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.94,12.84,,11.95,percent of total billed charges,12.84% of total billed charges,14.94,12.84,,11.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,75.63,65,,60.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,35,,32.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,104.72,90,,83.78,percent of total billed charges,90% of total billed charges for outpatient setting,14.94,104.72,
V-LOC 2-0 V-20 12IN  PBT/ VLOCN0615,69169330,CDM,272,RC,,,Outpatient,,,145.45,145.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.82,70,,81.46,percent of total billed charges,70% of total billed charges for outpatient setting,123.46,84.88,,98.77,percent of total billed charges,84.88% of total billed charges for outpatient setting,72.73,50,,58.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.09,75,,87.27,percent of total billed charges,75% of total billed charges for outpatient setting,101.82,70,,81.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,12.84,,14.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.36,80,,93.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.68,12.84,,14.94,percent of total billed charges,12.84% of total billed charges,18.68,12.84,,14.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,94.54,65,,75.63,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.91,35,,40.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,130.91,90,,104.73,percent of total billed charges,90% of total billed charges for outpatient setting,18.68,130.91,
V-LOC 3-0 CV-23 6IN DYED / VLOCM0804,69162791,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC 3-0 CV-23 6IN UNDYED / VLOCM1904,69162792,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC 3-0 CV-23 9IN DYE / VLOCM0844,69169851,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC 3-0 CV-23 9IN UNDYED / VLOCM1944,69169852,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC 3-0 V-20  9IN UND / VLOCM2044,69169522,CDM,272,RC,,,Outpatient,,,106.09,106.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.26,70,,59.41,percent of total billed charges,70% of total billed charges for outpatient setting,90.05,84.88,,72.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,53.05,50,,42.44,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.57,75,,63.66,percent of total billed charges,75% of total billed charges for outpatient setting,74.26,70,,59.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.62,12.84,,10.896,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.87,80,,67.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.62,12.84,,10.9,percent of total billed charges,12.84% of total billed charges,13.62,12.84,,10.9,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,68.96,65,,55.17,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.13,35,,29.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,95.48,90,,76.38,percent of total billed charges,90% of total billed charges for outpatient setting,13.62,95.48,
V-LOC 3-0 V-20 / 12 IN 180 / VLOCL0614,69162872,CDM,272,RC,,,Outpatient,,,147.6,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,84.88,,100.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.8,50,,59.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,75,,88.56,percent of total billed charges,75% of total billed charges for outpatient setting,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,80,,94.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.94,65,,76.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.66,35,,41.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.84,90,,106.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.95,132.84,
V-LOC 3-0 V-20 12 IN 90 DYED / VLOCM0614,1058921,CDM,272,RC,,,Outpatient,,,147.6,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,84.88,,100.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.8,50,,59.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,75,,88.56,percent of total billed charges,75% of total billed charges for outpatient setting,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,80,,94.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.94,65,,76.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.66,35,,41.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.84,90,,106.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.95,132.84,
V-LOC 3-0 V-20 9IN DYED / VLOCM0644,69162553,CDM,272,RC,,,Outpatient,,,140.6,140.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,119.34,84.88,,95.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,70.3,50,,56.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,75,,84.36,percent of total billed charges,75% of total billed charges for outpatient setting,98.42,70,,78.74,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.48,80,,89.98,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,18.05,12.84,,14.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,91.39,65,,73.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,35,,39.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,126.54,90,,101.23,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,126.54,
V-LOC PBT 0 GS-21 6IN / VLOCN0306,69162043,CDM,272,RC,,,Outpatient,,,147.6,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,84.88,,100.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,73.8,50,,59.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,75,,88.56,percent of total billed charges,75% of total billed charges for outpatient setting,103.32,70,,82.66,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,80,,94.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,18.95,12.84,,15.16,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,95.94,65,,76.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.66,35,,41.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,132.84,90,,106.27,percent of total billed charges,90% of total billed charges for outpatient setting,18.95,132.84,
V-LOC PBT 0 GS-22 18IN / VLOCN1126,69162075,CDM,272,RC,,,Outpatient,,,166,166,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.2,70,,92.96,percent of total billed charges,70% of total billed charges for outpatient setting,140.9,84.88,,112.72,percent of total billed charges,84.88% of total billed charges for outpatient setting,83,50,,66.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.5,75,,99.6,percent of total billed charges,75% of total billed charges for outpatient setting,116.2,70,,92.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,12.84,,17.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.8,80,,106.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,12.84,,17.05,percent of total billed charges,12.84% of total billed charges,21.31,12.84,,17.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,107.9,65,,86.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.1,35,,46.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,149.4,90,,119.52,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,149.4,
VMA 24 HR URINE,220107,CDM,301,RC,84585,HCPCS,Outpatient,,,69.75,62.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.83,70,,39.06,percent of total billed charges,70% of total billed charges for outpatient setting,59.2,84.88,,47.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.61,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,52.31,75,,41.85,percent of total billed charges,75% of total billed charges for outpatient setting,48.83,70,,39.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,80,,44.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,22.64,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of Custom Fee Schedule,62.78,90,,50.22,percent of total billed charges,90% of total billed charges for outpatient setting,15.5,62.78,
VOLUME MEASUREMENT FOR TIMED COLLECTION,201308,CDM,301,RC,81050,HCPCS,Outpatient,,,16.38,14.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.47,70,,9.18,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,84.88,,11.12,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.16,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,12.29,75,,9.83,percent of total billed charges,75% of total billed charges for outpatient setting,11.47,70,,9.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,80,,10.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.37,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.69,100,,,Fee Schedule,100% of Custom Fee Schedule,14.74,90,,11.79,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,14.74,
VORICONAZOLE (VFEND):200MG,3305516,CDM,259,RC,,,Outpatient,,,110.45,110.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,93.75,84.88,,75,percent of total billed charges,84.88% of total billed charges for outpatient setting,55.23,50,,44.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.84,75,,66.27,percent of total billed charges,75% of total billed charges for outpatient setting,77.32,70,,61.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.36,80,,70.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,14.18,12.84,,11.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,71.79,65,,57.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,35,,30.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,99.41,90,,79.53,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,99.41,
VORICONAZOLE(VFEND): 200 MG IV,3303197,CDM,250,RC,,,Outpatient,,,479.84,479.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.89,70,,268.71,percent of total billed charges,70% of total billed charges for outpatient setting,407.29,84.88,,325.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,239.92,50,,191.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.88,75,,287.9,percent of total billed charges,75% of total billed charges for outpatient setting,335.89,70,,268.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.61,12.84,,49.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.87,80,,307.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.61,12.84,,49.29,percent of total billed charges,12.84% of total billed charges,61.61,12.84,,49.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,311.9,65,,249.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.94,35,,134.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,431.86,90,,345.49,percent of total billed charges,90% of total billed charges for outpatient setting,61.61,431.86,
VORTEX 4.5MM / H9131,69159345,CDM,272,RC,,,Outpatient,,,247.97,247.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.58,70,,138.86,percent of total billed charges,70% of total billed charges for outpatient setting,210.48,84.88,,168.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.99,50,,99.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.98,75,,148.78,percent of total billed charges,75% of total billed charges for outpatient setting,173.58,70,,138.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.472,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.38,80,,158.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,31.84,12.84,,25.47,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,161.18,65,,128.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.79,35,,69.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,223.17,90,,178.54,percent of total billed charges,90% of total billed charges for outpatient setting,31.84,223.17,
VWF ACTIVITY,220823,CDM,305,RC,85245,HCPCS,Outpatient,,,103.23,92.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,87.62,84.88,,70.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.42,75,,61.94,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.58,80,,66.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,33.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.51,100,,,Fee Schedule,100% of Custom Fee Schedule,92.91,90,,74.33,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,92.91,
VWF ANTIGEN,220824,CDM,305,RC,85246,HCPCS,Outpatient,,,103.23,92.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,87.62,84.88,,70.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.42,75,,61.94,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.58,80,,66.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,33.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.51,100,,,Fee Schedule,100% of Custom Fee Schedule,92.91,90,,74.33,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,92.91,
VWF MULTIMER ANALYSIS,220748,CDM,305,RC,85247,HCPCS,Outpatient,,,103.23,92.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,87.62,84.88,,70.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,39.39,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,77.42,75,,61.94,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,70,,57.81,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.58,80,,66.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,33.51,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.51,100,,,Fee Schedule,100% of Custom Fee Schedule,92.91,90,,74.33,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,92.91,
VYTORIN (EZETIMIBE/SIMVASTATIN)10/20:TAB,3303073,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VYTORIN (EZETIMIBE/SIMVASTATIN)10/40:TAB,3303051,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
VYTORIN (EZETIMIBE/SIMVASTATIN)10/80:TAB,3303206,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
WAFER 2 1/4IN / 413156,69169058,CDM,270,RC,,,Outpatient,,,57.87,57.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.51,70,,32.41,percent of total billed charges,70% of total billed charges for outpatient setting,49.12,84.88,,39.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.94,50,,23.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.4,75,,34.72,percent of total billed charges,75% of total billed charges for outpatient setting,40.51,70,,32.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,12.84,,5.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.3,80,,37.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,12.84,,5.94,percent of total billed charges,12.84% of total billed charges,7.43,12.84,,5.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.62,65,,30.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,35,,16.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.08,90,,41.66,percent of total billed charges,90% of total billed charges for outpatient setting,7.43,52.08,
WARFARIN (COUMADIN) TAB 5 MG,3302177,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
WARFARIN (COUMADIN) TAB: 1 MG,3302173,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
WARFARIN (COUMADIN) TAB: 10 MG,3302179,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
WARFARIN (COUMADIN) TAB: 2 MG,3302175,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
WARFARIN (COUMADIN) TAB: 2.5 MG,3302174,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
WARFARIN (COUMADIN) TAB: 3 MG,3302172,CDM,259,RC,,,Outpatient,,,4.44,4.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,84.88,,3.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.22,50,,1.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,75,,2.66,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,70,,2.49,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.55,80,,2.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.57,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.89,65,,2.31,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.55,35,,1.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4,90,,3.2,percent of total billed charges,90% of total billed charges for outpatient setting,0.57,4,
WARFARIN (COUMADIN) TAB: 4 MG,3302176,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
WARFARIN (COUMADIN) TAB: 7.5 MG,3302178,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
WASHER 13MM / 219.99,6152142,CDM,270,RC,,,Outpatient,,,182.85,182.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128,70,,102.4,percent of total billed charges,70% of total billed charges for outpatient setting,155.2,84.88,,124.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,91.43,50,,73.14,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.14,75,,109.71,percent of total billed charges,75% of total billed charges for outpatient setting,128,70,,102.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.48,12.84,,18.784,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.28,80,,117.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.48,12.84,,18.78,percent of total billed charges,12.84% of total billed charges,23.48,12.84,,18.78,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,118.85,65,,95.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64,35,,51.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,164.57,90,,131.66,percent of total billed charges,90% of total billed charges for outpatient setting,23.48,164.57,
WASHER 4.0MM TI ASNIS III / 619905,70000176,CDM,278,RC,C1713,HCPCS,Outpatient,,,136.08,136.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.65,60,,65.32,percent of total billed charges,60% of total Billed charges for outpatient setting,115.5,84.88,,92.4,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.06,75,,81.65,percent of total billed charges,75% of total billed charges for outpatient setting,68.04,50,,54.43,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.47,12.84,,13.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.86,80,,87.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.47,12.84,,13.98,percent of total billed charges,12.84% of total billed charges,17.47,12.84,,13.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.08,65,,108.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.63,35,,38.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.65,60,,65.32,percent of total billed charges,60% of total billed charges for outpatient setting,17.47,136.08,
WASHER 7.0MM / 219.98,6152859,CDM,278,RC,,,Outpatient,,,162.03,162.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.22,60,,77.78,percent of total billed charges,60% of total Billed charges for outpatient setting,137.53,84.88,,110.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.02,50,,64.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.52,75,,97.22,percent of total billed charges,75% of total billed charges for outpatient setting,81.02,50,,64.82,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.62,80,,103.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,20.8,12.84,,16.64,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,162.03,65,,129.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.71,35,,45.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,97.22,60,,77.78,percent of total billed charges,60% of total billed charges for outpatient setting,20.8,162.03,
WASHER FOR 5MM SCREW / 390017,69162540,CDM,278,RC,,,Outpatient,,,234.41,234.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.65,60,,112.52,percent of total billed charges,60% of total Billed charges for outpatient setting,198.97,84.88,,159.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,117.21,50,,93.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.81,75,,140.65,percent of total billed charges,75% of total billed charges for outpatient setting,117.21,50,,93.77,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,12.84,,24.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.53,80,,150.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,12.84,,24.08,percent of total billed charges,12.84% of total billed charges,30.1,12.84,,24.08,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,234.41,65,,187.53,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.04,35,,65.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,140.65,60,,112.52,percent of total billed charges,60% of total billed charges for outpatient setting,30.1,234.41,
WASHER RED 7MM / 4933-1-713,70000776,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.4,257.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.44,60,,123.55,percent of total billed charges,60% of total Billed charges for outpatient setting,218.48,84.88,,174.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.05,75,,154.44,percent of total billed charges,75% of total billed charges for outpatient setting,128.7,50,,102.96,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.05,12.84,,26.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,80,,164.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.05,12.84,,26.44,percent of total billed charges,12.84% of total billed charges,33.05,12.84,,26.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,257.4,65,,205.92,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.09,35,,72.07,percent of total billed charges,35% of total Billed charges for Outpatient Setting,154.44,60,,123.55,percent of total billed charges,60% of total billed charges for outpatient setting,33.05,257.4,
WASHER SPIKED 13.5 /6.5MM / 219.951,69162770,CDM,278,RC,,,Outpatient,,,515.4,515.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.24,60,,247.39,percent of total billed charges,60% of total Billed charges for outpatient setting,437.47,84.88,,349.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,257.7,50,,206.16,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.55,75,,309.24,percent of total billed charges,75% of total billed charges for outpatient setting,257.7,50,,206.16,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.18,12.84,,52.944,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.32,80,,329.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.18,12.84,,52.94,percent of total billed charges,12.84% of total billed charges,66.18,12.84,,52.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,515.4,65,,412.32,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.39,35,,144.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,309.24,60,,247.39,percent of total billed charges,60% of total billed charges for outpatient setting,66.18,515.4,
WATER IRRG 3000CC BAG / 2B7117,6150077,CDM,272,RC,,,Outpatient,,,52.5,52.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,70,,29.4,percent of total billed charges,70% of total billed charges for outpatient setting,44.56,84.88,,35.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,26.25,50,,21,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.38,75,,31.5,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,70,,29.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,12.84,,5.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,80,,33.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,12.84,,5.39,percent of total billed charges,12.84% of total billed charges,6.74,12.84,,5.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,34.13,65,,27.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.38,35,,14.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,47.25,90,,37.8,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,47.25,
WATER IRRG 500ML BOTTLE / 2F7113,5050040,CDM,272,RC,,,Outpatient,,,17.59,17.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.31,70,,9.85,percent of total billed charges,70% of total billed charges for outpatient setting,14.93,84.88,,11.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.8,50,,7.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.19,75,,10.55,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,70,,9.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.808,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.07,80,,11.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,2.26,12.84,,1.81,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.43,65,,9.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,35,,4.93,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.83,90,,12.66,percent of total billed charges,90% of total billed charges for outpatient setting,2.26,15.83,
WATER IRRIG 1000ML BAG / 2B7114X,6150076,CDM,272,RC,,,Outpatient,,,26.16,26.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,84.88,,17.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.08,50,,10.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.62,75,,15.7,percent of total billed charges,75% of total billed charges for outpatient setting,18.31,70,,14.65,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.688,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,80,,16.74,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,3.36,12.84,,2.69,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17,65,,13.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.16,35,,7.33,percent of total billed charges,35% of total Billed charges for Outpatient Setting,23.54,90,,18.83,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,23.54,
WATER IRRIG 1000ML BOTTLE / 2F7114,6150109,CDM,272,RC,,,Outpatient,,,19.71,19.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,16.73,84.88,,13.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.86,50,,7.89,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.78,75,,11.82,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,70,,11.04,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.77,80,,12.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,2.53,12.84,,2.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,12.81,65,,10.25,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,35,,5.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,17.74,90,,14.19,percent of total billed charges,90% of total billed charges for outpatient setting,2.53,17.74,
WATER IRRIG 500ML BTL MEDLINE / 2F7114,70000211,CDM,272,RC,,,Outpatient,,,17.71,17.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.4,70,,9.92,percent of total billed charges,70% of total billed charges for outpatient setting,15.03,84.88,,12.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,8.86,50,,7.09,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.28,75,,10.62,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,70,,9.92,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,12.84,,1.816,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.17,80,,11.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,2.27,12.84,,1.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.51,65,,9.21,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,35,,4.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,15.94,90,,12.75,percent of total billed charges,90% of total billed charges for outpatient setting,2.27,15.94,
WATER STERILE F/INJ USP 1000ML/ 2B0304,3359007,CDM,258,RC,,,Outpatient,,,122.54,122.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,104.01,84.88,,83.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,61.27,50,,49.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.91,75,,73.53,percent of total billed charges,75% of total billed charges for outpatient setting,85.78,70,,68.62,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.584,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.03,80,,78.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,15.73,12.84,,12.58,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,79.65,65,,63.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.89,35,,34.31,percent of total billed charges,35% of total Billed charges for Outpatient Setting,110.29,90,,88.23,percent of total billed charges,90% of total billed charges for outpatient setting,15.73,110.29,
WBC,200570,CDM,300,RC,85048,HCPCS,Outpatient,,,11.43,10.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,84.88,,7.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.71,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of Custom Fee Schedule,10.29,90,,8.23,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,10.29,
WBC,201310,CDM,300,RC,85048,HCPCS,Outpatient,,,11.43,10.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,84.88,,7.76,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.35,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,8.57,75,,6.86,percent of total billed charges,75% of total billed charges for outpatient setting,8,70,,6.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,80,,7.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,3.71,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.81,100,,,Fee Schedule,100% of Custom Fee Schedule,10.29,90,,8.23,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,10.29,
"WBC, STOOL",220561,CDM,300,RC,87205,HCPCS,Outpatient,,,19.22,17.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,16.31,84.88,,13.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.33,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,14.42,75,,11.54,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,70,,10.76,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.38,80,,12.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,100,,,Fee Schedule,100% of Custom Fee Schedule,17.3,90,,13.84,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,17.3,
WEDGE FEMORAL SZ 3-4 /5MM  71421803,69169197,CDM,278,RC,,,Outpatient,,,2048.64,2048.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.18,60,,983.34,percent of total billed charges,60% of total Billed charges for outpatient setting,1738.89,84.88,,1391.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,1024.32,50,,819.46,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1536.48,75,,1229.18,percent of total billed charges,75% of total billed charges for outpatient setting,1024.32,50,,819.46,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.05,12.84,,210.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638.91,80,,1311.13,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.05,12.84,,210.44,percent of total billed charges,12.84% of total billed charges,263.05,12.84,,210.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2048.64,65,,1638.91,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.02,35,,573.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1229.18,60,,983.34,percent of total billed charges,60% of total billed charges for outpatient setting,263.05,2048.64,
WEDGE STEP SZ 3  5MM REV TK /1294-56-130,69169651,CDM,278,RC,C1776,HCPCS,Outpatient,,,3313,3313,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.8,60,,1590.24,percent of total billed charges,60% of total Billed charges for outpatient setting,2812.07,84.88,,2249.66,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484.75,75,,1987.8,percent of total billed charges,75% of total billed charges for outpatient setting,1656.5,50,,1325.2,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.39,12.84,,340.312,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2650.4,80,,2120.32,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.39,12.84,,340.31,percent of total billed charges,12.84% of total billed charges,425.39,12.84,,340.31,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3478.65,105,,2782.92,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.55,35,,927.64,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1987.8,60,,1590.24,percent of total billed charges,60% of total billed charges for outpatient setting,425.39,3478.65,
WEDGE SZ 4 5X5 LEGION / 71421731,71000692,CDM,278,RC,,,Outpatient,,,3251.44,3251.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950.86,60,,1560.69,percent of total billed charges,60% of total Billed charges for outpatient setting,2759.82,84.88,,2207.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,1625.72,50,,1300.58,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2438.58,75,,1950.86,percent of total billed charges,75% of total billed charges for outpatient setting,1625.72,50,,1300.58,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.48,12.84,,333.984,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2601.15,80,,2080.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.48,12.84,,333.98,percent of total billed charges,12.84% of total billed charges,417.48,12.84,,333.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3414.01,105,,2731.21,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1138,35,,910.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1950.86,60,,1560.69,percent of total billed charges,60% of total billed charges for outpatient setting,417.48,3414.01,
WELCHOL (COLESEVELAM): 625 MG,3303187,CDM,259,RC,,,Outpatient,,,13.57,13.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,84.88,,9.22,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.79,50,,5.43,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.18,75,,8.14,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,70,,7.6,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,80,,8.69,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,1.74,12.84,,1.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.82,65,,7.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,35,,3.8,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.21,90,,9.77,percent of total billed charges,90% of total billed charges for outpatient setting,1.74,12.21,
WELL LEG HOLDER FOAM / FP-ARTLEG,69160827,CDM,271,RC,,,Outpatient,,,50.96,50.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,43.25,84.88,,34.6,percent of total billed charges,84.88% of total billed charges for outpatient setting,25.48,50,,20.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.22,75,,30.58,percent of total billed charges,75% of total billed charges for outpatient setting,35.67,70,,28.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.77,80,,32.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,6.54,12.84,,5.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,33.12,65,,26.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.84,35,,14.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,45.86,90,,36.69,percent of total billed charges,90% of total billed charges for outpatient setting,6.54,45.86,
WELLBUTRIN XL: 300 MG TAB,3303085,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
"WEST NILE VIRUS ANTIBODY,SERUM",220877,CDM,302,RC,86788,HCPCS,Outpatient,,,75.83,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,70,,42.46,percent of total billed charges,70% of total billed charges for outpatient setting,64.36,84.88,,51.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.93,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,56.87,75,,45.5,percent of total billed charges,75% of total billed charges for outpatient setting,53.08,70,,42.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.66,80,,48.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,24.6,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.94,100,,,Fee Schedule,100% of Custom Fee Schedule,68.25,90,,54.6,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,68.25,
WHOLE BLOOD PROCESSING & STORAGE,1000225,CDM,390,RC,P9010,HCPCS,Outpatient,,,495.18,495.18,,245.07,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,346.63,70,,277.3,percent of total billed charges,70% of total billed charges for outpatient setting,420.31,84.88,,336.25,percent of total billed charges,84.88% of total billed charges for outpatient setting,218.24,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,371.39,75,,297.11,percent of total billed charges,75% of total billed charges for outpatient setting,346.63,70,,277.3,percent of total billed charges,70% of total billed charges for outpatient setting,260.38,170,,,Fee Schedule,170% of Medicare OPPS rate,329.31,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,63.58,12.84,,50.864,percent of total billed charges,12.84% of total billed charges,268.04,175,,,Fee Schedule,175% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,396.14,80,,316.91,percent of total billed charges,80% of total billed charges for outpatient setting,214.43,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,191.46,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,63.58,12.84,,50.86,percent of total billed charges,12.84% of total billed charges,63.58,12.84,,50.86,percent of total billed charges,12.84% of total billed charges,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,321.87,65,,257.5,percent of total billed charges,65% of total billed charges for outpatient setting,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,153.16,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,173.31,35,,138.65,percent of total billed charges,35% of total Billed charges for Outpatient Setting,445.66,90,,356.53,percent of total billed charges,90% of total billed charges for outpatient setting,63.58,445.66,
WHOLE BODY FOR FB 1 VIEW,2400875,CDM,320,RC,76010,HCPCS,Outpatient,,,266.81,200.11,,115.97,160,,,Fee Schedule,Pays at 160% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,86.4,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,123.22,170,,,Fee Schedule,170% of Medicare OPPS rate,155.83,215,,,Fee Schedule,Pays at 215% of Medicare OPPS rate,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,126.84,175,,,Fee Schedule,175% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,101.47,140,,,Fee Schedule,Pays at 140% of Medicare OPPS rate,90.6,125,,,Fee Schedule,Pays at 125% of Medicare OPPS rate,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,128,100,,,Case rate,pays based on fixed rate ,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,72.48,100,,,Fee Schedule,Pays at 100% of Medicare OPPS rate,68.22,100,,,Fee Schedule,100% of Custom Fee Schedule,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
WILSON FRAME KIT/WF1000,6152930,CDM,270,RC,,,Outpatient,,,149.49,149.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.64,70,,83.71,percent of total billed charges,70% of total billed charges for outpatient setting,126.89,84.88,,101.51,percent of total billed charges,84.88% of total billed charges for outpatient setting,74.75,50,,59.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.12,75,,89.7,percent of total billed charges,75% of total billed charges for outpatient setting,104.64,70,,83.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.19,12.84,,15.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.59,80,,95.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.19,12.84,,15.35,percent of total billed charges,12.84% of total billed charges,19.19,12.84,,15.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,97.17,65,,77.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,35,,41.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.54,90,,107.63,percent of total billed charges,90% of total billed charges for outpatient setting,19.19,134.54,
WIPE 1PK SAGE CHG / 9705,779839,CDM,271,RC,,,Outpatient,,,14.4,14.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,84.88,,9.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.2,50,,5.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,75,,8.64,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,70,,8.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,80,,9.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,1.85,12.84,,1.48,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.36,65,,7.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,35,,4.03,percent of total billed charges,35% of total Billed charges for Outpatient Setting,12.96,90,,10.37,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,12.96,
WIPE 6PK SAGE CHLORHEXIDINE / 9717,7349771,CDM,271,RC,,,Outpatient,,,38.32,38.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.82,70,,21.46,percent of total billed charges,70% of total billed charges for outpatient setting,32.53,84.88,,26.02,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.16,50,,15.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,75,,22.99,percent of total billed charges,75% of total billed charges for outpatient setting,26.82,70,,21.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,12.84,,3.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.66,80,,24.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,4.92,12.84,,3.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,24.91,65,,19.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.41,35,,10.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,34.49,90,,27.59,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,34.49,
WIPES SAGE CHG PATIENT PREOP / 9707,70000040,CDM,270,RC,,,Outpatient,,,58.03,58.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.62,70,,32.5,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,84.88,,39.41,percent of total billed charges,84.88% of total billed charges for outpatient setting,29.02,50,,23.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.52,75,,34.82,percent of total billed charges,75% of total billed charges for outpatient setting,40.62,70,,32.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,12.84,,5.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.42,80,,37.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,12.84,,5.96,percent of total billed charges,12.84% of total billed charges,7.45,12.84,,5.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.72,65,,30.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.31,35,,16.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,52.23,90,,41.78,percent of total billed charges,90% of total billed charges for outpatient setting,7.45,52.23,
WIRE 1.0MM CERCLAGE COIL / 291.05,6150647,CDM,278,RC,C1713,HCPCS,Outpatient,,,62.02,62.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.21,60,,29.77,percent of total billed charges,60% of total Billed charges for outpatient setting,52.64,84.88,,42.11,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.52,75,,37.22,percent of total billed charges,75% of total billed charges for outpatient setting,31.01,50,,24.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.96,12.84,,6.368,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.62,80,,39.7,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.96,12.84,,6.37,percent of total billed charges,12.84% of total billed charges,7.96,12.84,,6.37,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,62.02,65,,49.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.71,35,,17.37,percent of total billed charges,35% of total Billed charges for Outpatient Setting,37.21,60,,29.77,percent of total billed charges,60% of total billed charges for outpatient setting,7.96,62.02,
WIRE BOLT LONG 1.5 / 4933-1-003,70000773,CDM,278,RC,C1713,HCPCS,Outpatient,,,430.22,430.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.13,60,,206.5,percent of total billed charges,60% of total Billed charges for outpatient setting,365.17,84.88,,292.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.67,75,,258.14,percent of total billed charges,75% of total billed charges for outpatient setting,215.11,50,,172.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.24,12.84,,44.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.18,80,,275.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.24,12.84,,44.19,percent of total billed charges,12.84% of total billed charges,55.24,12.84,,44.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,430.22,65,,344.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.58,35,,120.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,258.13,60,,206.5,percent of total billed charges,60% of total billed charges for outpatient setting,55.24,430.22,
WIRE BOLT MEDIUM 1.5 / 4933-1-002,70000772,CDM,278,RC,C1713,HCPCS,Outpatient,,,430.22,430.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.13,60,,206.5,percent of total billed charges,60% of total Billed charges for outpatient setting,365.17,84.88,,292.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.67,75,,258.14,percent of total billed charges,75% of total billed charges for outpatient setting,215.11,50,,172.09,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.24,12.84,,44.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.18,80,,275.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.24,12.84,,44.19,percent of total billed charges,12.84% of total billed charges,55.24,12.84,,44.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,430.22,65,,344.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.58,35,,120.46,percent of total billed charges,35% of total Billed charges for Outpatient Setting,258.13,60,,206.5,percent of total billed charges,60% of total billed charges for outpatient setting,55.24,430.22,
WIRE CERCLAGE 1.0MM / 291.01,6150645,CDM,278,RC,,,Outpatient,,,77.62,77.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.57,60,,37.26,percent of total billed charges,60% of total Billed charges for outpatient setting,65.88,84.88,,52.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,38.81,50,,31.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.22,75,,46.58,percent of total billed charges,75% of total billed charges for outpatient setting,38.81,50,,31.05,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.976,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.1,80,,49.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,9.97,12.84,,7.98,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,77.62,65,,62.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,35,,21.74,percent of total billed charges,35% of total Billed charges for Outpatient Setting,46.57,60,,37.26,percent of total billed charges,60% of total billed charges for outpatient setting,9.97,77.62,
WIRE CERCLAGE COIL 1.25MM,6150648,CDM,278,RC,,,Outpatient,,,38.18,38.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.91,60,,18.33,percent of total billed charges,60% of total Billed charges for outpatient setting,32.41,84.88,,25.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.09,50,,15.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.64,75,,22.91,percent of total billed charges,75% of total billed charges for outpatient setting,19.09,50,,15.27,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,80,,24.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,4.9,12.84,,3.92,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,38.18,65,,30.54,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.36,35,,10.69,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.91,60,,18.33,percent of total billed charges,60% of total billed charges for outpatient setting,4.9,38.18,
WIRE CUTTING SCISSOR/SA1980,6152297,CDM,270,RC,,,Outpatient,,,117.05,117.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.94,70,,65.55,percent of total billed charges,70% of total billed charges for outpatient setting,99.35,84.88,,79.48,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.53,50,,46.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.79,75,,70.23,percent of total billed charges,75% of total billed charges for outpatient setting,81.94,70,,65.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.03,12.84,,12.024,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.64,80,,74.91,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.03,12.84,,12.02,percent of total billed charges,12.84% of total billed charges,15.03,12.84,,12.02,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.08,65,,60.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.97,35,,32.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.35,90,,84.28,percent of total billed charges,90% of total billed charges for outpatient setting,15.03,105.35,
WIRE DIAMOND POINT 1.8 / 4933-8-010,70000771,CDM,278,RC,C1713,HCPCS,Outpatient,,,224.3,224.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.58,60,,107.66,percent of total billed charges,60% of total Billed charges for outpatient setting,190.39,84.88,,152.31,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.23,75,,134.58,percent of total billed charges,75% of total billed charges for outpatient setting,112.15,50,,89.72,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,12.84,,23.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.44,80,,143.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,12.84,,23.04,percent of total billed charges,12.84% of total billed charges,28.8,12.84,,23.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,224.3,65,,179.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.51,35,,62.81,percent of total billed charges,35% of total Billed charges for Outpatient Setting,134.58,60,,107.66,percent of total billed charges,60% of total billed charges for outpatient setting,28.8,224.3,
WIRE GMBK RIPTION 1.6MMX150MM / AR14016,70000238,CDM,272,RC,,,Outpatient,,,98.42,98.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,83.54,84.88,,66.83,percent of total billed charges,84.88% of total billed charges for outpatient setting,49.21,50,,39.37,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,75,,59.06,percent of total billed charges,75% of total billed charges for outpatient setting,68.89,70,,55.11,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,80,,62.99,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,12.64,12.84,,10.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.97,65,,51.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,35,,27.56,percent of total billed charges,35% of total Billed charges for Outpatient Setting,88.58,90,,70.86,percent of total billed charges,90% of total billed charges for outpatient setting,12.64,88.58,
WIRE GUIDE W/ TRCR .078X8 / AR-8956K-01,70000092,CDM,272,RC,,,Outpatient,,,135.19,135.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,114.75,84.88,,91.8,percent of total billed charges,84.88% of total billed charges for outpatient setting,67.6,50,,54.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.39,75,,81.11,percent of total billed charges,75% of total billed charges for outpatient setting,94.63,70,,75.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.15,80,,86.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,17.36,12.84,,13.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,87.87,65,,70.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.32,35,,37.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,121.67,90,,97.34,percent of total billed charges,90% of total billed charges for outpatient setting,17.36,121.67,
"WIRE, REDUCTION 02.111.501.10",69161166,CDM,278,RC,,,Outpatient,,,136.34,136.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.8,60,,65.44,percent of total billed charges,60% of total Billed charges for outpatient setting,115.73,84.88,,92.58,percent of total billed charges,84.88% of total billed charges for outpatient setting,68.17,50,,54.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.26,75,,81.81,percent of total billed charges,75% of total billed charges for outpatient setting,68.17,50,,54.54,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.008,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.07,80,,87.26,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,17.51,12.84,,14.01,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,136.34,65,,109.07,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.72,35,,38.18,percent of total billed charges,35% of total Billed charges for Outpatient Setting,81.8,60,,65.44,percent of total billed charges,60% of total billed charges for outpatient setting,17.51,136.34,
WIXELA INHUB INHALATION DISK 250/50,3313708,CDM,250,RC,,,Outpatient,,,482.2,482.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.54,70,,270.03,percent of total billed charges,70% of total billed charges for outpatient setting,409.29,84.88,,327.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,241.1,50,,192.88,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.65,75,,289.32,percent of total billed charges,75% of total billed charges for outpatient setting,337.54,70,,270.03,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.91,12.84,,49.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.76,80,,308.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.91,12.84,,49.53,percent of total billed charges,12.84% of total billed charges,61.91,12.84,,49.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,313.43,65,,250.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.77,35,,135.02,percent of total billed charges,35% of total Billed charges for Outpatient Setting,433.98,90,,347.18,percent of total billed charges,90% of total billed charges for outpatient setting,61.91,433.98,
WOVEN PHILLIPS FOLLOWER 16Fr / 024016,69161643,CDM,272,RC,,,Outpatient,,,257.95,257.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,218.95,84.88,,175.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.98,50,,103.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.46,75,,154.77,percent of total billed charges,75% of total billed charges for outpatient setting,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.36,80,,165.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.67,65,,134.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.28,35,,72.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.16,90,,185.73,percent of total billed charges,90% of total billed charges for outpatient setting,33.12,232.16,
WOVEN PHILLIPS FOLLOWER 18Fr / 024018,69161644,CDM,272,RC,,,Outpatient,,,257.95,257.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,218.95,84.88,,175.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.98,50,,103.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.46,75,,154.77,percent of total billed charges,75% of total billed charges for outpatient setting,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.36,80,,165.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.67,65,,134.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.28,35,,72.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.16,90,,185.73,percent of total billed charges,90% of total billed charges for outpatient setting,33.12,232.16,
WOVEN PHILLIPS FOLLOWER 20Fr / 024020,69161645,CDM,272,RC,,,Outpatient,,,257.95,257.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,218.95,84.88,,175.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.98,50,,103.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.46,75,,154.77,percent of total billed charges,75% of total billed charges for outpatient setting,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.36,80,,165.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.67,65,,134.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.28,35,,72.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.16,90,,185.73,percent of total billed charges,90% of total billed charges for outpatient setting,33.12,232.16,
WOVEN PHILLIPS FOLLOWER 22Fr / 024022,69161663,CDM,272,RC,,,Outpatient,,,257.95,257.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,218.95,84.88,,175.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.98,50,,103.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.46,75,,154.77,percent of total billed charges,75% of total billed charges for outpatient setting,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.36,80,,165.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.67,65,,134.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.28,35,,72.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.16,90,,185.73,percent of total billed charges,90% of total billed charges for outpatient setting,33.12,232.16,
WOVEN PHILLIPS FOLLOWER 24Fr / 024024,69161664,CDM,272,RC,,,Outpatient,,,257.95,257.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,218.95,84.88,,175.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.98,50,,103.18,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.46,75,,154.77,percent of total billed charges,75% of total billed charges for outpatient setting,180.57,70,,144.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.36,80,,165.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,33.12,12.84,,26.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,167.67,65,,134.14,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.28,35,,72.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,232.16,90,,185.73,percent of total billed charges,90% of total billed charges for outpatient setting,33.12,232.16,
WRAP 1IN 5YD COBAN / 1581,2451019,CDM,272,RC,,,Outpatient,,,3.76,3.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,70,,2.1,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,84.88,,2.55,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.88,50,,1.5,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.82,75,,2.26,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,70,,2.1,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.01,80,,2.41,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,0.48,12.84,,0.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.44,65,,1.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.32,35,,1.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.38,90,,2.7,percent of total billed charges,90% of total billed charges for outpatient setting,0.48,3.38,
WRAP COLOR NS 2IN / CAH25LFMP,70000339,CDM,271,RC,,,Outpatient,,,8.04,8.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,70,,4.5,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,84.88,,5.46,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.02,50,,3.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.03,75,,4.82,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,70,,4.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.824,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.43,80,,5.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,1.03,12.84,,0.82,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.23,65,,4.18,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.81,35,,2.25,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.24,90,,5.79,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,7.24,
WRENCH 4.5MM PIN / 321.17,415119,CDM,272,RC,,,Outpatient,,,230.04,230.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.03,70,,128.82,percent of total billed charges,70% of total billed charges for outpatient setting,195.26,84.88,,156.21,percent of total billed charges,84.88% of total billed charges for outpatient setting,115.02,50,,92.02,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.53,75,,138.02,percent of total billed charges,75% of total billed charges for outpatient setting,161.03,70,,128.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.54,12.84,,23.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.03,80,,147.22,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.54,12.84,,23.63,percent of total billed charges,12.84% of total billed charges,29.54,12.84,,23.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,149.53,65,,119.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.51,35,,64.41,percent of total billed charges,35% of total Billed charges for Outpatient Setting,207.04,90,,165.63,percent of total billed charges,90% of total billed charges for outpatient setting,29.54,207.04,
WRENCH HEX 3IN / SC-4276,70000142,CDM,272,RC,,,Outpatient,,,202.79,202.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,172.13,84.88,,137.7,percent of total billed charges,84.88% of total billed charges for outpatient setting,101.4,50,,81.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.09,75,,121.67,percent of total billed charges,75% of total billed charges for outpatient setting,141.95,70,,113.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,80,,129.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,26.04,12.84,,20.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,131.81,65,,105.45,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.98,35,,56.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,182.51,90,,146.01,percent of total billed charges,90% of total billed charges for outpatient setting,26.04,182.51,
WRIST 2 VWS BILATERAL,2400532,CDM,320,RC,73100,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
WRIST 2 VWS LEFT,2400531,CDM,320,RC,73100,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
WRIST 2 VWS RIGHT,2400530,CDM,320,RC,73100,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
WRIST 3 VWS BILATERAL,2400537,CDM,320,RC,73110,HCPCS,Outpatient,,,400.23,300.17,50,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,339.72,84.88,,271.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,200.12,50,,160.1,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.17,75,,240.14,percent of total billed charges,75% of total billed charges for outpatient setting,280.16,70,,224.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.112,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.18,80,,256.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,51.39,12.84,,41.11,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.08,35,,112.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,360.21,90,,288.17,percent of total billed charges,90% of total billed charges for outpatient setting,51.39,360.21,
WRIST 3 VWS LEFT,2400536,CDM,320,RC,73110,HCPCS,Outpatient,,,266.81,200.11,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
WRIST 3 VWS RIGHT,2400535,CDM,320,RC,73110,HCPCS,Outpatient,,,266.81,200.11,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,226.47,84.88,,181.18,percent of total billed charges,84.88% of total billed charges for outpatient setting,133.41,50,,106.73,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.11,75,,160.09,percent of total billed charges,75% of total billed charges for outpatient setting,186.77,70,,149.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.45,80,,170.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,34.26,12.84,,27.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.38,35,,74.7,percent of total billed charges,35% of total Billed charges for Outpatient Setting,240.13,90,,192.1,percent of total billed charges,90% of total billed charges for outpatient setting,34.26,240.13,
WRIST ARTHROGRAPHY LEFT,2400541,CDM,322,RC,73115,HCPCS,Outpatient,,,1141.31,855.98,LT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
WRIST ARTHROGRAPHY RIGHT,2400540,CDM,322,RC,73115,HCPCS,Outpatient,,,1141.31,855.98,RT,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,968.74,84.88,,774.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,570.66,50,,456.53,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855.98,75,,684.78,percent of total billed charges,75% of total billed charges for outpatient setting,798.92,70,,639.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.232,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.05,80,,730.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,146.54,12.84,,117.23,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,128,100,,,Case rate,pays based on fixed rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.46,35,,319.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1027.18,90,,821.74,percent of total billed charges,90% of total billed charges for outpatient setting,128,1027.18,
WRIST BRACE LARGE LT / ORT18210LL,69160753,CDM,270,RC,,,Outpatient,,,117.68,117.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.38,70,,65.9,percent of total billed charges,70% of total billed charges for outpatient setting,99.89,84.88,,79.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,58.84,50,,47.07,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.26,75,,70.61,percent of total billed charges,75% of total billed charges for outpatient setting,82.38,70,,65.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.11,12.84,,12.088,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.14,80,,75.31,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.11,12.84,,12.09,percent of total billed charges,12.84% of total billed charges,15.11,12.84,,12.09,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,76.49,65,,61.19,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.19,35,,32.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,105.91,90,,84.73,percent of total billed charges,90% of total billed charges for outpatient setting,15.11,105.91,
WRIST BRACE LARGE RT / ORT18210RL,69160754,CDM,270,RC,,,Outpatient,,,91.36,91.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.95,70,,51.16,percent of total billed charges,70% of total billed charges for outpatient setting,77.55,84.88,,62.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,45.68,50,,36.54,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.52,75,,54.82,percent of total billed charges,75% of total billed charges for outpatient setting,63.95,70,,51.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.73,12.84,,9.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.09,80,,58.47,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.73,12.84,,9.38,percent of total billed charges,12.84% of total billed charges,11.73,12.84,,9.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,59.38,65,,47.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.98,35,,25.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,82.22,90,,65.78,percent of total billed charges,90% of total billed charges for outpatient setting,11.73,82.22,
WRIST BRACE MED LT / 79-87435,69160751,CDM,270,RC,,,Outpatient,,,27.6,27.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.32,70,,15.46,percent of total billed charges,70% of total billed charges for outpatient setting,23.43,84.88,,18.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,13.8,50,,11.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,75,,16.56,percent of total billed charges,75% of total billed charges for outpatient setting,19.32,70,,15.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,80,,17.66,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,3.54,12.84,,2.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,65,,14.35,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.66,35,,7.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,24.84,90,,19.87,percent of total billed charges,90% of total billed charges for outpatient setting,3.54,24.84,
WRIST BRACE MED RT / 79-87500,69160752,CDM,270,RC,,,Outpatient,,,57.12,57.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,70,,31.98,percent of total billed charges,70% of total billed charges for outpatient setting,48.48,84.88,,38.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.56,50,,22.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.84,75,,34.27,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,70,,31.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.7,80,,36.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,7.33,12.84,,5.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,37.13,65,,29.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,35,,15.99,percent of total billed charges,35% of total Billed charges for Outpatient Setting,51.41,90,,41.13,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,51.41,
WRIST SUP ARTRL ADULT / 29980,6152265,CDM,270,RC,,,Outpatient,,,31.92,31.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.34,70,,17.87,percent of total billed charges,70% of total billed charges for outpatient setting,27.09,84.88,,21.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,15.96,50,,12.77,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.94,75,,19.15,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,70,,17.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.54,80,,20.43,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,4.1,12.84,,3.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.75,65,,16.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.17,35,,8.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,28.73,90,,22.98,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,28.73,
X POST 8.0X20mm (60 deg) 118-80620,69161499,CDM,278,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2160,60,,1728,percent of total billed charges,60% of total Billed charges for outpatient setting,3055.68,84.88,,2444.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,75,,2160,percent of total billed charges,75% of total billed charges for outpatient setting,1800,50,,1440,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.792,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2880,80,,2304,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,462.24,12.84,,369.79,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3780,105,,3024,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,35,,1008,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2160,60,,1728,percent of total billed charges,60% of total billed charges for outpatient setting,462.24,3780,
XEMPLIFI 10CC DBM / 8103.0210S,69161728,CDM,278,RC,C9362,HCPCS,Outpatient,,,3237,3237,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1942.2,60,,1553.76,percent of total billed charges,60% of total Billed charges for outpatient setting,2747.57,84.88,,2198.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,110.85,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,2427.75,75,,1942.2,percent of total billed charges,75% of total billed charges for outpatient setting,1618.5,50,,1294.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.63,12.84,,332.504,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2589.6,80,,2071.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.63,12.84,,332.5,percent of total billed charges,12.84% of total billed charges,415.63,12.84,,332.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3398.85,105,,2719.08,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1132.95,35,,906.36,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1942.2,60,,1553.76,percent of total billed charges,60% of total billed charges for outpatient setting,110.85,3398.85,
XEMPLIFI 10ML DBM PUTTY / 8103.0010S,69161787,CDM,278,RC,C1713,HCPCS,Outpatient,,,3237.5,3237.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1942.5,60,,1554,percent of total billed charges,60% of total Billed charges for outpatient setting,2747.99,84.88,,2198.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2428.13,75,,1942.5,percent of total billed charges,75% of total billed charges for outpatient setting,1618.75,50,,1295,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.7,12.84,,332.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2590,80,,2072,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.7,12.84,,332.56,percent of total billed charges,12.84% of total billed charges,415.7,12.84,,332.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3399.38,105,,2719.5,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.13,35,,906.5,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1942.5,60,,1554,percent of total billed charges,60% of total billed charges for outpatient setting,415.7,3399.38,
XEMPLIFI 1CC DBM  PUTTY / 8103.0001S,69161742,CDM,278,RC,,,Outpatient,,,913.44,913.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.06,60,,438.45,percent of total billed charges,60% of total Billed charges for outpatient setting,775.33,84.88,,620.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,456.72,50,,365.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,685.08,75,,548.06,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,50,,365.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.75,80,,584.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,913.44,65,,730.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.7,35,,255.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,548.06,60,,438.45,percent of total billed charges,60% of total billed charges for outpatient setting,117.29,913.44,
XEMPLIFI 1CC DBM GEL   8103.0101S,69161880,CDM,278,RC,,,Outpatient,,,913.44,913.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.06,60,,438.45,percent of total billed charges,60% of total Billed charges for outpatient setting,775.33,84.88,,620.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,456.72,50,,365.38,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,685.08,75,,548.06,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,50,,365.38,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.832,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.75,80,,584.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,117.29,12.84,,93.83,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,913.44,65,,730.75,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.7,35,,255.76,percent of total billed charges,35% of total Billed charges for Outpatient Setting,548.06,60,,438.45,percent of total billed charges,60% of total billed charges for outpatient setting,117.29,913.44,
XEMPLIFI 1CC DBM PLUS   8103.0201S,69161779,CDM,278,RC,,,Outpatient,,,1007,1007,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.2,60,,483.36,percent of total billed charges,60% of total Billed charges for outpatient setting,854.74,84.88,,683.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,503.5,50,,402.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.25,75,,604.2,percent of total billed charges,75% of total billed charges for outpatient setting,503.5,50,,402.8,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.3,12.84,,103.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.6,80,,644.48,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.3,12.84,,103.44,percent of total billed charges,12.84% of total billed charges,129.3,12.84,,103.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1007,65,,805.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.45,35,,281.96,percent of total billed charges,35% of total Billed charges for Outpatient Setting,604.2,60,,483.36,percent of total billed charges,60% of total billed charges for outpatient setting,129.3,1007,
XEMPLIFI 3CC DBM PLUS / 8103.0203S,69161808,CDM,278,RC,,,Outpatient,,,2300.3,2300.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380.18,60,,1104.14,percent of total billed charges,60% of total Billed charges for outpatient setting,1952.49,84.88,,1561.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,1150.15,50,,920.12,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1725.23,75,,1380.18,percent of total billed charges,75% of total billed charges for outpatient setting,1150.15,50,,920.12,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.36,12.84,,236.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840.24,80,,1472.19,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.36,12.84,,236.29,percent of total billed charges,12.84% of total billed charges,295.36,12.84,,236.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2415.32,105,,1932.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.11,35,,644.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1380.18,60,,1104.14,percent of total billed charges,60% of total billed charges for outpatient setting,295.36,2415.32,
XEMPLIFI 5CC DBM GEL   8103.0105S,69161886,CDM,278,RC,,,Outpatient,,,3216.52,3216.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1929.91,60,,1543.93,percent of total billed charges,60% of total Billed charges for outpatient setting,2730.18,84.88,,2184.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,1608.26,50,,1286.61,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2412.39,75,,1929.91,percent of total billed charges,75% of total billed charges for outpatient setting,1608.26,50,,1286.61,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,12.84,,330.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2573.22,80,,2058.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,12.84,,330.4,percent of total billed charges,12.84% of total billed charges,413,12.84,,330.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3377.35,105,,2701.88,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.78,35,,900.62,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1929.91,60,,1543.93,percent of total billed charges,60% of total billed charges for outpatient setting,413,3377.35,
XEMPLIFI 5CC DBM GEL   8103.0110S,69161840,CDM,278,RC,,,Outpatient,,,2450,2450,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470,60,,1176,percent of total billed charges,60% of total Billed charges for outpatient setting,2079.56,84.88,,1663.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1837.5,75,,1470,percent of total billed charges,75% of total billed charges for outpatient setting,1225,50,,980,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,80,,1568,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,314.58,12.84,,251.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2572.5,105,,2058,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.5,35,,686,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1470,60,,1176,percent of total billed charges,60% of total billed charges for outpatient setting,314.58,2572.5,
XEMPLIFI 5CC DBM PUTTY / 8103.0005S,69161841,CDM,278,RC,C9359,HCPCS,Outpatient,,,1907.5,1907.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1144.5,60,,915.6,percent of total billed charges,60% of total Billed charges for outpatient setting,1619.09,84.88,,1295.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,130.5,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,1430.63,75,,1144.5,percent of total billed charges,75% of total billed charges for outpatient setting,953.75,50,,763,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.92,12.84,,195.936,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1526,80,,1220.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.92,12.84,,195.94,percent of total billed charges,12.84% of total billed charges,244.92,12.84,,195.94,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1907.5,65,,1526,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.63,35,,534.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1144.5,60,,915.6,percent of total billed charges,60% of total billed charges for outpatient setting,130.5,1907.5,
XEMPLIFI 8CC DBM / 8103.0208S,70000102,CDM,278,RC,C1713,HCPCS,Outpatient,,,2156,2156,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.6,60,,1034.88,percent of total billed charges,60% of total Billed charges for outpatient setting,1830.01,84.88,,1464.01,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617,75,,1293.6,percent of total billed charges,75% of total billed charges for outpatient setting,1078,50,,862.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.83,12.84,,221.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1724.8,80,,1379.84,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.83,12.84,,221.46,percent of total billed charges,12.84% of total billed charges,276.83,12.84,,221.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2263.8,105,,1811.04,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.6,35,,603.68,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1293.6,60,,1034.88,percent of total billed charges,60% of total billed charges for outpatient setting,276.83,2263.8,
XEN GEL STENT / 5513-001,69169677,CDM,278,RC,C1783,HCPCS,Outpatient,,,4100,4100,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460,60,,1968,percent of total billed charges,60% of total Billed charges for outpatient setting,3480.08,84.88,,2784.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3075,75,,2460,percent of total billed charges,75% of total billed charges for outpatient setting,2050,50,,1640,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.152,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3280,80,,2624,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,526.44,12.84,,421.15,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,4305,105,,3444,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1435,35,,1148,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2460,60,,1968,percent of total billed charges,60% of total billed charges for outpatient setting,526.44,4305,
XENADERM OINTMENT: 60 GM,3303202,CDM,259,RC,,,Outpatient,,,289.52,289.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.66,70,,162.13,percent of total billed charges,70% of total billed charges for outpatient setting,245.74,84.88,,196.59,percent of total billed charges,84.88% of total billed charges for outpatient setting,144.76,50,,115.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.14,75,,173.71,percent of total billed charges,75% of total billed charges for outpatient setting,202.66,70,,162.13,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.17,12.84,,29.736,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.62,80,,185.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.17,12.84,,29.74,percent of total billed charges,12.84% of total billed charges,37.17,12.84,,29.74,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,188.19,65,,150.55,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.33,35,,81.06,percent of total billed charges,35% of total Billed charges for Outpatient Setting,260.57,90,,208.46,percent of total billed charges,90% of total billed charges for outpatient setting,37.17,260.57,
XEROFORM 5X9 GAUZE/ CUR253590,6150185,CDM,272,RC,,,Outpatient,,,4.5,4.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,70,,2.52,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,84.88,,3.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.25,50,,1.8,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.38,75,,2.7,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,70,,2.52,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,80,,2.88,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.93,65,,2.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.58,35,,1.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.05,90,,3.24,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.05,
XEROFORM GAUZE 2X2 / CUR253220,6150184,CDM,272,RC,,,Outpatient,,,4.82,4.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.37,70,,2.7,percent of total billed charges,70% of total billed charges for outpatient setting,4.09,84.88,,3.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.41,50,,1.93,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.62,75,,2.9,percent of total billed charges,75% of total billed charges for outpatient setting,3.37,70,,2.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,80,,3.09,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.13,65,,2.5,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,35,,1.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.34,90,,3.47,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.34,
XEROGEL NASAL PKING 4X2.4CM  / XG-108,69161963,CDM,272,RC,,,Outpatient,,,432.6,432.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,367.19,84.88,,293.75,percent of total billed charges,84.88% of total billed charges for outpatient setting,216.3,50,,173.04,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.45,75,,259.56,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,70,,242.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.08,80,,276.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,55.55,12.84,,44.44,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,281.19,65,,224.95,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.41,35,,121.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,389.34,90,,311.47,percent of total billed charges,90% of total billed charges for outpatient setting,55.55,389.34,
Xi  2.5MM WHITE 30 ENDOWRST 48630W RLOAD,69169844,CDM,272,RC,,,Outpatient,,,683.36,683.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.35,70,,382.68,percent of total billed charges,70% of total billed charges for outpatient setting,580.04,84.88,,464.03,percent of total billed charges,84.88% of total billed charges for outpatient setting,341.68,50,,273.34,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,512.52,75,,410.02,percent of total billed charges,75% of total billed charges for outpatient setting,478.35,70,,382.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,12.84,,70.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.69,80,,437.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.74,12.84,,70.19,percent of total billed charges,12.84% of total billed charges,87.74,12.84,,70.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,444.18,65,,355.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.18,35,,191.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,615.02,90,,492.02,percent of total billed charges,90% of total billed charges for outpatient setting,87.74,615.02,
Xi 5-12MM UNIVERSAL SEAL / 470500,69169892,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,101.86,84.88,,81.49,percent of total billed charges,84.88% of total billed charges for outpatient setting,60,50,,48,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,75,,72,percent of total billed charges,75% of total billed charges for outpatient setting,84,70,,67.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,80,,76.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,15.41,12.84,,12.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,78,65,,62.4,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,35,,33.6,percent of total billed charges,35% of total Billed charges for Outpatient Setting,108,90,,86.4,percent of total billed charges,90% of total billed charges for outpatient setting,15.41,108,
Xi 5-8MM CANNULA SEAL / 470361,69162004,CDM,272,RC,,,Outpatient,,,113.4,113.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,96.25,84.88,,77,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.7,50,,45.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,75,,68.04,percent of total billed charges,75% of total billed charges for outpatient setting,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,80,,72.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.71,65,,58.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.69,35,,31.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.06,90,,81.65,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.06,
Xi 8MM BLADELESS OBTURATOR / 470357,69162005,CDM,272,RC,,,Outpatient,,,142.03,142.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,120.56,84.88,,96.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,71.02,50,,56.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.52,75,,85.22,percent of total billed charges,75% of total billed charges for outpatient setting,99.42,70,,79.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.62,80,,90.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,18.24,12.84,,14.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,92.32,65,,73.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.71,35,,39.77,percent of total billed charges,35% of total Billed charges for Outpatient Setting,127.83,90,,102.26,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,127.83,
Xi 8MM BLDLESS OBTURATOR/ 470359,69162470,CDM,272,RC,,,Outpatient,,,157.5,157.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,133.69,84.88,,106.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.75,50,,63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.13,75,,94.5,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,80,,100.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.38,65,,81.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,35,,44.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,90,,113.4,percent of total billed charges,90% of total billed charges for outpatient setting,20.22,141.75,
Xi 8MM LONG BLDLESS OBTURATOR / 470360,69162733,CDM,272,RC,,,Outpatient,,,157.5,157.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,133.69,84.88,,106.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,78.75,50,,63,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.13,75,,94.5,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,70,,88.2,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,80,,100.8,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,20.22,12.84,,16.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,102.38,65,,81.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,35,,44.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,141.75,90,,113.4,percent of total billed charges,90% of total billed charges for outpatient setting,20.22,141.75,
Xi CADIERE FORCEPS / 470049,69162601,CDM,272,RC,,,Outpatient,,,999.88,999.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,848.7,84.88,,678.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.94,50,,399.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.91,75,,599.93,percent of total billed charges,75% of total billed charges for outpatient setting,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.9,80,,639.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.92,65,,519.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.96,35,,279.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.89,90,,719.91,percent of total billed charges,90% of total billed charges for outpatient setting,128.38,899.89,
Xi CANNULA SEAL 12MM STAPLER / 470380,69162123,CDM,272,RC,,,Outpatient,,,129.78,129.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,110.16,84.88,,88.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,64.89,50,,51.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.34,75,,77.87,percent of total billed charges,75% of total billed charges for outpatient setting,90.85,70,,72.68,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.328,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,80,,83.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,16.66,12.84,,13.33,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,84.36,65,,67.49,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.42,35,,36.34,percent of total billed charges,35% of total Billed charges for Outpatient Setting,116.8,90,,93.44,percent of total billed charges,90% of total billed charges for outpatient setting,16.66,116.8,
Xi CAUTERY HOOK / 470183,69162001,CDM,272,RC,,,Outpatient,,,504,504,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,70,,282.24,percent of total billed charges,70% of total billed charges for outpatient setting,427.8,84.88,,342.24,percent of total billed charges,84.88% of total billed charges for outpatient setting,252,50,,201.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378,75,,302.4,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,70,,282.24,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.71,12.84,,51.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.2,80,,322.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.71,12.84,,51.77,percent of total billed charges,12.84% of total billed charges,64.71,12.84,,51.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,327.6,65,,262.08,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,35,,141.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,453.6,90,,362.88,percent of total billed charges,90% of total billed charges for outpatient setting,64.71,453.6,
Xi COBRA GRASPER 470190,69162208,CDM,272,RC,,,Outpatient,,,951.72,951.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.2,70,,532.96,percent of total billed charges,70% of total billed charges for outpatient setting,807.82,84.88,,646.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,475.86,50,,380.69,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,713.79,75,,571.03,percent of total billed charges,75% of total billed charges for outpatient setting,666.2,70,,532.96,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.2,12.84,,97.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.38,80,,609.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.2,12.84,,97.76,percent of total billed charges,12.84% of total billed charges,122.2,12.84,,97.76,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,618.62,65,,494.9,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.1,35,,266.48,percent of total billed charges,35% of total Billed charges for Outpatient Setting,856.55,90,,685.24,percent of total billed charges,90% of total billed charges for outpatient setting,122.2,856.55,
Xi DRAPE COLUMN / 470341,69162017,CDM,272,RC,,,Outpatient,,,113.4,113.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,96.25,84.88,,77,percent of total billed charges,84.88% of total billed charges for outpatient setting,56.7,50,,45.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,75,,68.04,percent of total billed charges,75% of total billed charges for outpatient setting,79.38,70,,63.5,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,80,,72.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,14.56,12.84,,11.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,73.71,65,,58.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.69,35,,31.75,percent of total billed charges,35% of total Billed charges for Outpatient Setting,102.06,90,,81.65,percent of total billed charges,90% of total billed charges for outpatient setting,14.56,102.06,
Xi DRAPE INSTRUMENT ARM / 470015,69162018,CDM,272,RC,,,Outpatient,,,218.4,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,185.38,84.88,,148.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,109.2,50,,87.36,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.8,75,,131.04,percent of total billed charges,75% of total billed charges for outpatient setting,152.88,70,,122.3,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.432,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,80,,139.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,28.04,12.84,,22.43,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,141.96,65,,113.57,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.44,35,,61.15,percent of total billed charges,35% of total Billed charges for Outpatient Setting,196.56,90,,157.25,percent of total billed charges,90% of total billed charges for outpatient setting,28.04,196.56,
Xi FENESTRATED BIPOLAR FORCEP / 471205,69161995,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,712.99,84.88,,570.39,percent of total billed charges,84.88% of total billed charges for outpatient setting,420,50,,336,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630,75,,504,percent of total billed charges,75% of total billed charges for outpatient setting,588,70,,470.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672,80,,537.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,107.86,12.84,,86.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,546,65,,436.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,35,,235.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,756,90,,604.8,percent of total billed charges,90% of total billed charges for outpatient setting,107.86,756,
Xi FORCE BIPOLAR 8MM / 471405,69169203,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658,70,,526.4,percent of total billed charges,70% of total billed charges for outpatient setting,797.87,84.88,,638.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,470,50,,376,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705,75,,564,percent of total billed charges,75% of total billed charges for outpatient setting,658,70,,526.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.7,12.84,,96.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752,80,,601.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.7,12.84,,96.56,percent of total billed charges,12.84% of total billed charges,120.7,12.84,,96.56,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,611,65,,488.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329,35,,263.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,846,90,,676.8,percent of total billed charges,90% of total billed charges for outpatient setting,120.7,846,
Xi HARMONIC ACE CURVED SHEARS / 480275,69162319,CDM,272,RC,,,Outpatient,,,2062.97,2062.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.08,70,,1155.26,percent of total billed charges,70% of total billed charges for outpatient setting,1751.05,84.88,,1400.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,1031.49,50,,825.19,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1547.23,75,,1237.78,percent of total billed charges,75% of total billed charges for outpatient setting,1444.08,70,,1155.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.89,12.84,,211.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1650.38,80,,1320.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.89,12.84,,211.91,percent of total billed charges,12.84% of total billed charges,264.89,12.84,,211.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1340.93,65,,1072.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.04,35,,577.63,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1856.67,90,,1485.34,percent of total billed charges,90% of total billed charges for outpatient setting,264.89,1856.67,
Xi LARGE CLIP APPLIER / 470230,69162002,CDM,272,RC,,,Outpatient,,,318.15,318.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,270.05,84.88,,216.04,percent of total billed charges,84.88% of total billed charges for outpatient setting,159.08,50,,127.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.61,75,,190.89,percent of total billed charges,75% of total billed charges for outpatient setting,222.71,70,,178.17,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.52,80,,203.62,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,40.85,12.84,,32.68,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,206.8,65,,165.44,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.35,35,,89.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,286.34,90,,229.07,percent of total billed charges,90% of total billed charges for outpatient setting,40.85,286.34,
Xi LARGE NEEDLE DRIVER / 471006,69161998,CDM,272,RC,,,Outpatient,,,714.12,714.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.88,70,,399.9,percent of total billed charges,70% of total billed charges for outpatient setting,606.15,84.88,,484.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,357.06,50,,285.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.59,75,,428.47,percent of total billed charges,75% of total billed charges for outpatient setting,499.88,70,,399.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.69,12.84,,73.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.3,80,,457.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.69,12.84,,73.35,percent of total billed charges,12.84% of total billed charges,91.69,12.84,,73.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,464.18,65,,371.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.94,35,,199.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642.71,90,,514.17,percent of total billed charges,90% of total billed charges for outpatient setting,91.69,642.71,
Xi LARGE SUTURECUT NDL DRIVER / 471296,69162659,CDM,272,RC,,,Outpatient,,,714.12,714.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.88,70,,399.9,percent of total billed charges,70% of total billed charges for outpatient setting,606.15,84.88,,484.92,percent of total billed charges,84.88% of total billed charges for outpatient setting,357.06,50,,285.65,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.59,75,,428.47,percent of total billed charges,75% of total billed charges for outpatient setting,499.88,70,,399.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.69,12.84,,73.352,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.3,80,,457.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.69,12.84,,73.35,percent of total billed charges,12.84% of total billed charges,91.69,12.84,,73.35,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,464.18,65,,371.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.94,35,,199.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,642.71,90,,514.17,percent of total billed charges,90% of total billed charges for outpatient setting,91.69,642.71,
Xi LONG TIP FORCEPS / 470048,69162636,CDM,272,RC,,,Outpatient,,,999.88,999.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,848.7,84.88,,678.96,percent of total billed charges,84.88% of total billed charges for outpatient setting,499.94,50,,399.95,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.91,75,,599.93,percent of total billed charges,75% of total billed charges for outpatient setting,699.92,70,,559.94,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.704,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.9,80,,639.92,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,128.38,12.84,,102.7,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,649.92,65,,519.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.96,35,,279.97,percent of total billed charges,35% of total Billed charges for Outpatient Setting,899.89,90,,719.91,percent of total billed charges,90% of total billed charges for outpatient setting,128.38,899.89,
Xi MARYLAND BIPOLAR FORCEP / 471172,69161994,CDM,272,RC,,,Outpatient,,,987.12,987.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,690.98,70,,552.78,percent of total billed charges,70% of total billed charges for outpatient setting,837.87,84.88,,670.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,493.56,50,,394.85,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,740.34,75,,592.27,percent of total billed charges,75% of total billed charges for outpatient setting,690.98,70,,552.78,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,12.84,,101.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.7,80,,631.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,12.84,,101.4,percent of total billed charges,12.84% of total billed charges,126.75,12.84,,101.4,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,641.63,65,,513.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.49,35,,276.39,percent of total billed charges,35% of total Billed charges for Outpatient Setting,888.41,90,,710.73,percent of total billed charges,90% of total billed charges for outpatient setting,126.75,888.41,
Xi MED/LARGE CLIP APPLIER / 470327,69162003,CDM,272,RC,,,Outpatient,,,73.5,73.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,62.39,84.88,,49.91,percent of total billed charges,84.88% of total billed charges for outpatient setting,36.75,50,,29.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.13,75,,44.1,percent of total billed charges,75% of total billed charges for outpatient setting,51.45,70,,41.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,80,,47.04,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,9.44,12.84,,7.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,47.78,65,,38.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.73,35,,20.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,66.15,90,,52.92,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,66.15,
Xi MEGA  NDL DRIVER / 470194,69162204,CDM,272,RC,,,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600.6,65,,480.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,90,,665.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.64,831.6,
Xi MEGA SUTURECUT NDL DRIVER / 471309,69161996,CDM,272,RC,,,Outpatient,,,735.2,735.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.64,70,,411.71,percent of total billed charges,70% of total billed charges for outpatient setting,624.04,84.88,,499.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,367.6,50,,294.08,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.4,75,,441.12,percent of total billed charges,75% of total billed charges for outpatient setting,514.64,70,,411.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.4,12.84,,75.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.16,80,,470.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.4,12.84,,75.52,percent of total billed charges,12.84% of total billed charges,94.4,12.84,,75.52,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,477.88,65,,382.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.32,35,,205.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,661.68,90,,529.34,percent of total billed charges,90% of total billed charges for outpatient setting,94.4,661.68,
Xi MONOPLR SCISR / 470179,69161993,CDM,272,RC,,,Outpatient,,,1344,1344,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,940.8,70,,752.64,percent of total billed charges,70% of total billed charges for outpatient setting,1140.79,84.88,,912.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,672,50,,537.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1008,75,,806.4,percent of total billed charges,75% of total billed charges for outpatient setting,940.8,70,,752.64,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.57,12.84,,138.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.2,80,,860.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.57,12.84,,138.06,percent of total billed charges,12.84% of total billed charges,172.57,12.84,,138.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,873.6,65,,698.88,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,35,,376.32,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1209.6,90,,967.68,percent of total billed charges,90% of total billed charges for outpatient setting,172.57,1209.6,
Xi PROGRASP FORCEPS / 471093,69161999,CDM,272,RC,,,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,409.5,65,,327.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,567,90,,453.6,percent of total billed charges,90% of total billed charges for outpatient setting,80.89,567,
Xi REDUCER 12/8MM STAPLER / 470381,69162124,CDM,272,RC,,,Outpatient,,,97.34,97.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,84.88,,66.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,48.67,50,,38.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.01,75,,58.41,percent of total billed charges,75% of total billed charges for outpatient setting,68.14,70,,54.51,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.87,80,,62.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,12.5,12.84,,10,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,63.27,65,,50.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.07,35,,27.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,87.61,90,,70.09,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,87.61,
Xi ROUND TIP SCISSOR / 470007,69162231,CDM,272,RC,,,Outpatient,,,630,630,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,534.74,84.88,,427.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,315,50,,252,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.5,75,,378,percent of total billed charges,75% of total billed charges for outpatient setting,441,70,,352.8,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.712,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,80,,403.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,80.89,12.84,,64.71,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,409.5,65,,327.6,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,35,,176.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,567,90,,453.6,percent of total billed charges,90% of total billed charges for outpatient setting,80.89,567,
Xi SHEATH  STAPLER / 410370,69161681,CDM,272,RC,,,Outpatient,,,133.68,133.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,113.47,84.88,,90.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,66.84,50,,53.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.26,75,,80.21,percent of total billed charges,75% of total billed charges for outpatient setting,93.58,70,,74.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.728,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.94,80,,85.55,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,17.16,12.84,,13.73,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,86.89,65,,69.51,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,35,,37.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,120.31,90,,96.25,percent of total billed charges,90% of total billed charges for outpatient setting,17.16,120.31,
Xi SMALL GRAPTOR / 470318,69161997,CDM,272,RC,,,Outpatient,,,1008,1008,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.6,70,,564.48,percent of total billed charges,70% of total billed charges for outpatient setting,855.59,84.88,,684.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,504,50,,403.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,756,75,,604.8,percent of total billed charges,75% of total billed charges for outpatient setting,705.6,70,,564.48,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.544,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,80,,645.12,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,129.43,12.84,,103.54,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,655.2,65,,524.16,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,35,,282.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,907.2,90,,725.76,percent of total billed charges,90% of total billed charges for outpatient setting,129.43,907.2,
Xi STAPLER 30 CURVED TIP / 470530,69169843,CDM,272,RC,,,Outpatient,,,576,576,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.2,70,,322.56,percent of total billed charges,70% of total billed charges for outpatient setting,488.91,84.88,,391.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,288,50,,230.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,432,75,,345.6,percent of total billed charges,75% of total billed charges for outpatient setting,403.2,70,,322.56,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.96,12.84,,59.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.8,80,,368.64,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.96,12.84,,59.17,percent of total billed charges,12.84% of total billed charges,73.96,12.84,,59.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,374.4,65,,299.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,35,,161.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,518.4,90,,414.72,percent of total billed charges,90% of total billed charges for outpatient setting,73.96,518.4,
Xi STAPLER 45 / 470298,69162115,CDM,272,RC,,,Outpatient,,,605.64,605.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,514.07,84.88,,411.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,302.82,50,,242.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.23,75,,363.38,percent of total billed charges,75% of total billed charges for outpatient setting,423.95,70,,339.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.51,80,,387.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,77.76,12.84,,62.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,393.67,65,,314.94,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.97,35,,169.58,percent of total billed charges,35% of total Billed charges for Outpatient Setting,545.08,90,,436.06,percent of total billed charges,90% of total billed charges for outpatient setting,77.76,545.08,
Xi STAPLR 45 BLUE 48645B RELOAD,69162008,CDM,272,RC,,,Outpatient,,,802.04,802.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.43,70,,449.14,percent of total billed charges,70% of total billed charges for outpatient setting,680.77,84.88,,544.62,percent of total billed charges,84.88% of total billed charges for outpatient setting,401.02,50,,320.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,601.53,75,,481.22,percent of total billed charges,75% of total billed charges for outpatient setting,561.43,70,,449.14,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.98,12.84,,82.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.63,80,,513.3,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.98,12.84,,82.38,percent of total billed charges,12.84% of total billed charges,102.98,12.84,,82.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,521.33,65,,417.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.71,35,,224.57,percent of total billed charges,35% of total Billed charges for Outpatient Setting,721.84,90,,577.47,percent of total billed charges,90% of total billed charges for outpatient setting,102.98,721.84,
Xi SUCTION IRRIGATOR / 478054,70000583,CDM,272,RC,,,Outpatient,,,162.23,162.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,70,,90.85,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,84.88,,110.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,81.12,50,,64.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.67,75,,97.34,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,70,,90.85,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,12.84,,16.664,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.78,80,,103.82,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.83,12.84,,16.66,percent of total billed charges,12.84% of total billed charges,20.83,12.84,,16.66,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,105.45,65,,84.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,35,,45.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,146.01,90,,116.81,percent of total billed charges,90% of total billed charges for outpatient setting,20.83,146.01,
Xi SUCTION IRRIGATOR ENDOWRIST / 480299,70000584,CDM,272,RC,,,Outpatient,,,1113.32,1113.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.32,70,,623.46,percent of total billed charges,70% of total billed charges for outpatient setting,944.99,84.88,,755.99,percent of total billed charges,84.88% of total billed charges for outpatient setting,556.66,50,,445.33,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,834.99,75,,667.99,percent of total billed charges,75% of total billed charges for outpatient setting,779.32,70,,623.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.95,12.84,,114.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.66,80,,712.53,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.95,12.84,,114.36,percent of total billed charges,12.84% of total billed charges,142.95,12.84,,114.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,723.66,65,,578.93,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.66,35,,311.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1001.99,90,,801.59,percent of total billed charges,90% of total billed charges for outpatient setting,142.95,1001.99,
Xi SUREFORM 2.5 WHITE 48360W RELOAD,69169283,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
Xi SUREFORM 3.5 BLUE 48360B RELOAD,69169209,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
Xi SUREFORM 4.3 BLACK 48360T RELOAD,69169211,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
Xi SUREFORM 4.3 GREEN 48360G RELOAD,69169210,CDM,272,RC,,,Outpatient,,,994.98,994.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,844.54,84.88,,675.63,percent of total billed charges,84.88% of total billed charges for outpatient setting,497.49,50,,397.99,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,746.24,75,,596.99,percent of total billed charges,75% of total billed charges for outpatient setting,696.49,70,,557.19,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.98,80,,636.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,127.76,12.84,,102.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,646.74,65,,517.39,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,35,,278.59,percent of total billed charges,35% of total Billed charges for Outpatient Setting,895.48,90,,716.38,percent of total billed charges,90% of total billed charges for outpatient setting,127.76,895.48,
Xi SUREFORM 60 STAPLER / 480460,69169208,CDM,272,RC,,,Outpatient,,,2006.18,2006.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.33,70,,1123.46,percent of total billed charges,70% of total billed charges for outpatient setting,1702.85,84.88,,1362.28,percent of total billed charges,84.88% of total billed charges for outpatient setting,1003.09,50,,802.47,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1504.64,75,,1203.71,percent of total billed charges,75% of total billed charges for outpatient setting,1404.33,70,,1123.46,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.59,12.84,,206.072,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1604.94,80,,1283.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.59,12.84,,206.07,percent of total billed charges,12.84% of total billed charges,257.59,12.84,,206.07,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1304.02,65,,1043.22,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.16,35,,561.73,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1805.56,90,,1444.45,percent of total billed charges,90% of total billed charges for outpatient setting,257.59,1805.56,
Xi TENACULUM FORCEP / 470207,69162046,CDM,272,RC,,,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600.6,65,,480.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,90,,665.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.64,831.6,
Xi TIP-UP FENESTRATED GRASPER / 470347,69162000,CDM,272,RC,,,Outpatient,,,924,924,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,784.29,84.88,,627.43,percent of total billed charges,84.88% of total billed charges for outpatient setting,462,50,,369.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693,75,,554.4,percent of total billed charges,75% of total billed charges for outpatient setting,646.8,70,,517.44,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.912,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.2,80,,591.36,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,118.64,12.84,,94.91,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,600.6,65,,480.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,35,,258.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,831.6,90,,665.28,percent of total billed charges,90% of total billed charges for outpatient setting,118.64,831.6,
Xi VESSEL SEALER / 480322,69162006,CDM,272,RC,,,Outpatient,,,1325.59,1325.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.91,70,,742.33,percent of total billed charges,70% of total billed charges for outpatient setting,1125.16,84.88,,900.13,percent of total billed charges,84.88% of total billed charges for outpatient setting,662.8,50,,530.24,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,994.19,75,,795.35,percent of total billed charges,75% of total billed charges for outpatient setting,927.91,70,,742.33,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,12.84,,136.168,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1060.47,80,,848.38,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,12.84,,136.17,percent of total billed charges,12.84% of total billed charges,170.21,12.84,,136.17,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,861.63,65,,689.3,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.96,35,,371.17,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1193.03,90,,954.42,percent of total billed charges,90% of total billed charges for outpatient setting,170.21,1193.03,
Xi VESSEL SEALER EXTENDED / 480422,69162910,CDM,272,RC,,,Outpatient,,,2297.15,2297.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1608.01,70,,1286.41,percent of total billed charges,70% of total billed charges for outpatient setting,1949.82,84.88,,1559.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,1148.58,50,,918.86,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1722.86,75,,1378.29,percent of total billed charges,75% of total billed charges for outpatient setting,1608.01,70,,1286.41,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.95,12.84,,235.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1837.72,80,,1470.18,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.95,12.84,,235.96,percent of total billed charges,12.84% of total billed charges,294.95,12.84,,235.96,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1493.15,65,,1194.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804,35,,643.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2067.44,90,,1653.95,percent of total billed charges,90% of total billed charges for outpatient setting,294.95,2067.44,
XOPENEX 1.25 / 3CC NEBULE,3302972,CDM,259,RC,,,Outpatient,,,25.38,25.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.77,70,,14.22,percent of total billed charges,70% of total billed charges for outpatient setting,21.54,84.88,,17.23,percent of total billed charges,84.88% of total billed charges for outpatient setting,12.69,50,,10.15,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.04,75,,15.23,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,70,,14.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,12.84,,2.608,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.3,80,,16.24,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,12.84,,2.61,percent of total billed charges,12.84% of total billed charges,3.26,12.84,,2.61,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,16.5,65,,13.2,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,35,,7.1,percent of total billed charges,35% of total Billed charges for Outpatient Setting,22.84,90,,18.27,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,22.84,
XPECT HC 600/5 : TAB : UD,3303125,CDM,259,RC,,,Outpatient,,,12.61,12.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,10.7,84.88,,8.56,percent of total billed charges,84.88% of total billed charges for outpatient setting,6.31,50,,5.05,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.46,75,,7.57,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,70,,7.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.296,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.09,80,,8.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,1.62,12.84,,1.3,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8.2,65,,6.56,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,35,,3.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,11.35,90,,9.08,percent of total billed charges,90% of total billed charges for outpatient setting,1.62,11.35,
XprESS 6X8MM LOPROFILE / LPLF-206,69169441,CDM,278,RC,C1726,HCPCS,Outpatient,,,2282.46,2282.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1369.48,60,,1095.58,percent of total billed charges,60% of total Billed charges for outpatient setting,1937.35,84.88,,1549.88,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1711.85,75,,1369.48,percent of total billed charges,75% of total billed charges for outpatient setting,1141.23,50,,912.98,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.07,12.84,,234.456,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1825.97,80,,1460.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.07,12.84,,234.46,percent of total billed charges,12.84% of total billed charges,293.07,12.84,,234.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2396.58,105,,1917.26,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.86,35,,639.09,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1369.48,60,,1095.58,percent of total billed charges,60% of total billed charges for outpatient setting,293.07,2396.58,
XTEND  AC PLATE 57MM / 161.357,69162827,CDM,278,RC,C1713,HCPCS,Outpatient,,,2350,2350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410,60,,1128,percent of total billed charges,60% of total Billed charges for outpatient setting,1994.68,84.88,,1595.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1762.5,75,,1410,percent of total billed charges,75% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1880,80,,1504,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2467.5,105,,1974,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.5,35,,658,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1410,60,,1128,percent of total billed charges,60% of total billed charges for outpatient setting,301.74,2467.5,
XTEND AC PLATE 10MM / 161.110,69162150,CDM,278,RC,,,Outpatient,,,4796,4796,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2877.6,60,,2302.08,percent of total billed charges,60% of total Billed charges for outpatient setting,4070.84,84.88,,3256.67,percent of total billed charges,84.88% of total billed charges for outpatient setting,2398,50,,1918.4,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3597,75,,2877.6,percent of total billed charges,75% of total billed charges for outpatient setting,2398,50,,1918.4,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.81,12.84,,492.648,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3836.8,80,,3069.44,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.81,12.84,,492.65,percent of total billed charges,12.84% of total billed charges,615.81,12.84,,492.65,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5035.8,105,,4028.64,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.6,35,,1342.88,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2877.6,60,,2302.08,percent of total billed charges,60% of total billed charges for outpatient setting,615.81,5035.8,
XTEND AC PLATE 12MM / 161.112,69161717,CDM,278,RC,,,Outpatient,,,3690.08,3690.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2214.05,60,,1771.24,percent of total billed charges,60% of total Billed charges for outpatient setting,3132.14,84.88,,2505.71,percent of total billed charges,84.88% of total billed charges for outpatient setting,1845.04,50,,1476.03,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2767.56,75,,2214.05,percent of total billed charges,75% of total billed charges for outpatient setting,1845.04,50,,1476.03,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.81,12.84,,379.048,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2952.06,80,,2361.65,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.81,12.84,,379.05,percent of total billed charges,12.84% of total billed charges,473.81,12.84,,379.05,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3874.58,105,,3099.66,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.53,35,,1033.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2214.05,60,,1771.24,percent of total billed charges,60% of total billed charges for outpatient setting,473.81,3874.58,
XTEND AC PLATE 16MM / 161.116,69161803,CDM,278,RC,,,Outpatient,,,2134,2134,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.4,60,,1024.32,percent of total billed charges,60% of total Billed charges for outpatient setting,1811.34,84.88,,1449.07,percent of total billed charges,84.88% of total billed charges for outpatient setting,1067,50,,853.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1600.5,75,,1280.4,percent of total billed charges,75% of total billed charges for outpatient setting,1067,50,,853.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.208,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.2,80,,1365.76,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,274.01,12.84,,219.21,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2240.7,105,,1792.56,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.9,35,,597.52,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1280.4,60,,1024.32,percent of total billed charges,60% of total billed charges for outpatient setting,274.01,2240.7,
XTEND AC PLATE 26MM / 161.226,69162181,CDM,278,RC,,,Outpatient,,,2150,2150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290,60,,1032,percent of total billed charges,60% of total Billed charges for outpatient setting,1824.92,84.88,,1459.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,1075,50,,860,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612.5,75,,1290,percent of total billed charges,75% of total billed charges for outpatient setting,1075,50,,860,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.06,12.84,,220.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720,80,,1376,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.06,12.84,,220.85,percent of total billed charges,12.84% of total billed charges,276.06,12.84,,220.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2257.5,105,,1806,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.5,35,,602,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1290,60,,1032,percent of total billed charges,60% of total billed charges for outpatient setting,276.06,2257.5,
XTEND AC PLATE 28MM / 161.228,69162026,CDM,278,RC,C1713,HCPCS,Outpatient,,,2940,2940,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1764,60,,1411.2,percent of total billed charges,60% of total Billed charges for outpatient setting,2495.47,84.88,,1996.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,75,,1764,percent of total billed charges,75% of total billed charges for outpatient setting,1470,50,,1176,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2352,80,,1881.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,377.5,12.84,,302,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3087,105,,2469.6,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1029,35,,823.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1764,60,,1411.2,percent of total billed charges,60% of total billed charges for outpatient setting,377.5,3087,
XTEND AC PLATE 30MM / 161.230,69161777,CDM,278,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
XTEND AC PLATE 32MM / 161.232,69162214,CDM,278,RC,,,Outpatient,,,3028.2,3028.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.92,60,,1453.54,percent of total billed charges,60% of total Billed charges for outpatient setting,2570.34,84.88,,2056.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2271.15,75,,1816.92,percent of total billed charges,75% of total billed charges for outpatient setting,1514.1,50,,1211.28,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.056,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.56,80,,1938.05,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,388.82,12.84,,311.06,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3179.61,105,,2543.69,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.87,35,,847.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1816.92,60,,1453.54,percent of total billed charges,60% of total billed charges for outpatient setting,388.82,3179.61,
XTEND AC PLATE 34MM / 161.234,69161797,CDM,278,RC,,,Outpatient,,,2150,2150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290,60,,1032,percent of total billed charges,60% of total Billed charges for outpatient setting,1824.92,84.88,,1459.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,1075,50,,860,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612.5,75,,1290,percent of total billed charges,75% of total billed charges for outpatient setting,1075,50,,860,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.06,12.84,,220.848,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720,80,,1376,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.06,12.84,,220.85,percent of total billed charges,12.84% of total billed charges,276.06,12.84,,220.85,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2257.5,105,,1806,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.5,35,,602,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1290,60,,1032,percent of total billed charges,60% of total billed charges for outpatient setting,276.06,2257.5,
XTEND AC PLATE 42MM / 161.342,69162099,CDM,278,RC,,,Outpatient,,,2350,2350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410,60,,1128,percent of total billed charges,60% of total Billed charges for outpatient setting,1994.68,84.88,,1595.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1762.5,75,,1410,percent of total billed charges,75% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1880,80,,1504,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2467.5,105,,1974,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.5,35,,658,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1410,60,,1128,percent of total billed charges,60% of total billed charges for outpatient setting,301.74,2467.5,
XTEND AC PLATE 45MM / 161.345,69161851,CDM,278,RC,,,Outpatient,,,2350,2350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410,60,,1128,percent of total billed charges,60% of total Billed charges for outpatient setting,1994.68,84.88,,1595.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1762.5,75,,1410,percent of total billed charges,75% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1880,80,,1504,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2467.5,105,,1974,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.5,35,,658,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1410,60,,1128,percent of total billed charges,60% of total billed charges for outpatient setting,301.74,2467.5,
XTEND AC PLATE 48MM / 161.348,69161739,CDM,278,RC,,,Outpatient,,,2350,2350,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410,60,,1128,percent of total billed charges,60% of total Billed charges for outpatient setting,1994.68,84.88,,1595.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1762.5,75,,1410,percent of total billed charges,75% of total billed charges for outpatient setting,1175,50,,940,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1880,80,,1504,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,301.74,12.84,,241.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2467.5,105,,1974,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.5,35,,658,percent of total billed charges,35% of total Billed charges for Outpatient Setting,1410,60,,1128,percent of total billed charges,60% of total billed charges for outpatient setting,301.74,2467.5,
XTEND PLATE 54MM / 161.354,69162251,CDM,278,RC,,,Outpatient,,,5130,5130,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3078,60,,2462.4,percent of total billed charges,60% of total Billed charges for outpatient setting,4354.34,84.88,,3483.47,percent of total billed charges,84.88% of total billed charges for outpatient setting,2565,50,,2052,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3847.5,75,,3078,percent of total billed charges,75% of total billed charges for outpatient setting,2565,50,,2052,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.69,12.84,,526.952,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4104,80,,3283.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.69,12.84,,526.95,percent of total billed charges,12.84% of total billed charges,658.69,12.84,,526.95,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5386.5,105,,4309.2,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1795.5,35,,1436.4,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3078,60,,2462.4,percent of total billed charges,60% of total billed charges for outpatient setting,658.69,5386.5,
XTEND PLATE 63MM / 161.463,69161947,CDM,278,RC,,,Outpatient,,,5404,5404,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3242.4,60,,2593.92,percent of total billed charges,60% of total Billed charges for outpatient setting,4586.92,84.88,,3669.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,2702,50,,2161.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4053,75,,3242.4,percent of total billed charges,75% of total billed charges for outpatient setting,2702,50,,2161.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.87,12.84,,555.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4323.2,80,,3458.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.87,12.84,,555.1,percent of total billed charges,12.84% of total billed charges,693.87,12.84,,555.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5674.2,105,,4539.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891.4,35,,1513.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3242.4,60,,2593.92,percent of total billed charges,60% of total billed charges for outpatient setting,693.87,5674.2,
XTEND PLATE 69MM / 161.469,69162078,CDM,278,RC,,,Outpatient,,,5404,5404,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3242.4,60,,2593.92,percent of total billed charges,60% of total Billed charges for outpatient setting,4586.92,84.88,,3669.54,percent of total billed charges,84.88% of total billed charges for outpatient setting,2702,50,,2161.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4053,75,,3242.4,percent of total billed charges,75% of total billed charges for outpatient setting,2702,50,,2161.6,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.87,12.84,,555.096,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4323.2,80,,3458.56,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.87,12.84,,555.1,percent of total billed charges,12.84% of total billed charges,693.87,12.84,,555.1,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5674.2,105,,4539.36,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891.4,35,,1513.12,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3242.4,60,,2593.92,percent of total billed charges,60% of total billed charges for outpatient setting,693.87,5674.2,
XTEND SCREW 4.6 x 14MM  ST 171.314,69161852,CDM,278,RC,,,Outpatient,,,1559.52,1559.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.71,60,,748.57,percent of total billed charges,60% of total Billed charges for outpatient setting,1323.72,84.88,,1058.98,percent of total billed charges,84.88% of total billed charges for outpatient setting,779.76,50,,623.81,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1169.64,75,,935.71,percent of total billed charges,75% of total billed charges for outpatient setting,779.76,50,,623.81,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.24,12.84,,160.192,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.62,80,,998.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.24,12.84,,160.19,percent of total billed charges,12.84% of total billed charges,200.24,12.84,,160.19,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1559.52,65,,1247.62,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.83,35,,436.66,percent of total billed charges,35% of total Billed charges for Outpatient Setting,935.71,60,,748.57,percent of total billed charges,60% of total billed charges for outpatient setting,200.24,1559.52,
XTEND SCREW 4.6 x16MM   171.016,69161796,CDM,278,RC,,,Outpatient,,,1514.1,1514.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,908.46,60,,726.77,percent of total billed charges,60% of total Billed charges for outpatient setting,1285.17,84.88,,1028.14,percent of total billed charges,84.88% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1135.58,75,,908.46,percent of total billed charges,75% of total billed charges for outpatient setting,757.05,50,,605.64,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.528,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.28,80,,969.02,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,194.41,12.84,,155.53,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,1514.1,65,,1211.28,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.94,35,,423.95,percent of total billed charges,35% of total Billed charges for Outpatient Setting,908.46,60,,726.77,percent of total billed charges,60% of total billed charges for outpatient setting,194.41,1514.1,
XTENDOBUTTON 6-10MM FIX DVCE/ 72200134,69169264,CDM,278,RC,,,Outpatient,,,625.8,625.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.48,60,,300.38,percent of total billed charges,60% of total Billed charges for outpatient setting,531.18,84.88,,424.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,312.9,50,,250.32,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.35,75,,375.48,percent of total billed charges,75% of total billed charges for outpatient setting,312.9,50,,250.32,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.35,12.84,,64.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.64,80,,400.51,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.35,12.84,,64.28,percent of total billed charges,12.84% of total billed charges,80.35,12.84,,64.28,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,625.8,65,,500.64,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.03,35,,175.22,percent of total billed charges,35% of total Billed charges for Outpatient Setting,375.48,60,,300.38,percent of total billed charges,60% of total billed charges for outpatient setting,80.35,625.8,
YANKAUER BULB TIP SUCTION / K86,6150458,CDM,270,RC,,,Outpatient,,,3.38,3.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,70,,1.9,percent of total billed charges,70% of total billed charges for outpatient setting,2.87,84.88,,2.3,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.69,50,,1.35,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.54,75,,2.03,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,70,,1.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.344,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,80,,2.16,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.43,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.2,65,,1.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,35,,0.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.04,90,,2.43,percent of total billed charges,90% of total billed charges for outpatient setting,0.43,3.04,
ZAFIRLUKAST (ACCOLATE) TAB: 20 MG,3302185,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
ZANTAC (RANITIDINE)25MG/ML INJ:6ML,3302629,CDM,250,RC,,,Outpatient,,,48.99,48.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,84.88,,33.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.74,75,,29.39,percent of total billed charges,75% of total billed charges for outpatient setting,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.19,80,,31.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.84,65,,25.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.09,90,,35.27,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.09,
ZANTAC 75 MG/5ML SYRP: 480ML,3302632,CDM,259,RC,,,Outpatient,,,4.54,4.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,84.88,,3.08,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.27,50,,1.82,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.41,75,,2.73,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,70,,2.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.464,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,80,,2.9,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,0.58,12.84,,0.46,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.95,65,,2.36,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.59,35,,1.27,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.09,90,,3.27,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,4.09,
ZANTAC(RANITIDINE)25MG/ML: 50MG,3302630,CDM,250,RC,,,Outpatient,,,48.99,48.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,84.88,,33.26,percent of total billed charges,84.88% of total billed charges for outpatient setting,24.5,50,,19.6,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.74,75,,29.39,percent of total billed charges,75% of total billed charges for outpatient setting,34.29,70,,27.43,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.032,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.19,80,,31.35,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,6.29,12.84,,5.03,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,31.84,65,,25.47,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.15,35,,13.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,44.09,90,,35.27,percent of total billed charges,90% of total billed charges for outpatient setting,6.29,44.09,
ZARONTIN,220033,CDM,300,RC,80168,HCPCS,Outpatient,,,73.53,66.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.47,70,,41.18,percent of total billed charges,70% of total billed charges for outpatient setting,62.41,84.88,,49.93,percent of total billed charges,84.88% of total billed charges for outpatient setting,28.05,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,55.15,75,,44.12,percent of total billed charges,75% of total billed charges for outpatient setting,51.47,70,,41.18,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.82,80,,47.06,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,23.86,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,100,,,Fee Schedule,100% of Custom Fee Schedule,66.18,90,,52.94,percent of total billed charges,90% of total billed charges for outpatient setting,16.34,66.18,
zDILTIAZEM (CARDIZEM) INJ 5MG/ML 5ML,3300926,CDM,250,RC,,,Outpatient,,,15.13,15.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.59,70,,8.47,percent of total billed charges,70% of total billed charges for outpatient setting,12.84,84.88,,10.27,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.57,50,,6.06,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.35,75,,9.08,percent of total billed charges,75% of total billed charges for outpatient setting,10.59,70,,8.47,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.552,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,80,,9.68,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,1.94,12.84,,1.55,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,9.83,65,,7.86,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.3,35,,4.24,percent of total billed charges,35% of total Billed charges for Outpatient Setting,13.62,90,,10.9,percent of total billed charges,90% of total billed charges for outpatient setting,1.94,13.62,
ZEPHYR DR PACEMAKER / 5826,69161678,CDM,278,RC,C1785,HCPCS,Outpatient,,,8500,8500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5100,60,,4080,percent of total billed charges,60% of total Billed charges for outpatient setting,7214.8,84.88,,5771.84,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6375,75,,5100,percent of total billed charges,75% of total billed charges for outpatient setting,4250,50,,3400,percent of total billed charges,50% of total billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.4,12.84,,873.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6800,80,,5440,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1091.4,12.84,,873.12,percent of total billed charges,12.84% of total billed charges,1091.4,12.84,,873.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,8925,105,,7140,percent of total billed charges,105% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2975,35,,2380,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5100,60,,4080,percent of total billed charges,60% of total billed charges for outpatient setting,1091.4,8925,
ZETIA: 10 MG TAB,3303130,CDM,259,RC,,,Outpatient,,,36.66,36.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.66,70,,20.53,percent of total billed charges,70% of total billed charges for outpatient setting,31.12,84.88,,24.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,18.33,50,,14.66,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.5,75,,22,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,70,,20.53,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.768,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.33,80,,23.46,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,4.71,12.84,,3.77,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,23.83,65,,19.06,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.83,35,,10.26,percent of total billed charges,35% of total Billed charges for Outpatient Setting,32.99,90,,26.39,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,32.99,
ZILEUTON (ZYFLO) TAB: 600 MG,3302186,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ZINC 1 MG/ML : 10 ML VIAL,3303247,CDM,250,RC,,,Outpatient,,,28.05,28.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.64,70,,15.71,percent of total billed charges,70% of total billed charges for outpatient setting,23.81,84.88,,19.05,percent of total billed charges,84.88% of total billed charges for outpatient setting,14.03,50,,11.22,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.04,75,,16.83,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,70,,15.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.44,80,,17.95,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,3.6,12.84,,2.88,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,18.23,65,,14.58,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.82,35,,7.86,percent of total billed charges,35% of total Billed charges for Outpatient Setting,25.25,90,,20.2,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,25.25,
ZINC GLUCONATE 50MG: TAB,3303106,CDM,259,RC,,,Outpatient,,,11.7,11.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,84.88,,7.94,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.85,50,,4.68,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.78,75,,7.02,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,70,,6.55,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,80,,7.49,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,1.5,12.84,,1.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.61,65,,6.09,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.1,35,,3.28,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.53,90,,8.42,percent of total billed charges,90% of total billed charges for outpatient setting,1.5,10.53,
ZINC OXIDE (DESITIN) OINT : 60GM,3302189,CDM,259,RC,,,Outpatient,,,8.62,8.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,7.32,84.88,,5.86,percent of total billed charges,84.88% of total billed charges for outpatient setting,4.31,50,,3.45,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.47,75,,5.18,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,70,,4.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.888,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.9,80,,5.52,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,1.11,12.84,,0.89,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,5.6,65,,4.48,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.02,35,,2.42,percent of total billed charges,35% of total Billed charges for Outpatient Setting,7.76,90,,6.21,percent of total billed charges,90% of total billed charges for outpatient setting,1.11,7.76,
ZINC OXIDE OINT : 60GM,3302188,CDM,259,RC,,,Outpatient,,,4.04,4.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,84.88,,2.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.02,50,,1.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.03,75,,2.42,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,70,,2.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.416,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,80,,2.58,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,0.52,12.84,,0.42,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.63,65,,2.1,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,35,,1.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3.64,90,,2.91,percent of total billed charges,90% of total billed charges for outpatient setting,0.52,3.64,
ZINC OXIDE OINT 30 GM,3302187,CDM,259,RC,,,Outpatient,,,4.84,4.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,70,,2.71,percent of total billed charges,70% of total billed charges for outpatient setting,4.11,84.88,,3.29,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.42,50,,1.94,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.63,75,,2.9,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,70,,2.71,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,80,,3.1,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,0.62,12.84,,0.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.15,65,,2.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.69,35,,1.35,percent of total billed charges,35% of total Billed charges for Outpatient Setting,4.36,90,,3.49,percent of total billed charges,90% of total billed charges for outpatient setting,0.62,4.36,
ZINC SULFATE 220MG CAP,3302190,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
"ZINC,PLASMA",220908,CDM,301,RC,84630,HCPCS,Outpatient,,,51.26,46.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,43.51,84.88,,34.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.45,75,,30.76,percent of total billed charges,75% of total billed charges for outpatient setting,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.01,80,,32.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,100% of Custom Fee Schedule,46.13,90,,36.9,percent of total billed charges,90% of total billed charges for outpatient setting,11.39,46.13,
"ZINC,WHOLE BLOOD",220061,CDM,301,RC,84630,HCPCS,Outpatient,,,51.26,46.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,43.51,84.88,,34.81,percent of total billed charges,84.88% of total billed charges for outpatient setting,19.55,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,38.45,75,,30.76,percent of total billed charges,75% of total billed charges for outpatient setting,35.88,70,,28.7,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.01,80,,32.81,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,16.63,100,,,Fee Schedule,Pays at 100% of Custom Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,100% of Custom Fee Schedule,46.13,90,,36.9,percent of total billed charges,90% of total billed charges for outpatient setting,11.39,46.13,
ZIP 16CM SURGICAL SKIN CLOSURE / PS1160,69169759,CDM,272,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,509.28,84.88,,407.42,percent of total billed charges,84.88% of total billed charges for outpatient setting,300,50,,240,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,75,,360,percent of total billed charges,75% of total billed charges for outpatient setting,420,70,,336,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.632,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,80,,384,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,77.04,12.84,,61.63,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,390,65,,312,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,35,,168,percent of total billed charges,35% of total Billed charges for Outpatient Setting,540,90,,432,percent of total billed charges,90% of total billed charges for outpatient setting,77.04,540,
ZIP 24CM SURGICAL SKIN CLOSURE / PS1240,70000442,CDM,272,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,70,,246.4,percent of total billed charges,70% of total billed charges for outpatient setting,373.47,84.88,,298.78,percent of total billed charges,84.88% of total billed charges for outpatient setting,220,50,,176,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330,75,,264,percent of total billed charges,75% of total billed charges for outpatient setting,308,70,,246.4,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352,80,,281.6,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,56.5,12.84,,45.2,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,286,65,,228.8,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154,35,,123.2,percent of total billed charges,35% of total Billed charges for Outpatient Setting,396,90,,316.8,percent of total billed charges,90% of total billed charges for outpatient setting,56.5,396,
ZIP 8CM SURGICAL SKIN CLOSURE / PS2080,69169758,CDM,272,RC,,,Outpatient,,,273,273,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.1,70,,152.88,percent of total billed charges,70% of total billed charges for outpatient setting,231.72,84.88,,185.38,percent of total billed charges,84.88% of total billed charges for outpatient setting,136.5,50,,109.2,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.75,75,,163.8,percent of total billed charges,75% of total billed charges for outpatient setting,191.1,70,,152.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,80,,174.72,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,35.05,12.84,,28.04,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,177.45,65,,141.96,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.55,35,,76.44,percent of total billed charges,35% of total Billed charges for Outpatient Setting,245.7,90,,196.56,percent of total billed charges,90% of total billed charges for outpatient setting,35.05,245.7,
ZIPRASIDONE(GEODON) 20 MG: CAP,3302821,CDM,259,RC,,,Outpatient,,,20.62,20.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.43,70,,11.54,percent of total billed charges,70% of total billed charges for outpatient setting,17.5,84.88,,14,percent of total billed charges,84.88% of total billed charges for outpatient setting,10.31,50,,8.25,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.47,75,,12.38,percent of total billed charges,75% of total billed charges for outpatient setting,14.43,70,,11.54,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.5,80,,13.2,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,2.65,12.84,,2.12,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,13.4,65,,10.72,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,35,,5.78,percent of total billed charges,35% of total Billed charges for Outpatient Setting,18.56,90,,14.85,percent of total billed charges,90% of total billed charges for outpatient setting,2.65,18.56,
ZIPRASIDONE(GEODON) CAP: 20MG,3303779,CDM,250,RC,,,Outpatient,,,23.17,23.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.22,70,,12.98,percent of total billed charges,70% of total billed charges for outpatient setting,19.67,84.88,,15.74,percent of total billed charges,84.88% of total billed charges for outpatient setting,11.59,50,,9.27,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.38,75,,13.9,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,70,,12.98,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.384,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.54,80,,14.83,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,2.98,12.84,,2.38,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,15.06,65,,12.05,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.11,35,,6.49,percent of total billed charges,35% of total Billed charges for Outpatient Setting,20.85,90,,16.68,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,20.85,
ZIPWIRE .025IN STRAIGHT / M0066802011,1260317,CDM,272,RC,C1769,HCPCS,Outpatient,,,178.35,178.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.85,70,,99.88,percent of total billed charges,70% of total billed charges for outpatient setting,151.38,84.88,,121.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.76,75,,107.01,percent of total billed charges,75% of total billed charges for outpatient setting,124.85,70,,99.88,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.9,12.84,,18.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.68,80,,114.14,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.9,12.84,,18.32,percent of total billed charges,12.84% of total billed charges,22.9,12.84,,18.32,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.93,65,,92.74,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.42,35,,49.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.52,90,,128.42,percent of total billed charges,90% of total billed charges for outpatient setting,22.9,160.52,
ZIPWIRE .035 STRAIGHT TIP / 630-205B1,69161616,CDM,272,RC,,,Outpatient,,,177.92,177.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.54,70,,99.63,percent of total billed charges,70% of total billed charges for outpatient setting,151.02,84.88,,120.82,percent of total billed charges,84.88% of total billed charges for outpatient setting,88.96,50,,71.17,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.44,75,,106.75,percent of total billed charges,75% of total billed charges for outpatient setting,124.54,70,,99.63,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,12.84,,18.272,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.34,80,,113.87,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,12.84,,18.27,percent of total billed charges,12.84% of total billed charges,22.84,12.84,,18.27,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,115.65,65,,92.52,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.27,35,,49.82,percent of total billed charges,35% of total Billed charges for Outpatient Setting,160.13,90,,128.1,percent of total billed charges,90% of total billed charges for outpatient setting,22.84,160.13,
ZIPWIRE .038 ANGLED / 630-209B,69160859,CDM,272,RC,,,Outpatient,,,187.27,187.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.09,70,,104.87,percent of total billed charges,70% of total billed charges for outpatient setting,158.95,84.88,,127.16,percent of total billed charges,84.88% of total billed charges for outpatient setting,93.64,50,,74.91,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.45,75,,112.36,percent of total billed charges,75% of total billed charges for outpatient setting,131.09,70,,104.87,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,12.84,,19.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.82,80,,119.86,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,12.84,,19.24,percent of total billed charges,12.84% of total billed charges,24.05,12.84,,19.24,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,121.73,65,,97.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,35,,52.43,percent of total billed charges,35% of total Billed charges for Outpatient Setting,168.54,90,,134.83,percent of total billed charges,90% of total billed charges for outpatient setting,24.05,168.54,
ZIPWIRE .038 STRAIGHT TIP / M0066802081,69160731,CDM,272,RC,,,Outpatient,,,169.45,169.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.62,70,,94.9,percent of total billed charges,70% of total billed charges for outpatient setting,143.83,84.88,,115.06,percent of total billed charges,84.88% of total billed charges for outpatient setting,84.73,50,,67.78,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.09,75,,101.67,percent of total billed charges,75% of total billed charges for outpatient setting,118.62,70,,94.9,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,12.84,,17.408,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.56,80,,108.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.76,12.84,,17.41,percent of total billed charges,12.84% of total billed charges,21.76,12.84,,17.41,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,110.14,65,,88.11,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.31,35,,47.45,percent of total billed charges,35% of total Billed charges for Outpatient Setting,152.51,90,,122.01,percent of total billed charges,90% of total billed charges for outpatient setting,21.76,152.51,
ZITHROMAX LIQ 200MG/5ML: 22.500ML,3302537,CDM,259,RC,,,Outpatient,,,89.76,89.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.83,70,,50.26,percent of total billed charges,70% of total billed charges for outpatient setting,76.19,84.88,,60.95,percent of total billed charges,84.88% of total billed charges for outpatient setting,44.88,50,,35.9,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,75,,53.86,percent of total billed charges,75% of total billed charges for outpatient setting,62.83,70,,50.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,12.84,,9.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.81,80,,57.45,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,11.53,12.84,,9.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,58.34,65,,46.67,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,35,,25.14,percent of total billed charges,35% of total Billed charges for Outpatient Setting,80.78,90,,64.62,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,80.78,
ZOLEDRONIC ACID (ZOMETA)4MG/5ML:SDV,3303041,CDM,636,RC,J3487,HCPCS,Outpatient,,,4266.85,4266.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2986.8,70,,2389.44,percent of total billed charges,70% of total billed charges for outpatient setting,3621.7,84.88,,2897.36,percent of total billed charges,84.88% of total billed charges for outpatient setting,2133.43,50,,1706.74,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3200.14,75,,2560.11,percent of total billed charges,75% of total billed charges for outpatient setting,2000,70,,1600,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,547.86,12.84,,438.288,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3413.48,80,,2730.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,547.86,12.84,,438.29,percent of total billed charges,12.84% of total billed charges,547.86,12.84,,438.29,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2773.45,65,,2218.76,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1493.4,35,,1194.72,percent of total billed charges,35% of total Billed charges for Outpatient Setting,3840.17,90,,3072.14,percent of total billed charges,90% of total billed charges for outpatient setting,547.86,3840.17,
ZOLEDRONIC ACID INJ. 5MG/100ML 1MG/UNIT,3308106,CDM,636,RC,J3489,HCPCS,Outpatient,,,31.42,31.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,26.67,84.88,,21.34,percent of total billed charges,84.88% of total billed charges for outpatient setting,7.3,139.08,,,Fee Schedule,139.08% of BCBS Custom fee Schedule,,,,,Other,Not Separately reimbursable,23.57,75,,18.86,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,70,,17.59,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,12.84,,3.224,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.14,80,,20.11,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.03,12.84,,3.22,percent of total billed charges,12.84% of total billed charges,4.03,12.84,,3.22,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,20.42,65,,16.34,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of Custom Fee Schedule,28.28,90,,22.62,percent of total billed charges,90% of total billed charges for outpatient setting,4.03,28.28,
ZOLPIDEM TAR (AMBIEN) TAB: 5 MG,3302191,CDM,259,RC,,,Outpatient,,,11.47,11.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,9.74,84.88,,7.79,percent of total billed charges,84.88% of total billed charges for outpatient setting,5.74,50,,4.59,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.6,75,,6.88,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,70,,6.42,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.176,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,80,,7.34,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,1.47,12.84,,1.18,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,65,,5.97,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.01,35,,3.21,percent of total billed charges,35% of total Billed charges for Outpatient Setting,10.32,90,,8.26,percent of total billed charges,90% of total billed charges for outpatient setting,1.47,10.32,
ZOLPIDEM TAR (genericAMBIEN) 10MG TAB,3303068,CDM,259,RC,,,Outpatient,,,3.24,3.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,84.88,,2.2,percent of total billed charges,84.88% of total billed charges for outpatient setting,1.62,50,,1.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.43,75,,1.94,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,70,,1.82,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.336,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,80,,2.07,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,0.42,12.84,,0.34,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,2.11,65,,1.69,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,35,,0.9,percent of total billed charges,35% of total Billed charges for Outpatient Setting,2.92,90,,2.34,percent of total billed charges,90% of total billed charges for outpatient setting,0.42,2.92,
ZONISAMIDE (ZONEGRAN) CAP: 100 MG,3302192,CDM,259,RC,,,Outpatient,,,5.74,5.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.02,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,4.87,84.88,,3.9,percent of total billed charges,84.88% of total billed charges for outpatient setting,2.87,50,,2.3,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.31,75,,3.45,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,70,,3.22,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.592,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.59,80,,3.67,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,0.74,12.84,,0.59,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,3.73,65,,2.98,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.01,35,,1.61,percent of total billed charges,35% of total Billed charges for Outpatient Setting,5.17,90,,4.14,percent of total billed charges,90% of total billed charges for outpatient setting,0.74,5.17,
zPRECEDEX (DEXMEDETOMIDINE)100MCG/ML:2ML,3303209,CDM,250,RC,,,Outpatient,,,246.89,246.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.82,70,,138.26,percent of total billed charges,70% of total billed charges for outpatient setting,209.56,84.88,,167.65,percent of total billed charges,84.88% of total billed charges for outpatient setting,123.45,50,,98.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.17,75,,148.14,percent of total billed charges,75% of total billed charges for outpatient setting,172.82,70,,138.26,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.51,80,,158.01,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,31.7,12.84,,25.36,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,160.48,65,,128.38,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.41,35,,69.13,percent of total billed charges,35% of total Billed charges for Outpatient Setting,222.2,90,,177.76,percent of total billed charges,90% of total billed charges for outpatient setting,31.7,222.2,
ZSODIUM POLY SULF LIQ 15GM/60ML : 60ML,3302005,CDM,259,RC,,,Outpatient,,,18.14,18.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.7,70,,10.16,percent of total billed charges,70% of total billed charges for outpatient setting,15.4,84.88,,12.32,percent of total billed charges,84.88% of total billed charges for outpatient setting,9.07,50,,7.26,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.61,75,,10.89,percent of total billed charges,75% of total billed charges for outpatient setting,12.7,70,,10.16,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.864,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.51,80,,11.61,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,2.33,12.84,,1.86,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,11.79,65,,9.43,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.35,35,,5.08,percent of total billed charges,35% of total Billed charges for Outpatient Setting,16.33,90,,13.06,percent of total billed charges,90% of total billed charges for outpatient setting,2.33,16.33,
ZYMAR (GATIFLOXACIN)0.3%: OPTH SOLN,3303226,CDM,259,RC,,,Outpatient,,,256.9,256.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.83,70,,143.86,percent of total billed charges,70% of total billed charges for outpatient setting,218.06,84.88,,174.45,percent of total billed charges,84.88% of total billed charges for outpatient setting,128.45,50,,102.76,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.68,75,,154.14,percent of total billed charges,75% of total billed charges for outpatient setting,179.83,70,,143.86,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.392,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.52,80,,164.42,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,32.99,12.84,,26.39,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,166.99,65,,133.59,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.92,35,,71.94,percent of total billed charges,35% of total Billed charges for Outpatient Setting,231.21,90,,184.97,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,231.21,
ZYRTEC LIQ. 1MG/ML: CETIRIZINE,3302706,CDM,259,RC,,,Outpatient,,,34.03,34.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.82,70,,19.06,percent of total billed charges,70% of total billed charges for outpatient setting,28.88,84.88,,23.1,percent of total billed charges,84.88% of total billed charges for outpatient setting,17.02,50,,13.62,percent of total billed charges,50% of total Billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.52,75,,20.42,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,70,,19.06,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,12.84,,3.496,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.22,80,,21.78,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,12.84,,3.5,percent of total billed charges,12.84% of total billed charges,4.37,12.84,,3.5,percent of total billed charges,12.84% of total billed charges,,,,,Other,Not Separately reimbursable,22.12,65,,17.7,percent of total billed charges,65% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,35,,9.53,percent of total billed charges,35% of total Billed charges for Outpatient Setting,30.63,90,,24.5,percent of total billed charges,90% of total billed charges for outpatient setting,4.37,30.63,
HOSPICE RESPITE,100000,CDM,101,RC,,,Inpatient,,,500,500,,,,,,other,Custom DRG with base of 7000,,,,,other,100% of Medicare CMS New Technology,500,100,,,per diem,"Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",424.4,84.88,,339.52,percent of total billed charges,84.88% of total billed charges,,,,,other,CMS Custom DRG with base rate of 7072,,,,,other,100% of Medicare CMS New Technology,,,,,per diem,Per day rate of 1200 for med/surg DRGs,,,,,per diem,Per day rate of 1093 for Inpatient rev codes,,,,,other,170% of Medicare CMS New Technology,,,,,per diem,"per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs",,,,,per diem,per day rate of 1173.72 ,,,,,other,175% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,400,80,,320,percent of total billed charges,80% of total billed charges,,,,,other,140% of Medicare CMS New Technology,,,,,other,125% of Medicare CMS New Technology,,,,,per diem,per day rate of 1173.72 ,,,,,per diem,per day rate of 1173.72 ,,,,,other,100% of Medicare CMS New Technology,3259,100,,,case rate,rate of 3259 for one day stays with rev code 100-214,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,200,40,,160,percent of total billed charges,40% of total billed charges,,,,,per diem,"per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs",200,3259,
HOSPICE INPATIENT,100001,CDM,101,RC,,,Inpatient,,,1000,1000,,,,,,other,Custom DRG with base of 7000,,,,,other,100% of Medicare CMS New Technology,1000,100,,,per diem,"Per day rate of 892.50 for Med DRGS, and 1406 for Surg DRGs",848.8,84.88,,679.04,percent of total billed charges,84.88% of total billed charges,,,,,other,CMS Custom DRG with base rate of 7072,,,,,other,100% of Medicare CMS New Technology,,,,,per diem,Per day rate of 1200 for med/surg DRGs,,,,,per diem,Per day rate of 1093 for Inpatient rev codes,,,,,other,170% of Medicare CMS New Technology,,,,,per diem,"per day rate of 1120 for Med DRGS, and 1370 for Surg DRGs",,,,,per diem,per day rate of 1173.72 ,,,,,other,175% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,800,80,,640,percent of total billed charges,80% of total billed charges,,,,,other,140% of Medicare CMS New Technology,,,,,other,125% of Medicare CMS New Technology,,,,,per diem,per day rate of 1173.72 ,,,,,per diem,per day rate of 1173.72 ,,,,,other,100% of Medicare CMS New Technology,3259,100,,,case rate,rate of 3259 for one day stays with rev code 100-214,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,,,,,other,100% of Medicare CMS New Technology,400,40,,320,percent of total billed charges,40% of total billed charges,,,,,per diem,"per day rate of 1050 for Med DRGs, and 1654 for Surg DRGs",400,3259,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,inpatient,,,,,,197022.7,100,MS-DRG,157618.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,167311.87,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,284430.18,170,MS-DRG,227544.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,292795.77,175,MS-DRG,234236.616,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,234236.62,140,MS-DRG,187389.3,other,140% of Medicare CMS MS-DRG,209139.84,125,MS-DRG,167311.87,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,167311.87,100,MS-DRG,133849.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,167311.87,292795.77,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,inpatient,,,,,,94311.7,100,MS-DRG,75449.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,75597.38,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,128515.55,170,MS-DRG,102812.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,132295.42,175,MS-DRG,105836.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,105836.33,140,MS-DRG,84669.06,other,140% of Medicare CMS MS-DRG,94496.73,125,MS-DRG,75597.38,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,75597.38,100,MS-DRG,60477.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75597.38,132295.42,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,inpatient,,,,,,141659.7,100,MS-DRG,113327.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,131635.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,223780.44,170,MS-DRG,179024.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,230362.21,175,MS-DRG,184289.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,184289.77,140,MS-DRG,147431.82,other,140% of Medicare CMS MS-DRG,164544.44,125,MS-DRG,131635.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,131635.55,100,MS-DRG,105308.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,131635.55,230362.21,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,inpatient,,,,,,96121.9,100,MS-DRG,76897.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,90760.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,154292.97,170,MS-DRG,123434.376,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,158831,175,MS-DRG,127064.8,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,127064.8,140,MS-DRG,101651.84,other,140% of Medicare CMS MS-DRG,113450.71,125,MS-DRG,90760.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,90760.57,100,MS-DRG,72608.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,90760.57,158831,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,inpatient,,,,,,79849,100,MS-DRG,63879.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,63902.85,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,108634.85,170,MS-DRG,86907.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,111829.99,175,MS-DRG,89463.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,89463.99,140,MS-DRG,71571.19,other,140% of Medicare CMS MS-DRG,79878.56,125,MS-DRG,63902.85,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,63902.85,100,MS-DRG,51122.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63902.85,111829.99,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,inpatient,,,,,,33665.1,100,MS-DRG,26932.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29863.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50768.68,170,MS-DRG,40614.944,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52261.88,175,MS-DRG,41809.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,41809.5,140,MS-DRG,33447.6,other,140% of Medicare CMS MS-DRG,37329.91,125,MS-DRG,29863.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,29863.93,100,MS-DRG,23891.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29863.93,52261.88,
LUNG TRANSPLANT,7,MS-DRG,,,,,inpatient,,,,,,85451.1,100,MS-DRG,68360.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,75735.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,128749.6,170,MS-DRG,102999.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,132536.36,175,MS-DRG,106029.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,106029.08,140,MS-DRG,84823.26,other,140% of Medicare CMS MS-DRG,94668.83,125,MS-DRG,75735.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75735.06,132536.36,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,inpatient,,,,,,39137.7,100,MS-DRG,31310.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,32486.73,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,55227.44,170,MS-DRG,44181.952,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,56851.78,175,MS-DRG,45481.424,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,45481.42,140,MS-DRG,36385.14,other,140% of Medicare CMS MS-DRG,40608.41,125,MS-DRG,32486.73,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,32486.73,100,MS-DRG,25989.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32486.73,56851.78,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,inpatient,,,,,,29027.6,100,MS-DRG,23222.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29720.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50524.12,170,MS-DRG,40419.296,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52010.12,175,MS-DRG,41608.096,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,41608.1,140,MS-DRG,33286.48,other,140% of Medicare CMS MS-DRG,37150.09,125,MS-DRG,29720.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,29720.07,100,MS-DRG,23776.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29027.6,52010.12,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,inpatient,,,,,,36156.4,100,MS-DRG,28925.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,31835.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54121.15,170,MS-DRG,43296.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,55712.95,175,MS-DRG,44570.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,44570.36,140,MS-DRG,35656.29,other,140% of Medicare CMS MS-DRG,39794.96,125,MS-DRG,31835.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,31835.97,100,MS-DRG,25468.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31835.97,55712.95,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,inpatient,,,,,,27366.5,100,MS-DRG,21893.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24727.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42035.92,170,MS-DRG,33628.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43272.27,175,MS-DRG,34617.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34617.81,140,MS-DRG,27694.25,other,140% of Medicare CMS MS-DRG,30908.76,125,MS-DRG,24727.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,24727.01,100,MS-DRG,19781.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24727.01,43272.27,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,inpatient,,,,,,19798.1,100,MS-DRG,15838.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16582.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28189.43,170,MS-DRG,22551.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29018.54,175,MS-DRG,23214.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23214.83,140,MS-DRG,18571.86,other,140% of Medicare CMS MS-DRG,20727.53,125,MS-DRG,16582.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,16582.02,100,MS-DRG,13265.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16582.02,29018.54,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,inpatient,,,,,,78351,100,MS-DRG,62680.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,70761.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,120294.99,170,MS-DRG,96235.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,123833.08,175,MS-DRG,99066.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,99066.46,140,MS-DRG,79253.17,other,140% of Medicare CMS MS-DRG,88452.2,125,MS-DRG,70761.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,70761.76,100,MS-DRG,56609.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,70761.76,123833.08,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,inpatient,,,,,,42590.8,100,MS-DRG,34072.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,38137.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64834.55,170,MS-DRG,51867.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66741.45,175,MS-DRG,53393.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53393.16,140,MS-DRG,42714.53,other,140% of Medicare CMS MS-DRG,47672.46,125,MS-DRG,38137.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38137.97,66741.45,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,inpatient,,,,,,30590.7,100,MS-DRG,24472.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,38137.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64834.55,170,MS-DRG,51867.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66741.45,175,MS-DRG,53393.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53393.16,140,MS-DRG,42714.53,other,140% of Medicare CMS MS-DRG,47672.46,125,MS-DRG,38137.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,38137.97,100,MS-DRG,30510.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30590.7,66741.45,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,inpatient,,,,,,253016.4,100,MS-DRG,202413.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,227473.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,386705.43,170,MS-DRG,309364.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,398079.12,175,MS-DRG,318463.296,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,318463.29,140,MS-DRG,254770.63,other,140% of Medicare CMS MS-DRG,284342.23,125,MS-DRG,227473.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,227473.78,100,MS-DRG,181979.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,227473.78,398079.12,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,inpatient,,,,,,49942.2,100,MS-DRG,39953.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,49353.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,83900.73,170,MS-DRG,67120.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,86368.4,175,MS-DRG,69094.72,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,69094.72,140,MS-DRG,55275.78,other,140% of Medicare CMS MS-DRG,61691.71,125,MS-DRG,49353.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,49353.37,100,MS-DRG,39482.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,49353.37,86368.4,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,inpatient,,,,,,65123.1,100,MS-DRG,52098.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,52186.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,88717.41,170,MS-DRG,70973.928,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,91326.74,175,MS-DRG,73061.392,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,73061.39,140,MS-DRG,58449.11,other,140% of Medicare CMS MS-DRG,65233.39,125,MS-DRG,52186.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,52186.71,100,MS-DRG,41749.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52186.71,91326.74,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,inpatient,,,,,,47524.4,100,MS-DRG,38019.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37918.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64460.87,170,MS-DRG,51568.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66356.78,175,MS-DRG,53085.424,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53085.42,140,MS-DRG,42468.34,other,140% of Medicare CMS MS-DRG,47397.7,125,MS-DRG,37918.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,37918.16,100,MS-DRG,30334.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37918.16,66356.78,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,inpatient,,,,,,30509.5,100,MS-DRG,24407.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24219.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41173.13,170,MS-DRG,32938.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42384.11,175,MS-DRG,33907.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33907.29,140,MS-DRG,27125.83,other,140% of Medicare CMS MS-DRG,30274.36,125,MS-DRG,24219.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,24219.49,100,MS-DRG,19375.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24219.49,42384.11,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,inpatient,,,,,,40119.8,100,MS-DRG,32095.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,35000.24,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59500.41,170,MS-DRG,47600.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,61250.42,175,MS-DRG,49000.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,49000.34,140,MS-DRG,39200.27,other,140% of Medicare CMS MS-DRG,43750.3,125,MS-DRG,35000.24,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,35000.24,100,MS-DRG,28000.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35000.24,61250.42,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,inpatient,,,,,,27641.6,100,MS-DRG,22113.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23392.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39767.69,170,MS-DRG,31814.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40937.33,175,MS-DRG,32749.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32749.86,140,MS-DRG,26199.89,other,140% of Medicare CMS MS-DRG,29240.95,125,MS-DRG,23392.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,23392.76,100,MS-DRG,18714.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23392.76,40937.33,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,inpatient,,,,,,31783.5,100,MS-DRG,25426.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27265.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46350.87,170,MS-DRG,37080.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47714.14,175,MS-DRG,38171.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38171.31,140,MS-DRG,30537.05,other,140% of Medicare CMS MS-DRG,34081.53,125,MS-DRG,27265.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,27265.22,100,MS-DRG,21812.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27265.22,47714.14,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,inpatient,,,,,,21164.5,100,MS-DRG,16931.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18233,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30996.1,170,MS-DRG,24796.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31907.75,175,MS-DRG,25526.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25526.2,140,MS-DRG,20420.96,other,140% of Medicare CMS MS-DRG,22791.25,125,MS-DRG,18233,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,18233,100,MS-DRG,14586.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18233,31907.75,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,inpatient,,,,,,17467.8,100,MS-DRG,13974.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15021.18,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25536.01,170,MS-DRG,20428.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26287.07,175,MS-DRG,21029.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21029.65,140,MS-DRG,16823.72,other,140% of Medicare CMS MS-DRG,18776.48,125,MS-DRG,15021.18,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,15021.18,100,MS-DRG,12016.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15021.18,26287.07,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,inpatient,,,,,,41142.5,100,MS-DRG,32914,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37206.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63250.68,170,MS-DRG,50600.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65110.99,175,MS-DRG,52088.792,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52088.79,140,MS-DRG,41671.03,other,140% of Medicare CMS MS-DRG,46507.85,125,MS-DRG,37206.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,37206.28,100,MS-DRG,29765.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37206.28,65110.99,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,inpatient,,,,,,23923.2,100,MS-DRG,19138.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21166.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35982.81,170,MS-DRG,28786.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37041.13,175,MS-DRG,29632.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29632.9,140,MS-DRG,23706.32,other,140% of Medicare CMS MS-DRG,26457.95,125,MS-DRG,21166.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,21166.36,100,MS-DRG,16933.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21166.36,37041.13,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,inpatient,,,,,,16388.4,100,MS-DRG,13110.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14317.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24340.5,170,MS-DRG,19472.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25056.4,175,MS-DRG,20045.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20045.12,140,MS-DRG,16036.1,other,140% of Medicare CMS MS-DRG,17897.43,125,MS-DRG,14317.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,14317.94,100,MS-DRG,11454.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14317.94,25056.4,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,inpatient,,,,,,28847,100,MS-DRG,23077.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,25416.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43208.34,170,MS-DRG,34566.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44479.17,175,MS-DRG,35583.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35583.34,140,MS-DRG,28466.67,other,140% of Medicare CMS MS-DRG,31770.84,125,MS-DRG,25416.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,25416.67,100,MS-DRG,20333.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25416.67,44479.17,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,inpatient,,,,,,14381.5,100,MS-DRG,11505.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13297.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22606.55,170,MS-DRG,18085.24,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23271.45,175,MS-DRG,18617.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18617.16,140,MS-DRG,14893.73,other,140% of Medicare CMS MS-DRG,16622.46,125,MS-DRG,13297.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,13297.97,100,MS-DRG,10638.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13297.97,23271.45,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,inpatient,,,,,,11889.5,100,MS-DRG,9511.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10020.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17034.15,170,MS-DRG,13627.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17535.16,175,MS-DRG,14028.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14028.13,140,MS-DRG,11222.5,other,140% of Medicare CMS MS-DRG,12525.11,125,MS-DRG,10020.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,10020.09,100,MS-DRG,8016.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10020.09,17535.16,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,inpatient,,,,,,27995.8,100,MS-DRG,22396.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24087.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40949.57,170,MS-DRG,32759.656,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42153.97,175,MS-DRG,33723.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33723.17,140,MS-DRG,26978.54,other,140% of Medicare CMS MS-DRG,30109.98,125,MS-DRG,24087.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,24087.98,100,MS-DRG,19270.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24087.98,42153.97,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,inpatient,,,,,,15986.6,100,MS-DRG,12789.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14197.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24135.84,170,MS-DRG,19308.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24845.71,175,MS-DRG,19876.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19876.57,140,MS-DRG,15901.26,other,140% of Medicare CMS MS-DRG,17746.94,125,MS-DRG,14197.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,14197.55,100,MS-DRG,11358.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14197.55,24845.71,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,inpatient,,,,,,13164.9,100,MS-DRG,10531.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11164.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18979.07,170,MS-DRG,15183.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19537.28,175,MS-DRG,15629.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15629.82,140,MS-DRG,12503.86,other,140% of Medicare CMS MS-DRG,13955.2,125,MS-DRG,11164.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,11164.16,100,MS-DRG,8931.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11164.16,19537.28,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,inpatient,,,,,,23611,100,MS-DRG,18888.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20841.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35430.7,170,MS-DRG,28344.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36472.78,175,MS-DRG,29178.224,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29178.23,140,MS-DRG,23342.58,other,140% of Medicare CMS MS-DRG,26051.99,125,MS-DRG,20841.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,20841.59,100,MS-DRG,16673.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20841.59,36472.78,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,inpatient,,,,,,11448.5,100,MS-DRG,9158.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9878.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16792.75,170,MS-DRG,13434.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17286.66,175,MS-DRG,13829.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13829.33,140,MS-DRG,11063.46,other,140% of Medicare CMS MS-DRG,12347.61,125,MS-DRG,9878.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,9878.09,100,MS-DRG,7902.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9878.09,17286.66,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,inpatient,,,,,,8068.9,100,MS-DRG,6455.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7044.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11976.08,170,MS-DRG,9580.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12328.31,175,MS-DRG,9862.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9862.65,140,MS-DRG,7890.12,other,140% of Medicare CMS MS-DRG,8805.94,125,MS-DRG,7044.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,7044.75,100,MS-DRG,5635.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7044.75,12328.31,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,inpatient,,,,,,26518.8,100,MS-DRG,21215.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23773.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40415.31,170,MS-DRG,32332.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41603.99,175,MS-DRG,33283.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33283.19,140,MS-DRG,26626.55,other,140% of Medicare CMS MS-DRG,29717.14,125,MS-DRG,23773.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,23773.71,100,MS-DRG,19018.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23773.71,41603.99,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,inpatient,,,,,,16366.7,100,MS-DRG,13093.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13772.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23413.71,170,MS-DRG,18730.968,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24102.35,175,MS-DRG,19281.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19281.88,140,MS-DRG,15425.5,other,140% of Medicare CMS MS-DRG,17215.96,125,MS-DRG,13772.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,13772.77,100,MS-DRG,11018.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13772.77,24102.35,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,inpatient,,,,,,12947.9,100,MS-DRG,10358.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10741.85,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18261.15,170,MS-DRG,14608.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18798.24,175,MS-DRG,15038.592,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15038.59,140,MS-DRG,12030.87,other,140% of Medicare CMS MS-DRG,13427.31,125,MS-DRG,10741.85,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,10741.85,100,MS-DRG,8593.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10741.85,18798.24,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,inpatient,,,,,,12462.1,100,MS-DRG,9969.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12005.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20409.71,170,MS-DRG,16327.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21009.99,175,MS-DRG,16807.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16807.99,140,MS-DRG,13446.39,other,140% of Medicare CMS MS-DRG,15007.14,125,MS-DRG,12005.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,12005.71,100,MS-DRG,9604.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12005.71,21009.99,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,inpatient,,,,,,7159.6,100,MS-DRG,5727.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6074.17,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10326.09,170,MS-DRG,8260.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10629.8,175,MS-DRG,8503.84,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8503.84,140,MS-DRG,6803.07,other,140% of Medicare CMS MS-DRG,7592.71,125,MS-DRG,6074.17,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6074.17,10629.8,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,inpatient,,,,,,9709,100,MS-DRG,7767.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9097.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15466.04,170,MS-DRG,12372.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15920.92,175,MS-DRG,12736.736,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12736.74,140,MS-DRG,10189.39,other,140% of Medicare CMS MS-DRG,11372.09,125,MS-DRG,9097.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,9097.67,100,MS-DRG,7278.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9097.67,15920.92,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,inpatient,,,,,,7058.1,100,MS-DRG,5646.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6626.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11264.44,170,MS-DRG,9011.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11595.75,175,MS-DRG,9276.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9276.6,140,MS-DRG,7421.28,other,140% of Medicare CMS MS-DRG,8282.68,125,MS-DRG,6626.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,6626.14,100,MS-DRG,5300.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6626.14,11595.75,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,inpatient,,,,,,15615.6,100,MS-DRG,12492.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14781.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25127.72,170,MS-DRG,20102.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25866.77,175,MS-DRG,20693.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20693.41,140,MS-DRG,16554.73,other,140% of Medicare CMS MS-DRG,18476.26,125,MS-DRG,14781.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,14781.01,100,MS-DRG,11824.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14781.01,25866.77,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,inpatient,,,,,,9110.5,100,MS-DRG,7288.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8416.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14308.31,170,MS-DRG,11446.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14729.14,175,MS-DRG,11783.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11783.31,140,MS-DRG,9426.65,other,140% of Medicare CMS MS-DRG,10520.81,125,MS-DRG,8416.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,8416.65,100,MS-DRG,6733.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8416.65,14729.14,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,inpatient,,,,,,12077.1,100,MS-DRG,9661.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10668.38,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18136.25,170,MS-DRG,14509,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18669.67,175,MS-DRG,14935.736,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14935.73,140,MS-DRG,11948.58,other,140% of Medicare CMS MS-DRG,13335.48,125,MS-DRG,10668.38,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,10668.38,100,MS-DRG,8534.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10668.38,18669.67,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,inpatient,,,,,,8004.5,100,MS-DRG,6403.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7329.99,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12460.98,170,MS-DRG,9968.784,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12827.48,175,MS-DRG,10261.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10261.99,140,MS-DRG,8209.59,other,140% of Medicare CMS MS-DRG,9162.49,125,MS-DRG,7329.99,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,7329.99,100,MS-DRG,5863.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7329.99,12827.48,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,inpatient,,,,,,6344.1,100,MS-DRG,5075.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5540.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9419.21,170,MS-DRG,7535.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9696.24,175,MS-DRG,7756.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7756.99,140,MS-DRG,6205.59,other,140% of Medicare CMS MS-DRG,6925.89,125,MS-DRG,5540.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,5540.71,100,MS-DRG,4432.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5540.71,9696.24,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,inpatient,,,,,,20528.2,100,MS-DRG,16422.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17305.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29418.53,170,MS-DRG,23534.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30283.79,175,MS-DRG,24227.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24227.03,140,MS-DRG,19381.62,other,140% of Medicare CMS MS-DRG,21631.28,125,MS-DRG,17305.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,17305.02,100,MS-DRG,13844.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17305.02,30283.79,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,inpatient,,,,,,13420.4,100,MS-DRG,10736.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11556.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19645.59,170,MS-DRG,15716.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20223.4,175,MS-DRG,16178.72,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16178.72,140,MS-DRG,12942.98,other,140% of Medicare CMS MS-DRG,14445.29,125,MS-DRG,11556.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,11556.23,100,MS-DRG,9244.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11556.23,20223.4,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,inpatient,,,,,,11067,100,MS-DRG,8853.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9179.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15605.64,170,MS-DRG,12484.512,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16064.63,175,MS-DRG,12851.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12851.71,140,MS-DRG,10281.37,other,140% of Medicare CMS MS-DRG,11474.74,125,MS-DRG,9179.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,9179.79,100,MS-DRG,7343.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9179.79,16064.63,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,inpatient,,,,,,13804,100,MS-DRG,11043.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12366.9,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21023.73,170,MS-DRG,16818.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21642.08,175,MS-DRG,17313.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17313.66,140,MS-DRG,13850.93,other,140% of Medicare CMS MS-DRG,15458.63,125,MS-DRG,12366.9,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,12366.9,100,MS-DRG,9893.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12366.9,21642.08,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,inpatient,,,,,,7114.8,100,MS-DRG,5691.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6275.45,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10668.27,170,MS-DRG,8534.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10982.04,175,MS-DRG,8785.632,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8785.63,140,MS-DRG,7028.5,other,140% of Medicare CMS MS-DRG,7844.31,125,MS-DRG,6275.45,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,6275.45,100,MS-DRG,5020.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6275.45,10982.04,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,inpatient,,,,,,4889.5,100,MS-DRG,3911.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4244.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7216.09,170,MS-DRG,5772.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7428.33,175,MS-DRG,5942.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5942.66,140,MS-DRG,4754.13,other,140% of Medicare CMS MS-DRG,5305.95,125,MS-DRG,4244.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,4244.76,100,MS-DRG,3395.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4244.76,7428.33,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,inpatient,,,,,,9898.7,100,MS-DRG,7918.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8748.21,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14871.96,170,MS-DRG,11897.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15309.37,175,MS-DRG,12247.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12247.49,140,MS-DRG,9797.99,other,140% of Medicare CMS MS-DRG,10935.26,125,MS-DRG,8748.21,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,8748.21,100,MS-DRG,6998.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8748.21,15309.37,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,inpatient,,,,,,6325.9,100,MS-DRG,5060.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5377.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9142.12,170,MS-DRG,7313.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9411.01,175,MS-DRG,7528.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7528.81,140,MS-DRG,6023.05,other,140% of Medicare CMS MS-DRG,6722.15,125,MS-DRG,5377.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,5377.72,100,MS-DRG,4302.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5377.72,9411.01,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,inpatient,,,,,,5585.3,100,MS-DRG,4468.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4931.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8383.26,170,MS-DRG,6706.608,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8629.83,175,MS-DRG,6903.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6903.86,140,MS-DRG,5523.09,other,140% of Medicare CMS MS-DRG,6164.16,125,MS-DRG,4931.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.33,8629.83,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,inpatient,,,,,,12069.4,100,MS-DRG,9655.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11048.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18782.81,170,MS-DRG,15026.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19335.24,175,MS-DRG,15468.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15468.19,140,MS-DRG,12374.55,other,140% of Medicare CMS MS-DRG,13810.89,125,MS-DRG,11048.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,11048.71,100,MS-DRG,8838.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11048.71,19335.24,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,inpatient,,,,,,7483,100,MS-DRG,5986.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6555.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11144.78,170,MS-DRG,8915.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11472.56,175,MS-DRG,9178.048,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9178.05,140,MS-DRG,7342.44,other,140% of Medicare CMS MS-DRG,8194.69,125,MS-DRG,6555.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,6555.75,100,MS-DRG,5244.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6555.75,11472.56,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,inpatient,,,,,,5404,100,MS-DRG,4323.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4834.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8218.46,170,MS-DRG,6574.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8460.18,175,MS-DRG,6768.144,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6768.15,140,MS-DRG,5414.52,other,140% of Medicare CMS MS-DRG,6042.99,125,MS-DRG,4834.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,4834.39,100,MS-DRG,3867.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4834.39,8460.18,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,inpatient,,,,,,10495.1,100,MS-DRG,8396.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9341.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15880.62,170,MS-DRG,12704.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16347.7,175,MS-DRG,13078.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13078.16,140,MS-DRG,10462.53,other,140% of Medicare CMS MS-DRG,11676.93,125,MS-DRG,9341.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,9341.54,100,MS-DRG,7473.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9341.54,16347.7,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,inpatient,,,,,,7165.2,100,MS-DRG,5732.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6335.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10771.12,170,MS-DRG,8616.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11087.91,175,MS-DRG,8870.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8870.33,140,MS-DRG,7096.26,other,140% of Medicare CMS MS-DRG,7919.94,125,MS-DRG,6335.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,6335.95,100,MS-DRG,5068.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6335.95,11087.91,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,inpatient,,,,,,12775,100,MS-DRG,10220,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11816.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20087.47,170,MS-DRG,16069.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20678.28,175,MS-DRG,16542.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16542.62,140,MS-DRG,13234.1,other,140% of Medicare CMS MS-DRG,14770.2,125,MS-DRG,11816.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,11816.16,100,MS-DRG,9452.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11816.16,20678.28,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,inpatient,,,,,,6911.1,100,MS-DRG,5528.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5695.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9682.67,170,MS-DRG,7746.136,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9967.46,175,MS-DRG,7973.968,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7973.97,140,MS-DRG,6379.18,other,140% of Medicare CMS MS-DRG,7119.61,125,MS-DRG,5695.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,5695.69,100,MS-DRG,4556.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5695.69,9967.46,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,inpatient,,,,,,10949.4,100,MS-DRG,8759.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9328.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15858.59,170,MS-DRG,12686.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16325.02,175,MS-DRG,13060.016,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13060.01,140,MS-DRG,10448.01,other,140% of Medicare CMS MS-DRG,11660.73,125,MS-DRG,9328.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,9328.58,100,MS-DRG,7462.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9328.58,16325.02,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,inpatient,,,,,,6949.6,100,MS-DRG,5559.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6278.53,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10673.5,170,MS-DRG,8538.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10987.43,175,MS-DRG,8789.944,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8789.94,140,MS-DRG,7031.95,other,140% of Medicare CMS MS-DRG,7848.16,125,MS-DRG,6278.53,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,6278.53,100,MS-DRG,5022.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6278.53,10987.43,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,inpatient,,,,,,5137.3,100,MS-DRG,4109.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4573.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7775.53,170,MS-DRG,6220.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8004.22,175,MS-DRG,6403.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6403.38,140,MS-DRG,5122.7,other,140% of Medicare CMS MS-DRG,5717.3,125,MS-DRG,4573.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,4573.84,100,MS-DRG,3659.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4573.84,8004.22,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,inpatient,,,,,,14278.6,100,MS-DRG,11422.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13636.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23182.78,170,MS-DRG,18546.224,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23864.63,175,MS-DRG,19091.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19091.7,140,MS-DRG,15273.36,other,140% of Medicare CMS MS-DRG,17046.16,125,MS-DRG,13636.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,13636.93,100,MS-DRG,10909.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13636.93,23864.63,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,inpatient,,,,,,6289.5,100,MS-DRG,5031.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5615.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9546.23,170,MS-DRG,7636.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9827,175,MS-DRG,7861.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7861.6,140,MS-DRG,6289.28,other,140% of Medicare CMS MS-DRG,7019.29,125,MS-DRG,5615.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,5615.43,100,MS-DRG,4492.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5615.43,9827,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,inpatient,,,,,,15857.1,100,MS-DRG,12685.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14066.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23913.31,170,MS-DRG,19130.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24616.64,175,MS-DRG,19693.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19693.31,140,MS-DRG,15754.65,other,140% of Medicare CMS MS-DRG,17583.31,125,MS-DRG,14066.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,14066.65,100,MS-DRG,11253.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14066.65,24616.64,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,inpatient,,,,,,9437.4,100,MS-DRG,7549.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8374.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14236.94,170,MS-DRG,11389.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14655.67,175,MS-DRG,11724.536,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11724.54,140,MS-DRG,9379.63,other,140% of Medicare CMS MS-DRG,10468.34,125,MS-DRG,8374.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,8374.67,100,MS-DRG,6699.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8374.67,14655.67,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,inpatient,,,,,,6415.5,100,MS-DRG,5132.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5678.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9653.28,170,MS-DRG,7722.624,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9937.2,175,MS-DRG,7949.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7949.76,140,MS-DRG,6359.81,other,140% of Medicare CMS MS-DRG,7098,125,MS-DRG,5678.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,5678.4,100,MS-DRG,4542.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5678.4,9937.2,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,inpatient,,,,,,16349.9,100,MS-DRG,13079.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14032.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23855.59,170,MS-DRG,19084.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24557.23,175,MS-DRG,19645.784,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19645.78,140,MS-DRG,15716.62,other,140% of Medicare CMS MS-DRG,17540.88,125,MS-DRG,14032.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,14032.7,100,MS-DRG,11226.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14032.7,24557.23,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,inpatient,,,,,,9097.9,100,MS-DRG,7278.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8132.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13824.43,170,MS-DRG,11059.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14231.04,175,MS-DRG,11384.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11384.83,140,MS-DRG,9107.86,other,140% of Medicare CMS MS-DRG,10165.03,125,MS-DRG,8132.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,8132.02,100,MS-DRG,6505.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8132.02,14231.04,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,inpatient,,,,,,6106.8,100,MS-DRG,4885.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5471.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9301.65,170,MS-DRG,7441.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9575.23,175,MS-DRG,7660.184,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7660.18,140,MS-DRG,6128.14,other,140% of Medicare CMS MS-DRG,6839.45,125,MS-DRG,5471.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,5471.56,100,MS-DRG,4377.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5471.56,9575.23,
CONCUSSION WITH MCC,88,MS-DRG,,,,,inpatient,,,,,,11034.1,100,MS-DRG,8827.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9469.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16098.95,170,MS-DRG,12879.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16572.45,175,MS-DRG,13257.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13257.96,140,MS-DRG,10606.37,other,140% of Medicare CMS MS-DRG,11837.46,125,MS-DRG,9469.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,9469.97,100,MS-DRG,7575.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9469.97,16572.45,
CONCUSSION WITH CC,89,MS-DRG,,,,,inpatient,,,,,,8173.9,100,MS-DRG,6539.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7099.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12069.49,170,MS-DRG,9655.592,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12424.48,175,MS-DRG,9939.584,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9939.58,140,MS-DRG,7951.66,other,140% of Medicare CMS MS-DRG,8874.63,125,MS-DRG,7099.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,7099.7,100,MS-DRG,5679.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7099.7,12424.48,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,inpatient,,,,,,5761.7,100,MS-DRG,4609.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5771.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9811.77,170,MS-DRG,7849.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10100.35,175,MS-DRG,8080.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8080.28,140,MS-DRG,6464.22,other,140% of Medicare CMS MS-DRG,7214.54,125,MS-DRG,5771.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,5771.63,100,MS-DRG,4617.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5761.7,10100.35,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,inpatient,,,,,,12091.8,100,MS-DRG,9673.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11046.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18779.66,170,MS-DRG,15023.728,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19332.01,175,MS-DRG,15465.608,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15465.6,140,MS-DRG,12372.48,other,140% of Medicare CMS MS-DRG,13808.58,125,MS-DRG,11046.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,11046.86,100,MS-DRG,8837.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11046.86,19332.01,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,inpatient,,,,,,6960.1,100,MS-DRG,5568.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6335.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10770.06,170,MS-DRG,8616.048,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11086.83,175,MS-DRG,8869.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8869.46,140,MS-DRG,7095.57,other,140% of Medicare CMS MS-DRG,7919.16,125,MS-DRG,6335.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,6335.33,100,MS-DRG,5068.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6335.33,11086.83,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,inpatient,,,,,,5353.6,100,MS-DRG,4282.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4781.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8128.19,170,MS-DRG,6502.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8367.26,175,MS-DRG,6693.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6693.81,140,MS-DRG,5355.05,other,140% of Medicare CMS MS-DRG,5976.61,125,MS-DRG,4781.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,4781.29,100,MS-DRG,3825.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4781.29,8367.26,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,inpatient,,,,,,25014.5,100,MS-DRG,20011.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22367.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38024.29,170,MS-DRG,30419.432,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39142.65,175,MS-DRG,31314.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31314.12,140,MS-DRG,25051.3,other,140% of Medicare CMS MS-DRG,27959.04,125,MS-DRG,22367.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,22367.23,100,MS-DRG,17893.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22367.23,39142.65,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,inpatient,,,,,,17897.6,100,MS-DRG,14318.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14720.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25024.85,170,MS-DRG,20019.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25760.88,175,MS-DRG,20608.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20608.7,140,MS-DRG,16486.96,other,140% of Medicare CMS MS-DRG,18400.63,125,MS-DRG,14720.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,14720.5,100,MS-DRG,11776.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14720.5,25760.88,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,inpatient,,,,,,15990.1,100,MS-DRG,12792.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13457.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22878.4,170,MS-DRG,18302.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23551.29,175,MS-DRG,18841.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18841.03,140,MS-DRG,15072.82,other,140% of Medicare CMS MS-DRG,16822.35,125,MS-DRG,13457.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,13457.88,100,MS-DRG,10766.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13457.88,23551.29,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,inpatient,,,,,,27217.4,100,MS-DRG,21773.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22454.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38173.35,170,MS-DRG,30538.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39296.09,175,MS-DRG,31436.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31436.87,140,MS-DRG,25149.5,other,140% of Medicare CMS MS-DRG,28068.64,125,MS-DRG,22454.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,22454.91,100,MS-DRG,17963.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22454.91,39296.09,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,inpatient,,,,,,14589.4,100,MS-DRG,11671.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13302.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22613.89,170,MS-DRG,18091.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23279.01,175,MS-DRG,18623.208,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18623.21,140,MS-DRG,14898.57,other,140% of Medicare CMS MS-DRG,16627.86,125,MS-DRG,13302.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,13302.29,100,MS-DRG,10641.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13302.29,23279.01,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,inpatient,,,,,,9789.5,100,MS-DRG,7831.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8151.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13856.97,170,MS-DRG,11085.576,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14264.53,175,MS-DRG,11411.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11411.62,140,MS-DRG,9129.3,other,140% of Medicare CMS MS-DRG,10188.95,125,MS-DRG,8151.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,8151.16,100,MS-DRG,6520.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8151.16,14264.53,
SEIZURES WITH MCC,100,MS-DRG,,,,,inpatient,,,,,,13447,100,MS-DRG,10757.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12240.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20808.56,170,MS-DRG,16646.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21420.58,175,MS-DRG,17136.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17136.46,140,MS-DRG,13709.17,other,140% of Medicare CMS MS-DRG,15300.41,125,MS-DRG,12240.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,12240.33,100,MS-DRG,9792.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12240.33,21420.58,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,inpatient,,,,,,6310.5,100,MS-DRG,5048.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5616.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9547.27,170,MS-DRG,7637.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9828.07,175,MS-DRG,7862.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7862.46,140,MS-DRG,6289.97,other,140% of Medicare CMS MS-DRG,7020.05,125,MS-DRG,5616.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,5616.04,100,MS-DRG,4492.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5616.04,9828.07,
HEADACHES WITH MCC,102,MS-DRG,,,,,inpatient,,,,,,8049.3,100,MS-DRG,6439.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7449.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12664.61,170,MS-DRG,10131.688,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13037.1,175,MS-DRG,10429.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10429.68,140,MS-DRG,8343.74,other,140% of Medicare CMS MS-DRG,9312.21,125,MS-DRG,7449.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,7449.77,100,MS-DRG,5959.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7449.77,13037.1,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,inpatient,,,,,,5827.5,100,MS-DRG,4662,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5201.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8841.94,170,MS-DRG,7073.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9102,175,MS-DRG,7281.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7281.6,140,MS-DRG,5825.28,other,140% of Medicare CMS MS-DRG,6501.43,125,MS-DRG,5201.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,5201.14,100,MS-DRG,4160.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5201.14,9102,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,inpatient,,,,,,15717.1,100,MS-DRG,12573.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15480.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26316.94,170,MS-DRG,21053.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27090.96,175,MS-DRG,21672.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21672.77,140,MS-DRG,17338.22,other,140% of Medicare CMS MS-DRG,19350.69,125,MS-DRG,15480.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,15480.55,100,MS-DRG,12384.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15480.55,27090.96,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,inpatient,,,,,,9119.6,100,MS-DRG,7295.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7605.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12929.13,170,MS-DRG,10343.304,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13309.4,175,MS-DRG,10647.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10647.52,140,MS-DRG,8518.02,other,140% of Medicare CMS MS-DRG,9506.71,125,MS-DRG,7605.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,7605.37,100,MS-DRG,6084.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7605.37,13309.4,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,inpatient,,,,,,10633.7,100,MS-DRG,8506.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9658.9,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16420.13,170,MS-DRG,13136.104,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16903.08,175,MS-DRG,13522.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13522.46,140,MS-DRG,10817.97,other,140% of Medicare CMS MS-DRG,12073.63,125,MS-DRG,9658.9,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,9658.9,100,MS-DRG,7727.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9658.9,16903.08,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,inpatient,,,,,,13205.5,100,MS-DRG,10564.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11303.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19216.29,170,MS-DRG,15373.032,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19781.48,175,MS-DRG,15825.184,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15825.18,140,MS-DRG,12660.14,other,140% of Medicare CMS MS-DRG,14129.63,125,MS-DRG,11303.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,11303.7,100,MS-DRG,9042.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11303.7,19781.48,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,inpatient,,,,,,6949.6,100,MS-DRG,5559.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7399.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12578.54,170,MS-DRG,10062.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12948.5,175,MS-DRG,10358.8,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10358.8,140,MS-DRG,8287.04,other,140% of Medicare CMS MS-DRG,9248.93,125,MS-DRG,7399.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,7399.14,100,MS-DRG,5919.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6949.6,12948.5,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,inpatient,,,,,,8577.1,100,MS-DRG,6861.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7910.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13447.63,170,MS-DRG,10758.104,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13843.15,175,MS-DRG,11074.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11074.52,140,MS-DRG,8859.62,other,140% of Medicare CMS MS-DRG,9887.96,125,MS-DRG,7910.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,7910.37,100,MS-DRG,6328.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7910.37,13843.15,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,inpatient,,,,,,4835.6,100,MS-DRG,3868.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4596.68,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7814.36,170,MS-DRG,6251.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8044.19,175,MS-DRG,6435.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6435.35,140,MS-DRG,5148.28,other,140% of Medicare CMS MS-DRG,5745.85,125,MS-DRG,4596.68,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,4596.68,100,MS-DRG,3677.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4596.68,8044.19,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,inpatient,,,,,,5556.6,100,MS-DRG,4445.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4964.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8438.89,170,MS-DRG,6751.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8687.09,175,MS-DRG,6949.672,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6949.67,140,MS-DRG,5559.74,other,140% of Medicare CMS MS-DRG,6205.06,125,MS-DRG,4964.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,4964.05,100,MS-DRG,3971.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4964.05,8687.09,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,inpatient,,,,,,9804.9,100,MS-DRG,7843.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8161.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13874.82,170,MS-DRG,11099.856,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14282.91,175,MS-DRG,11426.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11426.32,140,MS-DRG,9141.06,other,140% of Medicare CMS MS-DRG,10202.08,125,MS-DRG,8161.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,8161.66,100,MS-DRG,6529.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8161.66,14282.91,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,inpatient,,,,,,6034.7,100,MS-DRG,4827.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4923.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8370.65,170,MS-DRG,6696.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8616.84,175,MS-DRG,6893.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6893.47,140,MS-DRG,5514.78,other,140% of Medicare CMS MS-DRG,6154.89,125,MS-DRG,4923.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,4923.91,100,MS-DRG,3939.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4923.91,8616.84,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,inpatient,,,,,,17154.9,100,MS-DRG,13723.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16374.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27836.77,170,MS-DRG,22269.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28655.5,175,MS-DRG,22924.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22924.4,140,MS-DRG,18339.52,other,140% of Medicare CMS MS-DRG,20468.21,125,MS-DRG,16374.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,16374.57,100,MS-DRG,13099.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16374.57,28655.5,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,inpatient,,,,,,8122.1,100,MS-DRG,6497.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6447.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10961.09,170,MS-DRG,8768.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11283.48,175,MS-DRG,9026.784,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9026.78,140,MS-DRG,7221.42,other,140% of Medicare CMS MS-DRG,8059.63,125,MS-DRG,6447.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,6447.7,100,MS-DRG,5158.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6447.7,11283.48,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,inpatient,,,,,,10497.2,100,MS-DRG,8397.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9290.3,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15793.51,170,MS-DRG,12634.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16258.03,175,MS-DRG,13006.424,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13006.42,140,MS-DRG,10405.14,other,140% of Medicare CMS MS-DRG,11612.88,125,MS-DRG,9290.3,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,9290.3,100,MS-DRG,7432.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9290.3,16258.03,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,inpatient,,,,,,6190.1,100,MS-DRG,4952.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5344.99,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9086.48,170,MS-DRG,7269.184,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9353.73,175,MS-DRG,7482.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7482.99,140,MS-DRG,5986.39,other,140% of Medicare CMS MS-DRG,6681.24,125,MS-DRG,5344.99,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,5344.99,100,MS-DRG,4275.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5344.99,9353.73,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,inpatient,,,,,,8802.5,100,MS-DRG,7042,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7333.08,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12466.24,170,MS-DRG,9972.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12832.89,175,MS-DRG,10266.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10266.31,140,MS-DRG,8213.05,other,140% of Medicare CMS MS-DRG,9166.35,125,MS-DRG,7333.08,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,7333.08,100,MS-DRG,5866.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7333.08,12832.89,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,inpatient,,,,,,29094.1,100,MS-DRG,23275.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23326.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39655.39,170,MS-DRG,31724.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40821.73,175,MS-DRG,32657.384,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32657.38,140,MS-DRG,26125.9,other,140% of Medicare CMS MS-DRG,29158.38,125,MS-DRG,23326.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,23326.7,100,MS-DRG,18661.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23326.7,40821.73,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,inpatient,,,,,,15628.2,100,MS-DRG,12502.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12791.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21744.8,170,MS-DRG,17395.84,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22384.36,175,MS-DRG,17907.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17907.48,140,MS-DRG,14325.98,other,140% of Medicare CMS MS-DRG,15988.83,125,MS-DRG,12791.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,12791.06,100,MS-DRG,10232.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12791.06,22384.36,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,inpatient,,,,,,11911.9,100,MS-DRG,9529.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9539.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16216.5,170,MS-DRG,12973.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16693.46,175,MS-DRG,13354.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13354.77,140,MS-DRG,10683.82,other,140% of Medicare CMS MS-DRG,11923.9,125,MS-DRG,9539.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,9539.12,100,MS-DRG,7631.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9539.12,16693.46,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,inpatient,,,,,,22208.2,100,MS-DRG,17766.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20532.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34905.9,170,MS-DRG,27924.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35932.54,175,MS-DRG,28746.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28746.03,140,MS-DRG,22996.82,other,140% of Medicare CMS MS-DRG,25666.1,125,MS-DRG,20532.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,20532.88,100,MS-DRG,16426.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20532.88,35932.54,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,inpatient,,,,,,12665.1,100,MS-DRG,10132.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10684.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18163.53,170,MS-DRG,14530.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18697.75,175,MS-DRG,14958.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14958.2,140,MS-DRG,11966.56,other,140% of Medicare CMS MS-DRG,13355.54,125,MS-DRG,10684.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,10684.43,100,MS-DRG,8547.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10684.43,18697.75,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,inpatient,,,,,,8454.6,100,MS-DRG,6763.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7539.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12816.83,170,MS-DRG,10253.464,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13193.79,175,MS-DRG,10555.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10555.03,140,MS-DRG,8444.02,other,140% of Medicare CMS MS-DRG,9424.14,125,MS-DRG,7539.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,7539.31,100,MS-DRG,6031.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7539.31,13193.79,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,inpatient,,,,,,14099.4,100,MS-DRG,11279.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13033.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22157.31,170,MS-DRG,17725.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22808.99,175,MS-DRG,18247.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18247.19,140,MS-DRG,14597.75,other,140% of Medicare CMS MS-DRG,16292.14,125,MS-DRG,13033.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,13033.71,100,MS-DRG,10426.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13033.71,22808.99,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,inpatient,,,,,,8477.7,100,MS-DRG,6782.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7630.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12971.1,170,MS-DRG,10376.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13352.61,175,MS-DRG,10682.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10682.08,140,MS-DRG,8545.66,other,140% of Medicare CMS MS-DRG,9537.58,125,MS-DRG,7630.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,7630.06,100,MS-DRG,6104.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7630.06,13352.61,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,inpatient,,,,,,5723.2,100,MS-DRG,4578.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5493.18,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9338.41,170,MS-DRG,7470.728,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9613.07,175,MS-DRG,7690.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7690.45,140,MS-DRG,6152.36,other,140% of Medicare CMS MS-DRG,6866.48,125,MS-DRG,5493.18,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,5493.18,100,MS-DRG,4394.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5493.18,9613.07,
DYSEQUILIBRIUM,149,MS-DRG,,,,,inpatient,,,,,,5285,100,MS-DRG,4228,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4597.92,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7816.46,170,MS-DRG,6253.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8046.36,175,MS-DRG,6437.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6437.09,140,MS-DRG,5149.67,other,140% of Medicare CMS MS-DRG,5747.4,125,MS-DRG,4597.92,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4597.92,8046.36,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,inpatient,,,,,,9655.1,100,MS-DRG,7724.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8115.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13797.15,170,MS-DRG,11037.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14202.95,175,MS-DRG,11362.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11362.36,140,MS-DRG,9089.89,other,140% of Medicare CMS MS-DRG,10144.96,125,MS-DRG,8115.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,8115.97,100,MS-DRG,6492.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8115.97,14202.95,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,inpatient,,,,,,5397,100,MS-DRG,4317.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4758.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8089.35,170,MS-DRG,6471.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8327.27,175,MS-DRG,6661.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6661.82,140,MS-DRG,5329.46,other,140% of Medicare CMS MS-DRG,5948.05,125,MS-DRG,4758.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,4758.44,100,MS-DRG,3806.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4758.44,8327.27,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,inpatient,,,,,,8383.9,100,MS-DRG,6707.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7336.17,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12471.49,170,MS-DRG,9977.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12838.3,175,MS-DRG,10270.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10270.64,140,MS-DRG,8216.51,other,140% of Medicare CMS MS-DRG,9170.21,125,MS-DRG,7336.17,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,7336.17,100,MS-DRG,5868.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7336.17,12838.3,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,inpatient,,,,,,4833.5,100,MS-DRG,3866.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4536.8,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7712.56,170,MS-DRG,6170.048,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7939.4,175,MS-DRG,6351.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6351.52,140,MS-DRG,5081.22,other,140% of Medicare CMS MS-DRG,5671,125,MS-DRG,4536.8,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,4536.8,100,MS-DRG,3629.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4536.8,7939.4,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,inpatient,,,,,,10520.3,100,MS-DRG,8416.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9497.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16145.14,170,MS-DRG,12916.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16620,175,MS-DRG,13296,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13296,140,MS-DRG,10636.8,other,140% of Medicare CMS MS-DRG,11871.43,125,MS-DRG,9497.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,9497.14,100,MS-DRG,7597.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9497.14,16620,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,inpatient,,,,,,6435.1,100,MS-DRG,5148.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5844.48,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9935.62,170,MS-DRG,7948.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10227.84,175,MS-DRG,8182.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8182.27,140,MS-DRG,6545.82,other,140% of Medicare CMS MS-DRG,7305.6,125,MS-DRG,5844.48,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,5844.48,100,MS-DRG,4675.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5844.48,10227.84,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,inpatient,,,,,,4771.9,100,MS-DRG,3817.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4047.18,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6880.21,170,MS-DRG,5504.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7082.57,175,MS-DRG,5666.056,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5666.05,140,MS-DRG,4532.84,other,140% of Medicare CMS MS-DRG,5058.98,125,MS-DRG,4047.18,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,4047.18,100,MS-DRG,3237.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4047.18,7082.57,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,inpatient,,,,,,11702.6,100,MS-DRG,9362.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10539.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17916.88,170,MS-DRG,14333.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18443.85,175,MS-DRG,14755.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14755.08,140,MS-DRG,11804.06,other,140% of Medicare CMS MS-DRG,13174.18,125,MS-DRG,10539.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,10539.34,100,MS-DRG,8431.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10539.34,18443.85,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,inpatient,,,,,,6503.7,100,MS-DRG,5202.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5794.48,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9850.62,170,MS-DRG,7880.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10140.34,175,MS-DRG,8112.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8112.27,140,MS-DRG,6489.82,other,140% of Medicare CMS MS-DRG,7243.1,125,MS-DRG,5794.48,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,5794.48,100,MS-DRG,4635.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5794.48,10140.34,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,inpatient,,,,,,5249.3,100,MS-DRG,4199.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4168.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7086.99,170,MS-DRG,5669.592,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7295.44,175,MS-DRG,5836.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5836.35,140,MS-DRG,4669.08,other,140% of Medicare CMS MS-DRG,5211.03,125,MS-DRG,4168.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,4168.82,100,MS-DRG,3335.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4168.82,7295.44,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,inpatient,,,,,,33905.9,100,MS-DRG,27124.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29102.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,49474.52,170,MS-DRG,39579.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50929.66,175,MS-DRG,40743.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,40743.72,140,MS-DRG,32594.98,other,140% of Medicare CMS MS-DRG,36378.33,125,MS-DRG,29102.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,29102.66,100,MS-DRG,23282.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29102.66,50929.66,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,inpatient,,,,,,18078.9,100,MS-DRG,14463.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15746.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26769.31,170,MS-DRG,21415.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27556.64,175,MS-DRG,22045.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22045.31,140,MS-DRG,17636.25,other,140% of Medicare CMS MS-DRG,19683.31,125,MS-DRG,15746.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,15746.65,100,MS-DRG,12597.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15746.65,27556.64,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,inpatient,,,,,,13488.3,100,MS-DRG,10790.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11585.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19694.93,170,MS-DRG,15755.944,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20274.19,175,MS-DRG,16219.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16219.35,140,MS-DRG,12975.48,other,140% of Medicare CMS MS-DRG,14481.56,125,MS-DRG,11585.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,11585.25,100,MS-DRG,9268.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11585.25,20274.19,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,inpatient,,,,,,25660.6,100,MS-DRG,20528.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,25053.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42591.15,170,MS-DRG,34072.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43843.84,175,MS-DRG,35075.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35075.07,140,MS-DRG,28060.06,other,140% of Medicare CMS MS-DRG,31317.03,125,MS-DRG,25053.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,25053.62,100,MS-DRG,20042.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25053.62,43843.84,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,inpatient,,,,,,13307.7,100,MS-DRG,10646.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11235.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19100.84,170,MS-DRG,15280.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19662.63,175,MS-DRG,15730.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15730.11,140,MS-DRG,12584.09,other,140% of Medicare CMS MS-DRG,14044.74,125,MS-DRG,11235.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,11235.79,100,MS-DRG,8988.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11235.79,19662.63,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,inpatient,,,,,,9923.2,100,MS-DRG,7938.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8370.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14229.58,170,MS-DRG,11383.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14648.1,175,MS-DRG,11718.48,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11718.48,140,MS-DRG,9374.78,other,140% of Medicare CMS MS-DRG,10462.93,125,MS-DRG,8370.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,8370.34,100,MS-DRG,6696.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8370.34,14648.1,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,18985.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32275.57,170,MS-DRG,25820.456,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33224.85,175,MS-DRG,26579.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26579.88,140,MS-DRG,21263.9,other,140% of Medicare CMS MS-DRG,23732.04,125,MS-DRG,18985.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,18985.63,100,MS-DRG,15188.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18985.63,33224.85,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,inpatient,,,,,,9777.6,100,MS-DRG,7822.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8662.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14726.06,170,MS-DRG,11780.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15159.18,175,MS-DRG,12127.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12127.35,140,MS-DRG,9701.88,other,140% of Medicare CMS MS-DRG,10827.99,125,MS-DRG,8662.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,8662.39,100,MS-DRG,6929.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8662.39,15159.18,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,inpatient,,,,,,5723.2,100,MS-DRG,4578.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5035.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8560.64,170,MS-DRG,6848.512,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8812.42,175,MS-DRG,7049.936,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7049.94,140,MS-DRG,5639.95,other,140% of Medicare CMS MS-DRG,6294.59,125,MS-DRG,5035.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,5035.67,100,MS-DRG,4028.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5035.67,8812.42,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,inpatient,,,,,,12459.3,100,MS-DRG,9967.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10473.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17805.61,170,MS-DRG,14244.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18329.31,175,MS-DRG,14663.448,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14663.45,140,MS-DRG,11730.76,other,140% of Medicare CMS MS-DRG,13092.36,125,MS-DRG,10473.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,10473.89,100,MS-DRG,8379.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10473.89,18329.31,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,inpatient,,,,,,7609,100,MS-DRG,6087.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6092.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10356.52,170,MS-DRG,8285.216,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10661.12,175,MS-DRG,8528.896,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8528.9,140,MS-DRG,6823.12,other,140% of Medicare CMS MS-DRG,7615.09,125,MS-DRG,6092.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,6092.07,100,MS-DRG,4873.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6092.07,10661.12,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,inpatient,,,,,,5497.8,100,MS-DRG,4398.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4712.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8011.69,170,MS-DRG,6409.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8247.33,175,MS-DRG,6597.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6597.86,140,MS-DRG,5278.29,other,140% of Medicare CMS MS-DRG,5890.95,125,MS-DRG,4712.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,4712.76,100,MS-DRG,3770.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4712.76,8247.33,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,inpatient,,,,,,11857.3,100,MS-DRG,9485.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10731.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18244.35,170,MS-DRG,14595.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18780.95,175,MS-DRG,15024.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15024.76,140,MS-DRG,12019.81,other,140% of Medicare CMS MS-DRG,13414.96,125,MS-DRG,10731.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,10731.97,100,MS-DRG,8585.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10731.97,18780.95,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,inpatient,,,,,,7935.9,100,MS-DRG,6348.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6798.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11557.28,170,MS-DRG,9245.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11897.2,175,MS-DRG,9517.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9517.76,140,MS-DRG,7614.21,other,140% of Medicare CMS MS-DRG,8498,125,MS-DRG,6798.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,6798.4,100,MS-DRG,5438.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6798.4,11897.2,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,inpatient,,,,,,6212.5,100,MS-DRG,4970,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4931.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8384.3,170,MS-DRG,6707.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8630.9,175,MS-DRG,6904.72,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6904.72,140,MS-DRG,5523.78,other,140% of Medicare CMS MS-DRG,6164.93,125,MS-DRG,4931.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,4931.94,100,MS-DRG,3945.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.94,8630.9,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,inpatient,,,,,,10515.4,100,MS-DRG,8412.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9721.26,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16526.14,170,MS-DRG,13220.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17012.21,175,MS-DRG,13609.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13609.76,140,MS-DRG,10887.81,other,140% of Medicare CMS MS-DRG,12151.58,125,MS-DRG,9721.26,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,9721.26,100,MS-DRG,7777.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9721.26,17012.21,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,inpatient,,,,,,7316.4,100,MS-DRG,5853.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6494.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11040.87,170,MS-DRG,8832.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11365.6,175,MS-DRG,9092.48,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9092.48,140,MS-DRG,7273.98,other,140% of Medicare CMS MS-DRG,8118.29,125,MS-DRG,6494.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,6494.63,100,MS-DRG,5195.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6494.63,11365.6,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,inpatient,,,,,,5285,100,MS-DRG,4228,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4665.83,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7931.91,170,MS-DRG,6345.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8165.2,175,MS-DRG,6532.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6532.16,140,MS-DRG,5225.73,other,140% of Medicare CMS MS-DRG,5832.29,125,MS-DRG,4665.83,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,4665.83,100,MS-DRG,3732.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4665.83,8165.2,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,inpatient,,,,,,10687.6,100,MS-DRG,8550.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9582.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16291.03,170,MS-DRG,13032.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16770.18,175,MS-DRG,13416.144,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13416.14,140,MS-DRG,10732.91,other,140% of Medicare CMS MS-DRG,11978.7,125,MS-DRG,9582.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,9582.96,100,MS-DRG,7666.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9582.96,16770.18,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,inpatient,,,,,,7321.3,100,MS-DRG,5857.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6151.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10457.28,170,MS-DRG,8365.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10764.85,175,MS-DRG,8611.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8611.88,140,MS-DRG,6889.5,other,140% of Medicare CMS MS-DRG,7689.18,125,MS-DRG,6151.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,6151.34,100,MS-DRG,4921.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6151.34,10764.85,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,inpatient,,,,,,5068,100,MS-DRG,4054.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4609.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7835.37,170,MS-DRG,6268.296,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8065.82,175,MS-DRG,6452.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6452.66,140,MS-DRG,5162.13,other,140% of Medicare CMS MS-DRG,5761.3,125,MS-DRG,4609.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,4609.04,100,MS-DRG,3687.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4609.04,8065.82,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,inpatient,,,,,,8449,100,MS-DRG,6759.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7606.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12931.22,170,MS-DRG,10344.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13311.55,175,MS-DRG,10649.24,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10649.24,140,MS-DRG,8519.39,other,140% of Medicare CMS MS-DRG,9508.25,125,MS-DRG,7606.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,7606.6,100,MS-DRG,6085.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7606.6,13311.55,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,inpatient,,,,,,7598.5,100,MS-DRG,6078.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6803.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11566.72,170,MS-DRG,9253.376,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11906.91,175,MS-DRG,9525.528,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9525.53,140,MS-DRG,7620.42,other,140% of Medicare CMS MS-DRG,8504.94,125,MS-DRG,6803.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,6803.95,100,MS-DRG,5443.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6803.95,11906.91,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,inpatient,,,,,,6049.4,100,MS-DRG,4839.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5241.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8911.21,170,MS-DRG,7128.968,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9173.31,175,MS-DRG,7338.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7338.65,140,MS-DRG,5870.92,other,140% of Medicare CMS MS-DRG,6552.36,125,MS-DRG,5241.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,5241.89,100,MS-DRG,4193.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5241.89,9173.31,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,inpatient,,,,,,4564.7,100,MS-DRG,3651.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3962.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6736.4,170,MS-DRG,5389.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6934.53,175,MS-DRG,5547.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5547.63,140,MS-DRG,4438.1,other,140% of Medicare CMS MS-DRG,4953.24,125,MS-DRG,3962.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,3962.59,100,MS-DRG,3170.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3962.59,6934.53,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,inpatient,,,,,,9090.9,100,MS-DRG,7272.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8190.68,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13924.16,170,MS-DRG,11139.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14333.69,175,MS-DRG,11466.952,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11466.95,140,MS-DRG,9173.56,other,140% of Medicare CMS MS-DRG,10238.35,125,MS-DRG,8190.68,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,8190.68,100,MS-DRG,6552.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8190.68,14333.69,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,inpatient,,,,,,5881.4,100,MS-DRG,4705.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5076.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8629.91,170,MS-DRG,6903.928,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8883.74,175,MS-DRG,7106.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7106.99,140,MS-DRG,5685.59,other,140% of Medicare CMS MS-DRG,6345.53,125,MS-DRG,5076.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,5076.42,100,MS-DRG,4061.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5076.42,8883.74,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,inpatient,,,,,,4492.6,100,MS-DRG,3594.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3862.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6566.37,170,MS-DRG,5253.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6759.5,175,MS-DRG,5407.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5407.6,140,MS-DRG,4326.08,other,140% of Medicare CMS MS-DRG,4828.21,125,MS-DRG,3862.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,3862.57,100,MS-DRG,3090.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3862.57,6759.5,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,inpatient,,,,,,12163.9,100,MS-DRG,9731.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11702.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19894.35,170,MS-DRG,15915.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20479.48,175,MS-DRG,16383.584,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16383.58,140,MS-DRG,13106.86,other,140% of Medicare CMS MS-DRG,14628.2,125,MS-DRG,11702.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,11702.56,100,MS-DRG,9362.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11702.56,20479.48,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,inpatient,,,,,,6885.2,100,MS-DRG,5508.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6158.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10469.89,170,MS-DRG,8375.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10777.83,175,MS-DRG,8622.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8622.26,140,MS-DRG,6897.81,other,140% of Medicare CMS MS-DRG,7698.45,125,MS-DRG,6158.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,6158.76,100,MS-DRG,4927.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6158.76,10777.83,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,inpatient,,,,,,4976.3,100,MS-DRG,3981.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4804.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8168.09,170,MS-DRG,6534.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8408.33,175,MS-DRG,6726.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6726.66,140,MS-DRG,5381.33,other,140% of Medicare CMS MS-DRG,6005.95,125,MS-DRG,4804.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,4804.76,100,MS-DRG,3843.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4804.76,8408.33,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,inpatient,,,,,,12310.2,100,MS-DRG,9848.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10953.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18621.17,170,MS-DRG,14896.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19168.85,175,MS-DRG,15335.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15335.08,140,MS-DRG,12268.06,other,140% of Medicare CMS MS-DRG,13692.04,125,MS-DRG,10953.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,10953.63,100,MS-DRG,8762.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10953.63,19168.85,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,inpatient,,,,,,7504,100,MS-DRG,6003.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6649.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11304.32,170,MS-DRG,9043.456,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11636.8,175,MS-DRG,9309.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9309.44,140,MS-DRG,7447.55,other,140% of Medicare CMS MS-DRG,8312,125,MS-DRG,6649.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,6649.6,100,MS-DRG,5319.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6649.6,11636.8,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,inpatient,,,,,,5095.3,100,MS-DRG,4076.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4359.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7411.32,170,MS-DRG,5929.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7629.3,175,MS-DRG,6103.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6103.44,140,MS-DRG,4882.75,other,140% of Medicare CMS MS-DRG,5449.5,125,MS-DRG,4359.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,4359.6,100,MS-DRG,3487.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4359.6,7629.3,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,inpatient,,,,,,6480.6,100,MS-DRG,5184.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5911.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10050.03,170,MS-DRG,8040.024,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10345.62,175,MS-DRG,8276.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8276.49,140,MS-DRG,6621.19,other,140% of Medicare CMS MS-DRG,7389.73,125,MS-DRG,5911.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,5911.78,100,MS-DRG,4729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5911.78,10345.62,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,inpatient,,,,,,4669.7,100,MS-DRG,3735.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4290.45,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7293.77,170,MS-DRG,5835.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7508.29,175,MS-DRG,6006.632,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6006.63,140,MS-DRG,4805.3,other,140% of Medicare CMS MS-DRG,5363.06,125,MS-DRG,4290.45,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,4290.45,100,MS-DRG,3432.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4290.45,7508.29,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,inpatient,,,,,,5665.8,100,MS-DRG,4532.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5080.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8637.26,170,MS-DRG,6909.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8891.3,175,MS-DRG,7113.04,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7113.04,140,MS-DRG,5690.43,other,140% of Medicare CMS MS-DRG,6350.93,125,MS-DRG,5080.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,5080.74,100,MS-DRG,4064.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5080.74,8891.3,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,inpatient,,,,,,12467,100,MS-DRG,9973.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11177.13,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19001.12,170,MS-DRG,15200.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19559.98,175,MS-DRG,15647.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15647.98,140,MS-DRG,12518.38,other,140% of Medicare CMS MS-DRG,13971.41,125,MS-DRG,11177.13,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,11177.13,100,MS-DRG,8941.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11177.13,19559.98,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,inpatient,,,,,,6253.8,100,MS-DRG,5003.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5640.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9588.2,170,MS-DRG,7670.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9870.21,175,MS-DRG,7896.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7896.17,140,MS-DRG,6316.94,other,140% of Medicare CMS MS-DRG,7050.15,125,MS-DRG,5640.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,5640.12,100,MS-DRG,4512.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5640.12,9870.21,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,inpatient,,,,,,45961.3,100,MS-DRG,36769.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,42651.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,72507.19,170,MS-DRG,58005.752,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,74639.76,175,MS-DRG,59711.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,59711.81,140,MS-DRG,47769.45,other,140% of Medicare CMS MS-DRG,53314.11,125,MS-DRG,42651.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,42651.29,100,MS-DRG,34121.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42651.29,74639.76,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,inpatient,,,,,,18200.7,100,MS-DRG,14560.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16693.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28379.41,170,MS-DRG,22703.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29214.1,175,MS-DRG,23371.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23371.28,140,MS-DRG,18697.02,other,140% of Medicare CMS MS-DRG,20867.21,125,MS-DRG,16693.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,16693.77,100,MS-DRG,13355.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16693.77,29214.1,
CONCOMITANT AORTIC AND MITRAL VALVE?PROCEDURES,212,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,66500.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,113050.56,170,MS-DRG,90440.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,116375.58,175,MS-DRG,93100.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,93100.46,140,MS-DRG,74480.37,other,140% of Medicare CMS MS-DRG,83125.41,125,MS-DRG,66500.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,66500.33,100,MS-DRG,53200.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66500.33,116375.58,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,inpatient,,,,,,72122.4,100,MS-DRG,57697.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,63068.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,107215.77,170,MS-DRG,85772.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,110369.18,175,MS-DRG,88295.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,88295.34,140,MS-DRG,70636.27,other,140% of Medicare CMS MS-DRG,78835.13,125,MS-DRG,63068.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,63068.1,100,MS-DRG,50454.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63068.1,110369.18,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,inpatient,,,,,,68193.3,100,MS-DRG,54554.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,59922.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,101868,170,MS-DRG,81494.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,104864.11,175,MS-DRG,83891.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,83891.29,140,MS-DRG,67113.03,other,140% of Medicare CMS MS-DRG,74902.94,125,MS-DRG,59922.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,59922.35,100,MS-DRG,47937.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59922.35,104864.11,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,inpatient,,,,,,44441.6,100,MS-DRG,35553.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,39300.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66810.95,170,MS-DRG,53448.76,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,68775.98,175,MS-DRG,55020.784,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,55020.78,140,MS-DRG,44016.62,other,140% of Medicare CMS MS-DRG,49125.7,125,MS-DRG,39300.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,39300.56,100,MS-DRG,31440.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39300.56,68775.98,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,inpatient,,,,,,41570.9,100,MS-DRG,33256.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,35172.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59793.25,170,MS-DRG,47834.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,61551.88,175,MS-DRG,49241.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,49241.5,140,MS-DRG,39393.2,other,140% of Medicare CMS MS-DRG,43965.63,125,MS-DRG,35172.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,35172.5,100,MS-DRG,28138,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35172.5,61551.88,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,inpatient,,,,,,56898.1,100,MS-DRG,45518.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,47610.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,80937.7,170,MS-DRG,64750.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,83318.22,175,MS-DRG,66654.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,66654.57,140,MS-DRG,53323.66,other,140% of Medicare CMS MS-DRG,59513.01,125,MS-DRG,47610.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,47610.41,100,MS-DRG,38088.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47610.41,83318.22,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,inpatient,,,,,,38045.7,100,MS-DRG,30436.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,32381.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,55047.96,170,MS-DRG,44038.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,56667.01,175,MS-DRG,45333.608,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,45333.61,140,MS-DRG,36266.89,other,140% of Medicare CMS MS-DRG,40476.44,125,MS-DRG,32381.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,32381.15,100,MS-DRG,25904.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32381.15,56667.01,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,inpatient,,,,,,33121.2,100,MS-DRG,26496.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,28701.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48792.28,170,MS-DRG,39033.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50227.35,175,MS-DRG,40181.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,40181.88,140,MS-DRG,32145.5,other,140% of Medicare CMS MS-DRG,35876.68,125,MS-DRG,28701.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,28701.34,100,MS-DRG,22961.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28701.34,50227.35,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,inpatient,,,,,,34498.1,100,MS-DRG,27598.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,31109.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52886.8,170,MS-DRG,42309.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54442.29,175,MS-DRG,43553.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43553.83,140,MS-DRG,34843.06,other,140% of Medicare CMS MS-DRG,38887.35,125,MS-DRG,31109.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,31109.88,100,MS-DRG,24887.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31109.88,54442.29,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,inpatient,,,,,,23106.3,100,MS-DRG,18485.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19631.45,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33373.47,170,MS-DRG,26698.776,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34355.04,175,MS-DRG,27484.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27484.03,140,MS-DRG,21987.22,other,140% of Medicare CMS MS-DRG,24539.31,125,MS-DRG,19631.45,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,19631.45,100,MS-DRG,15705.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19631.45,34355.04,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,inpatient,,,,,,58752.4,100,MS-DRG,47001.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,50104.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,85178.11,170,MS-DRG,68142.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,87683.35,175,MS-DRG,70146.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,70146.68,140,MS-DRG,56117.34,other,140% of Medicare CMS MS-DRG,62630.96,125,MS-DRG,50104.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,50104.77,100,MS-DRG,40083.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50104.77,87683.35,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,inpatient,,,,,,41004.6,100,MS-DRG,32803.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,36727.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,62437.23,170,MS-DRG,49949.784,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64273.62,175,MS-DRG,51418.896,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,51418.89,140,MS-DRG,41135.11,other,140% of Medicare CMS MS-DRG,45909.73,125,MS-DRG,36727.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,36727.78,100,MS-DRG,29382.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36727.78,64273.62,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,inpatient,,,,,,54214.3,100,MS-DRG,43371.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,48156.2,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,81865.54,170,MS-DRG,65492.432,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,84273.35,175,MS-DRG,67418.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,67418.68,140,MS-DRG,53934.94,other,140% of Medicare CMS MS-DRG,60195.25,125,MS-DRG,48156.2,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,48156.2,100,MS-DRG,38524.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48156.2,84273.35,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,inpatient,,,,,,36304.1,100,MS-DRG,29043.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,32092.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54557.78,170,MS-DRG,43646.224,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,56162.42,175,MS-DRG,44929.936,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,44929.93,140,MS-DRG,35943.94,other,140% of Medicare CMS MS-DRG,40116.01,125,MS-DRG,32092.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,32092.81,100,MS-DRG,25674.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32092.81,56162.42,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,inpatient,,,,,,41930,100,MS-DRG,33544,other,Custom DRG with base of 7000. See MS-DRG rows for rates,36307.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,61723.48,170,MS-DRG,49378.784,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63538.88,175,MS-DRG,50831.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,50831.1,140,MS-DRG,40664.88,other,140% of Medicare CMS MS-DRG,45384.91,125,MS-DRG,36307.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,36307.93,100,MS-DRG,29046.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36307.93,63538.88,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,inpatient,,,,,,28548.8,100,MS-DRG,22839.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24951.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42416.94,170,MS-DRG,33933.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43664.5,175,MS-DRG,34931.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34931.6,140,MS-DRG,27945.28,other,140% of Medicare CMS MS-DRG,31188.93,125,MS-DRG,24951.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,24951.14,100,MS-DRG,19960.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24951.14,43664.5,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,inpatient,,,,,,32550.7,100,MS-DRG,26040.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29678.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50452.75,170,MS-DRG,40362.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,51936.66,175,MS-DRG,41549.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,41549.33,140,MS-DRG,33239.46,other,140% of Medicare CMS MS-DRG,37097.61,125,MS-DRG,29678.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,29678.09,100,MS-DRG,23742.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29678.09,51936.66,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,inpatient,,,,,,18999.4,100,MS-DRG,15199.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17344.53,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29485.7,170,MS-DRG,23588.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30352.93,175,MS-DRG,24282.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24282.34,140,MS-DRG,19425.87,other,140% of Medicare CMS MS-DRG,21680.66,125,MS-DRG,17344.53,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,17344.53,100,MS-DRG,13875.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17344.53,30352.93,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,inpatient,,,,,,10842.3,100,MS-DRG,8673.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8606.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14631.59,170,MS-DRG,11705.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15061.94,175,MS-DRG,12049.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12049.55,140,MS-DRG,9639.64,other,140% of Medicare CMS MS-DRG,10758.53,125,MS-DRG,8606.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,8606.82,100,MS-DRG,6885.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8606.82,15061.94,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,inpatient,,,,,,24314.5,100,MS-DRG,19451.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21332.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36265.15,170,MS-DRG,29012.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37331.77,175,MS-DRG,29865.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29865.42,140,MS-DRG,23892.34,other,140% of Medicare CMS MS-DRG,26665.55,125,MS-DRG,21332.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,21332.44,100,MS-DRG,17065.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21332.44,37331.77,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,inpatient,,,,,,16408,100,MS-DRG,13126.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14062.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23905.96,170,MS-DRG,19124.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24609.08,175,MS-DRG,19687.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19687.26,140,MS-DRG,15749.81,other,140% of Medicare CMS MS-DRG,17577.91,125,MS-DRG,14062.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,14062.33,100,MS-DRG,11249.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14062.33,24609.08,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,inpatient,,,,,,13307.7,100,MS-DRG,10646.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11295.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19202.64,170,MS-DRG,15362.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19767.42,175,MS-DRG,15813.936,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15813.94,140,MS-DRG,12651.15,other,140% of Medicare CMS MS-DRG,14119.59,125,MS-DRG,11295.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,11295.67,100,MS-DRG,9036.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11295.67,19767.42,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,inpatient,,,,,,34132,100,MS-DRG,27305.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27977.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47562.12,170,MS-DRG,38049.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48961.01,175,MS-DRG,39168.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,39168.81,140,MS-DRG,31335.05,other,140% of Medicare CMS MS-DRG,34972.15,125,MS-DRG,27977.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,27977.72,100,MS-DRG,22382.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27977.72,48961.01,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,inpatient,,,,,,16937.9,100,MS-DRG,13550.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14514.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24674.28,170,MS-DRG,19739.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25399.99,175,MS-DRG,20319.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20319.99,140,MS-DRG,16255.99,other,140% of Medicare CMS MS-DRG,18142.85,125,MS-DRG,14514.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,14514.28,100,MS-DRG,11611.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14514.28,25399.99,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,inpatient,,,,,,11377.1,100,MS-DRG,9101.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9797.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16656.29,170,MS-DRG,13325.032,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17146.19,175,MS-DRG,13716.952,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13716.95,140,MS-DRG,10973.56,other,140% of Medicare CMS MS-DRG,12247.28,125,MS-DRG,9797.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,9797.82,100,MS-DRG,7838.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9797.82,17146.19,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,inpatient,,,,,,23403.1,100,MS-DRG,18722.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20706.99,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35201.88,170,MS-DRG,28161.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36237.23,175,MS-DRG,28989.784,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28989.79,140,MS-DRG,23191.83,other,140% of Medicare CMS MS-DRG,25883.74,125,MS-DRG,20706.99,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,20706.99,100,MS-DRG,16565.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20706.99,36237.23,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,inpatient,,,,,,18718,100,MS-DRG,14974.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15750.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26776.65,170,MS-DRG,21421.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27564.2,175,MS-DRG,22051.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22051.36,140,MS-DRG,17641.09,other,140% of Medicare CMS MS-DRG,19688.71,125,MS-DRG,15750.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,15750.97,100,MS-DRG,12600.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15750.97,27564.2,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,inpatient,,,,,,12799.5,100,MS-DRG,10239.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10712.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18211.83,170,MS-DRG,14569.464,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18747.47,175,MS-DRG,14997.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14997.98,140,MS-DRG,11998.38,other,140% of Medicare CMS MS-DRG,13391.05,125,MS-DRG,10712.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,10712.84,100,MS-DRG,8570.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10712.84,18747.47,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,inpatient,,,,,,17959.2,100,MS-DRG,14367.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16962.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28837.05,170,MS-DRG,23069.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29685.2,175,MS-DRG,23748.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23748.16,140,MS-DRG,18998.53,other,140% of Medicare CMS MS-DRG,21203.71,125,MS-DRG,16962.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,16962.97,100,MS-DRG,13570.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16962.97,29685.2,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,inpatient,,,,,,11425.4,100,MS-DRG,9140.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10123.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17210.48,170,MS-DRG,13768.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17716.67,175,MS-DRG,14173.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14173.33,140,MS-DRG,11338.66,other,140% of Medicare CMS MS-DRG,12654.76,125,MS-DRG,10123.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,10123.81,100,MS-DRG,8099.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10123.81,17716.67,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,inpatient,,,,,,7340.9,100,MS-DRG,5872.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6118.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10401.65,170,MS-DRG,8321.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10707.59,175,MS-DRG,8566.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8566.07,140,MS-DRG,6852.86,other,140% of Medicare CMS MS-DRG,7648.28,125,MS-DRG,6118.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,6118.62,100,MS-DRG,4894.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6118.62,10707.59,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,inpatient,,,,,,19959.1,100,MS-DRG,15967.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16723.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28429.8,170,MS-DRG,22743.84,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29265.97,175,MS-DRG,23412.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23412.77,140,MS-DRG,18730.22,other,140% of Medicare CMS MS-DRG,20904.26,125,MS-DRG,16723.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,16723.41,100,MS-DRG,13378.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16723.41,29265.97,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,inpatient,,,,,,13958.7,100,MS-DRG,11166.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11524.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19592.06,170,MS-DRG,15673.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20168.3,175,MS-DRG,16134.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16134.64,140,MS-DRG,12907.71,other,140% of Medicare CMS MS-DRG,14405.93,125,MS-DRG,11524.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,11524.74,100,MS-DRG,9219.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11524.74,20168.3,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,inpatient,,,,,,24490.2,100,MS-DRG,19592.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20468.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34796.74,170,MS-DRG,27837.392,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35820.17,175,MS-DRG,28656.136,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28656.14,140,MS-DRG,22924.91,other,140% of Medicare CMS MS-DRG,25585.84,125,MS-DRG,20468.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,20468.67,100,MS-DRG,16374.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20468.67,35820.17,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,inpatient,,,,,,13375.6,100,MS-DRG,10700.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11618.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19751.6,170,MS-DRG,15801.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20332.53,175,MS-DRG,16266.024,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16266.03,140,MS-DRG,13012.82,other,140% of Medicare CMS MS-DRG,14523.24,125,MS-DRG,11618.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,11618.59,100,MS-DRG,9294.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11618.59,20332.53,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,inpatient,,,,,,11737.6,100,MS-DRG,9390.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10158.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17269.26,170,MS-DRG,13815.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17777.18,175,MS-DRG,14221.744,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14221.75,140,MS-DRG,11377.4,other,140% of Medicare CMS MS-DRG,12697.99,125,MS-DRG,10158.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,10158.39,100,MS-DRG,8126.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10158.39,17777.18,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,inpatient,,,,,,19502,100,MS-DRG,15601.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17443.32,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29653.64,170,MS-DRG,23722.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30525.81,175,MS-DRG,24420.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24420.65,140,MS-DRG,19536.52,other,140% of Medicare CMS MS-DRG,21804.15,125,MS-DRG,17443.32,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,17443.32,100,MS-DRG,13954.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17443.32,30525.81,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,inpatient,,,,,,23167.9,100,MS-DRG,18534.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20164.9,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34280.33,170,MS-DRG,27424.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35288.58,175,MS-DRG,28230.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28230.86,140,MS-DRG,22584.69,other,140% of Medicare CMS MS-DRG,25206.13,125,MS-DRG,20164.9,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,20164.9,100,MS-DRG,16131.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20164.9,35288.58,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,inpatient,,,,,,23674.7,100,MS-DRG,18939.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21820.2,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37094.34,170,MS-DRG,29675.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38185.35,175,MS-DRG,30548.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30548.28,140,MS-DRG,24438.62,other,140% of Medicare CMS MS-DRG,27275.25,125,MS-DRG,21820.2,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,21820.2,100,MS-DRG,17456.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21820.2,38185.35,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,inpatient,,,,,,46204.9,100,MS-DRG,36963.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,38564.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65559.82,170,MS-DRG,52447.856,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,67488.05,175,MS-DRG,53990.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53990.44,140,MS-DRG,43192.35,other,140% of Medicare CMS MS-DRG,48205.75,125,MS-DRG,38564.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,38564.6,100,MS-DRG,30851.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38564.6,67488.05,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,inpatient,,,,,,36124.2,100,MS-DRG,28899.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,30131.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,51223.18,170,MS-DRG,40978.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52729.74,175,MS-DRG,42183.792,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42183.79,140,MS-DRG,33747.03,other,140% of Medicare CMS MS-DRG,37664.1,125,MS-DRG,30131.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,30131.28,100,MS-DRG,24105.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30131.28,52729.74,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,inpatient,,,,,,48445.6,100,MS-DRG,38756.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,42322.21,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,71947.76,170,MS-DRG,57558.208,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,74063.87,175,MS-DRG,59251.096,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,59251.09,140,MS-DRG,47400.87,other,140% of Medicare CMS MS-DRG,52902.76,125,MS-DRG,42322.21,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,42322.21,100,MS-DRG,33857.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42322.21,74063.87,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,inpatient,,,,,,29934.1,100,MS-DRG,23947.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,25675.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43649.17,170,MS-DRG,34919.336,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44932.97,175,MS-DRG,35946.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35946.37,140,MS-DRG,28757.1,other,140% of Medicare CMS MS-DRG,32094.98,125,MS-DRG,25675.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,25675.98,100,MS-DRG,20540.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25675.98,44932.97,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,inpatient,,,,,,35788.2,100,MS-DRG,28630.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,31222.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,53077.83,170,MS-DRG,42462.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54638.94,175,MS-DRG,43711.152,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43711.15,140,MS-DRG,34968.92,other,140% of Medicare CMS MS-DRG,39027.81,125,MS-DRG,31222.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,31222.25,100,MS-DRG,24977.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31222.25,54638.94,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,inpatient,,,,,,24386.6,100,MS-DRG,19509.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21339.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36276.69,170,MS-DRG,29021.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37343.65,175,MS-DRG,29874.92,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29874.92,140,MS-DRG,23899.94,other,140% of Medicare CMS MS-DRG,26674.04,125,MS-DRG,21339.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,21339.23,100,MS-DRG,17071.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21339.23,37343.65,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,inpatient,,,,,,18174.8,100,MS-DRG,14539.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15061.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25605.28,170,MS-DRG,20484.224,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26358.38,175,MS-DRG,21086.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21086.7,140,MS-DRG,16869.36,other,140% of Medicare CMS MS-DRG,18827.41,125,MS-DRG,15061.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,15061.93,100,MS-DRG,12049.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15061.93,26358.38,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,inpatient,,,,,,28091,100,MS-DRG,22472.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24060.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40903.38,170,MS-DRG,32722.704,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42106.42,175,MS-DRG,33685.136,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33685.13,140,MS-DRG,26948.1,other,140% of Medicare CMS MS-DRG,30076.01,125,MS-DRG,24060.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,24060.81,100,MS-DRG,19248.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24060.81,42106.42,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,inpatient,,,,,,23516.5,100,MS-DRG,18813.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20009.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34015.83,170,MS-DRG,27212.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35016.29,175,MS-DRG,28013.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28013.03,140,MS-DRG,22410.42,other,140% of Medicare CMS MS-DRG,25011.64,125,MS-DRG,20009.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,20009.31,100,MS-DRG,16007.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20009.31,35016.29,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,43440.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,73848.6,170,MS-DRG,59078.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,76020.61,175,MS-DRG,60816.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,60816.49,140,MS-DRG,48653.19,other,140% of Medicare CMS MS-DRG,54300.44,125,MS-DRG,43440.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,43440.35,100,MS-DRG,34752.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43440.35,76020.61,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,38342.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65183,170,MS-DRG,52146.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,67100.15,175,MS-DRG,53680.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53680.12,140,MS-DRG,42944.1,other,140% of Medicare CMS MS-DRG,47928.68,125,MS-DRG,38342.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,38342.94,100,MS-DRG,30674.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38342.94,67100.15,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,29527.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50196.65,170,MS-DRG,40157.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,51673.02,175,MS-DRG,41338.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,41338.42,140,MS-DRG,33070.74,other,140% of Medicare CMS MS-DRG,36909.3,125,MS-DRG,29527.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,29527.44,100,MS-DRG,23621.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29527.44,51673.02,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,27539.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46816.9,170,MS-DRG,37453.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48193.86,175,MS-DRG,38555.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38555.09,140,MS-DRG,30844.07,other,140% of Medicare CMS MS-DRG,34424.19,125,MS-DRG,27539.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,27539.35,100,MS-DRG,22031.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27539.35,48193.86,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,19761.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33593.87,170,MS-DRG,26875.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34581.93,175,MS-DRG,27665.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27665.54,140,MS-DRG,22132.43,other,140% of Medicare CMS MS-DRG,24701.38,125,MS-DRG,19761.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,19761.1,100,MS-DRG,15808.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19761.1,34581.93,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,inpatient,,,,,,11244.8,100,MS-DRG,8995.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9795.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16652.1,170,MS-DRG,13321.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17141.86,175,MS-DRG,13713.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13713.49,140,MS-DRG,10970.79,other,140% of Medicare CMS MS-DRG,12244.19,125,MS-DRG,9795.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9795.35,17141.86,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,inpatient,,,,,,6430.2,100,MS-DRG,5144.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5637.03,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9582.95,170,MS-DRG,7666.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9864.8,175,MS-DRG,7891.84,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7891.84,140,MS-DRG,6313.47,other,140% of Medicare CMS MS-DRG,7046.29,125,MS-DRG,5637.03,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,5637.03,100,MS-DRG,4509.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5637.03,9864.8,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,inpatient,,,,,,5016.9,100,MS-DRG,4013.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4433.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7537.27,170,MS-DRG,6029.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7758.96,175,MS-DRG,6207.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6207.17,140,MS-DRG,4965.74,other,140% of Medicare CMS MS-DRG,5542.11,125,MS-DRG,4433.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,4433.69,100,MS-DRG,3546.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4433.69,7758.96,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,inpatient,,,,,,13430.2,100,MS-DRG,10744.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12171.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20692.04,170,MS-DRG,16553.632,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21300.63,175,MS-DRG,17040.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17040.51,140,MS-DRG,13632.41,other,140% of Medicare CMS MS-DRG,15214.74,125,MS-DRG,12171.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,12171.79,100,MS-DRG,9737.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12171.79,21300.63,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,inpatient,,,,,,5147.8,100,MS-DRG,4118.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4567.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7763.99,170,MS-DRG,6211.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7992.34,175,MS-DRG,6393.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6393.87,140,MS-DRG,5115.1,other,140% of Medicare CMS MS-DRG,5708.81,125,MS-DRG,4567.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,4567.05,100,MS-DRG,3653.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4567.05,7992.34,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,inpatient,,,,,,3792.6,100,MS-DRG,3034.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3017.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5129.46,170,MS-DRG,4103.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5280.33,175,MS-DRG,4224.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4224.26,140,MS-DRG,3379.41,other,140% of Medicare CMS MS-DRG,3771.66,125,MS-DRG,3017.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,3017.33,100,MS-DRG,2413.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3017.33,5280.33,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,inpatient,,,,,,14847,100,MS-DRG,11877.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13309.08,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22625.44,170,MS-DRG,18100.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23290.89,175,MS-DRG,18632.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18632.71,140,MS-DRG,14906.17,other,140% of Medicare CMS MS-DRG,16636.35,125,MS-DRG,13309.08,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,13309.08,100,MS-DRG,10647.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13309.08,23290.89,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,inpatient,,,,,,7701.4,100,MS-DRG,6161.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6678.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11352.62,170,MS-DRG,9082.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11686.52,175,MS-DRG,9349.216,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9349.21,140,MS-DRG,7479.37,other,140% of Medicare CMS MS-DRG,8347.51,125,MS-DRG,6678.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,6678.01,100,MS-DRG,5342.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6678.01,11686.52,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,inpatient,,,,,,18875.5,100,MS-DRG,15100.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16009.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27216.44,170,MS-DRG,21773.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28016.92,175,MS-DRG,22413.536,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22413.54,140,MS-DRG,17930.83,other,140% of Medicare CMS MS-DRG,20012.09,125,MS-DRG,16009.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,16009.67,100,MS-DRG,12807.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16009.67,28016.92,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,inpatient,,,,,,11249.7,100,MS-DRG,8999.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9123.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15510.12,170,MS-DRG,12408.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15966.3,175,MS-DRG,12773.04,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12773.04,140,MS-DRG,10218.43,other,140% of Medicare CMS MS-DRG,11404.5,125,MS-DRG,9123.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,9123.6,100,MS-DRG,7298.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9123.6,15966.3,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,inpatient,,,,,,8439.9,100,MS-DRG,6751.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6699.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11389.35,170,MS-DRG,9111.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11724.34,175,MS-DRG,9379.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9379.47,140,MS-DRG,7503.58,other,140% of Medicare CMS MS-DRG,8374.53,125,MS-DRG,6699.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,6699.62,100,MS-DRG,5359.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6699.62,11724.34,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,inpatient,,,,,,8958.6,100,MS-DRG,7166.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7927.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13475.99,170,MS-DRG,10780.792,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13872.34,175,MS-DRG,11097.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11097.87,140,MS-DRG,8878.3,other,140% of Medicare CMS MS-DRG,9908.81,125,MS-DRG,7927.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,7927.05,100,MS-DRG,6341.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7927.05,13872.34,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,inpatient,,,,,,6039.6,100,MS-DRG,4831.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5288.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8989.92,170,MS-DRG,7191.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9254.33,175,MS-DRG,7403.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7403.47,140,MS-DRG,5922.78,other,140% of Medicare CMS MS-DRG,6610.24,125,MS-DRG,5288.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,5288.19,100,MS-DRG,4230.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5288.19,9254.33,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,inpatient,,,,,,3922.1,100,MS-DRG,3137.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3466.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5893.58,170,MS-DRG,4714.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6066.92,175,MS-DRG,4853.536,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4853.53,140,MS-DRG,3882.82,other,140% of Medicare CMS MS-DRG,4333.51,125,MS-DRG,3466.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,3466.81,100,MS-DRG,2773.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3466.81,6066.92,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,inpatient,,,,,,8081.5,100,MS-DRG,6465.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6752.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11479.61,170,MS-DRG,9183.688,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11817.24,175,MS-DRG,9453.792,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9453.79,140,MS-DRG,7563.03,other,140% of Medicare CMS MS-DRG,8440.89,125,MS-DRG,6752.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,6752.71,100,MS-DRG,5402.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6752.71,11817.24,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,inpatient,,,,,,6199.9,100,MS-DRG,4959.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4921.45,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8366.47,170,MS-DRG,6693.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8612.54,175,MS-DRG,6890.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6890.03,140,MS-DRG,5512.02,other,140% of Medicare CMS MS-DRG,6151.81,125,MS-DRG,4921.45,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,4921.45,100,MS-DRG,3937.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4921.45,8612.54,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,inpatient,,,,,,11468.1,100,MS-DRG,9174.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9898.46,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16827.38,170,MS-DRG,13461.904,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17322.31,175,MS-DRG,13857.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13857.84,140,MS-DRG,11086.27,other,140% of Medicare CMS MS-DRG,12373.08,125,MS-DRG,9898.46,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,9898.46,100,MS-DRG,7918.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9898.46,17322.31,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,inpatient,,,,,,4454.1,100,MS-DRG,3563.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4498.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7647.47,170,MS-DRG,6117.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7872.39,175,MS-DRG,6297.912,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6297.91,140,MS-DRG,5038.33,other,140% of Medicare CMS MS-DRG,5623.14,125,MS-DRG,4498.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,4498.51,100,MS-DRG,3598.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4454.1,7872.39,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,inpatient,,,,,,3419.5,100,MS-DRG,2735.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,2714.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4615.14,170,MS-DRG,3692.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4750.88,175,MS-DRG,3800.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3800.71,140,MS-DRG,3040.57,other,140% of Medicare CMS MS-DRG,3393.49,125,MS-DRG,2714.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,2714.79,100,MS-DRG,2171.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,2714.79,4750.88,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,inpatient,,,,,,10766,100,MS-DRG,8612.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9731.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16543.99,170,MS-DRG,13235.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17030.58,175,MS-DRG,13624.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13624.46,140,MS-DRG,10899.57,other,140% of Medicare CMS MS-DRG,12164.7,125,MS-DRG,9731.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,9731.76,100,MS-DRG,7785.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9731.76,17030.58,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,inpatient,,,,,,7217.7,100,MS-DRG,5774.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6587.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11199.36,170,MS-DRG,8959.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11528.76,175,MS-DRG,9223.008,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9223,140,MS-DRG,7378.4,other,140% of Medicare CMS MS-DRG,8234.83,125,MS-DRG,6587.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,6587.86,100,MS-DRG,5270.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6587.86,11528.76,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,inpatient,,,,,,5013.4,100,MS-DRG,4010.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4382.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7450.15,170,MS-DRG,5960.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7669.27,175,MS-DRG,6135.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6135.42,140,MS-DRG,4908.34,other,140% of Medicare CMS MS-DRG,5478.05,125,MS-DRG,4382.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,4382.44,100,MS-DRG,3505.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4382.44,7669.27,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,inpatient,,,,,,8440.6,100,MS-DRG,6752.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6921.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11767.2,170,MS-DRG,9413.76,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12113.29,175,MS-DRG,9690.632,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9690.63,140,MS-DRG,7752.5,other,140% of Medicare CMS MS-DRG,8652.35,125,MS-DRG,6921.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,6921.88,100,MS-DRG,5537.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6921.88,12113.29,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,inpatient,,,,,,4732.7,100,MS-DRG,3786.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4063.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6907.49,170,MS-DRG,5525.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7110.65,175,MS-DRG,5688.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5688.52,140,MS-DRG,4550.82,other,140% of Medicare CMS MS-DRG,5079.04,125,MS-DRG,4063.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,4063.23,100,MS-DRG,3250.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4063.23,7110.65,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,inpatient,,,,,,7690.2,100,MS-DRG,6152.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7094.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12060.06,170,MS-DRG,9648.048,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12414.76,175,MS-DRG,9931.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9931.81,140,MS-DRG,7945.45,other,140% of Medicare CMS MS-DRG,8867.69,125,MS-DRG,7094.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,7094.15,100,MS-DRG,5675.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7094.15,12414.76,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,inpatient,,,,,,5219.2,100,MS-DRG,4175.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4652.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7908.83,170,MS-DRG,6327.064,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8141.44,175,MS-DRG,6513.152,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6513.15,140,MS-DRG,5210.52,other,140% of Medicare CMS MS-DRG,5815.31,125,MS-DRG,4652.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,4652.25,100,MS-DRG,3721.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4652.25,8141.44,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,inpatient,,,,,,10330.6,100,MS-DRG,8264.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9488.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16130.45,170,MS-DRG,12904.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16604.88,175,MS-DRG,13283.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13283.9,140,MS-DRG,10627.12,other,140% of Medicare CMS MS-DRG,11860.63,125,MS-DRG,9488.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,9488.5,100,MS-DRG,7590.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9488.5,16604.88,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,inpatient,,,,,,6379.8,100,MS-DRG,5103.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5819.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9893.64,170,MS-DRG,7914.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10184.63,175,MS-DRG,8147.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8147.71,140,MS-DRG,6518.17,other,140% of Medicare CMS MS-DRG,7274.74,125,MS-DRG,5819.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,5819.79,100,MS-DRG,4655.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5819.79,10184.63,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,inpatient,,,,,,8208.2,100,MS-DRG,6566.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7422.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12618.44,170,MS-DRG,10094.752,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12989.57,175,MS-DRG,10391.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10391.65,140,MS-DRG,8313.32,other,140% of Medicare CMS MS-DRG,9278.26,125,MS-DRG,7422.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,7422.61,100,MS-DRG,5938.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7422.61,12989.57,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,inpatient,,,,,,5163.2,100,MS-DRG,4130.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4597.92,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7816.46,170,MS-DRG,6253.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8046.36,175,MS-DRG,6437.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6437.09,140,MS-DRG,5149.67,other,140% of Medicare CMS MS-DRG,5747.4,125,MS-DRG,4597.92,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,4597.92,100,MS-DRG,3678.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4597.92,8046.36,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,inpatient,,,,,,3858.4,100,MS-DRG,3086.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3414.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5804.36,170,MS-DRG,4643.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5975.08,175,MS-DRG,4780.064,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4780.06,140,MS-DRG,3824.05,other,140% of Medicare CMS MS-DRG,4267.91,125,MS-DRG,3414.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,3414.33,100,MS-DRG,2731.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3414.33,5975.08,
ANGINA PECTORIS,311,MS-DRG,,,,,inpatient,,,,,,4676.7,100,MS-DRG,3741.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4310.2,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7327.34,170,MS-DRG,5861.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7542.85,175,MS-DRG,6034.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6034.28,140,MS-DRG,4827.42,other,140% of Medicare CMS MS-DRG,5387.75,125,MS-DRG,4310.2,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,4310.2,100,MS-DRG,3448.16,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4310.2,7542.85,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,inpatient,,,,,,5968.9,100,MS-DRG,4775.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5331.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9063.4,170,MS-DRG,7250.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9329.97,175,MS-DRG,7463.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7463.97,140,MS-DRG,5971.18,other,140% of Medicare CMS MS-DRG,6664.26,125,MS-DRG,5331.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,5331.41,100,MS-DRG,4265.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5331.41,9329.97,
CHEST PAIN,313,MS-DRG,,,,,inpatient,,,,,,5063.8,100,MS-DRG,4051.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4467.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7595.01,170,MS-DRG,6076.008,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7818.39,175,MS-DRG,6254.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6254.71,140,MS-DRG,5003.77,other,140% of Medicare CMS MS-DRG,5584.56,125,MS-DRG,4467.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,4467.65,100,MS-DRG,3574.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4467.65,7818.39,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,inpatient,,,,,,14578.2,100,MS-DRG,11662.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12925.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21973.62,170,MS-DRG,17578.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22619.91,175,MS-DRG,18095.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18095.92,140,MS-DRG,14476.74,other,140% of Medicare CMS MS-DRG,16157.08,125,MS-DRG,12925.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,12925.66,100,MS-DRG,10340.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12925.66,22619.91,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,inpatient,,,,,,6779.5,100,MS-DRG,5423.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5972.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10152.89,170,MS-DRG,8122.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10451.51,175,MS-DRG,8361.208,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8361.21,140,MS-DRG,6688.97,other,140% of Medicare CMS MS-DRG,7465.36,125,MS-DRG,5972.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,5972.29,100,MS-DRG,4777.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5972.29,10451.51,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,inpatient,,,,,,4774,100,MS-DRG,3819.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4276.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7270.66,170,MS-DRG,5816.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7484.51,175,MS-DRG,5987.608,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5987.6,140,MS-DRG,4790.08,other,140% of Medicare CMS MS-DRG,5346.08,125,MS-DRG,4276.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,4276.86,100,MS-DRG,3421.49,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4276.86,7484.51,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,inpatient,,,,,,30146.2,100,MS-DRG,24116.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,26931.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,45783.02,170,MS-DRG,36626.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47129.58,175,MS-DRG,37703.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37703.67,140,MS-DRG,30162.94,other,140% of Medicare CMS MS-DRG,33663.99,125,MS-DRG,26931.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,26931.19,100,MS-DRG,21544.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26931.19,47129.58,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,inpatient,,,,,,17299.8,100,MS-DRG,13839.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13743.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23364.36,170,MS-DRG,18691.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24051.55,175,MS-DRG,19241.24,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19241.24,140,MS-DRG,15392.99,other,140% of Medicare CMS MS-DRG,17179.68,125,MS-DRG,13743.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,13743.74,100,MS-DRG,10994.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13743.74,24051.55,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,17748.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30173.2,170,MS-DRG,24138.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31060.65,175,MS-DRG,24848.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24848.52,140,MS-DRG,19878.82,other,140% of Medicare CMS MS-DRG,22186.18,125,MS-DRG,17748.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,17748.94,100,MS-DRG,14199.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17748.94,31060.65,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,11258.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19138.62,170,MS-DRG,15310.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19701.52,175,MS-DRG,15761.216,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15761.21,140,MS-DRG,12608.97,other,140% of Medicare CMS MS-DRG,14072.51,125,MS-DRG,11258.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,11258.01,100,MS-DRG,9006.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11258.01,19701.52,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,25561.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43453.94,170,MS-DRG,34763.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44732,175,MS-DRG,35785.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35785.6,140,MS-DRG,28628.48,other,140% of Medicare CMS MS-DRG,31951.43,125,MS-DRG,25561.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,25561.14,100,MS-DRG,20448.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25561.14,44732,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,18328.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31158.79,170,MS-DRG,24927.032,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32075.23,175,MS-DRG,25660.184,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25660.18,140,MS-DRG,20528.14,other,140% of Medicare CMS MS-DRG,22910.88,125,MS-DRG,18328.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,18328.7,100,MS-DRG,14662.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18328.7,32075.23,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,16326.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27754.88,170,MS-DRG,22203.904,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28571.2,175,MS-DRG,22856.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22856.96,140,MS-DRG,18285.57,other,140% of Medicare CMS MS-DRG,20408,125,MS-DRG,16326.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,16326.4,100,MS-DRG,13061.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16326.4,28571.2,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,inpatient,,,,,,35831.6,100,MS-DRG,28665.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,31358.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,53309.81,170,MS-DRG,42647.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54877.74,175,MS-DRG,43902.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43902.19,140,MS-DRG,35121.75,other,140% of Medicare CMS MS-DRG,39198.39,125,MS-DRG,31358.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,31358.71,100,MS-DRG,25086.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31358.71,54877.74,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,inpatient,,,,,,17929.1,100,MS-DRG,14343.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15419.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26213.01,170,MS-DRG,20970.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26983.99,175,MS-DRG,21587.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21587.19,140,MS-DRG,17269.75,other,140% of Medicare CMS MS-DRG,19274.28,125,MS-DRG,15419.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,15419.42,100,MS-DRG,12335.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15419.42,26983.99,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,inpatient,,,,,,11603.9,100,MS-DRG,9283.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9862.03,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16765.45,170,MS-DRG,13412.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17258.55,175,MS-DRG,13806.84,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13806.84,140,MS-DRG,11045.47,other,140% of Medicare CMS MS-DRG,12327.54,125,MS-DRG,9862.03,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,9862.03,100,MS-DRG,7889.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9862.03,17258.55,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,inpatient,,,,,,32363.1,100,MS-DRG,25890.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27887.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47408.87,170,MS-DRG,37927.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48803.25,175,MS-DRG,39042.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,39042.6,140,MS-DRG,31234.08,other,140% of Medicare CMS MS-DRG,34859.46,125,MS-DRG,27887.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,27887.57,100,MS-DRG,22310.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27887.57,48803.25,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,inpatient,,,,,,17187.8,100,MS-DRG,13750.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14645.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24897.84,170,MS-DRG,19918.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25630.13,175,MS-DRG,20504.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20504.11,140,MS-DRG,16403.29,other,140% of Medicare CMS MS-DRG,18307.24,125,MS-DRG,14645.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,14645.79,100,MS-DRG,11716.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14645.79,25630.13,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,inpatient,,,,,,11961.6,100,MS-DRG,9569.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10323.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17549.53,170,MS-DRG,14039.624,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18065.69,175,MS-DRG,14452.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14452.55,140,MS-DRG,11562.04,other,140% of Medicare CMS MS-DRG,12904.06,125,MS-DRG,10323.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,10323.25,100,MS-DRG,8258.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10323.25,18065.69,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,inpatient,,,,,,28422.1,100,MS-DRG,22737.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22562.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38355.98,170,MS-DRG,30684.784,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39484.1,175,MS-DRG,31587.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31587.28,140,MS-DRG,25269.82,other,140% of Medicare CMS MS-DRG,28202.93,125,MS-DRG,22562.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,22562.34,100,MS-DRG,18049.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22562.34,39484.1,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,inpatient,,,,,,15631.7,100,MS-DRG,12505.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12839.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21826.69,170,MS-DRG,17461.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22468.65,175,MS-DRG,17974.92,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17974.92,140,MS-DRG,14379.94,other,140% of Medicare CMS MS-DRG,16049.04,125,MS-DRG,12839.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,12839.23,100,MS-DRG,10271.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12839.23,22468.65,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,inpatient,,,,,,12001.5,100,MS-DRG,9601.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9910.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16847.32,170,MS-DRG,13477.856,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17342.83,175,MS-DRG,13874.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13874.27,140,MS-DRG,11099.42,other,140% of Medicare CMS MS-DRG,12387.74,125,MS-DRG,9910.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,9910.19,100,MS-DRG,7928.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9910.19,17342.83,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,inpatient,,,,,,25786.6,100,MS-DRG,20629.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22072.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37523.62,170,MS-DRG,30018.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38627.26,175,MS-DRG,30901.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30901.81,140,MS-DRG,24721.45,other,140% of Medicare CMS MS-DRG,27590.9,125,MS-DRG,22072.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,22072.72,100,MS-DRG,17658.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22072.72,38627.26,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,inpatient,,,,,,14889,100,MS-DRG,11911.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12998.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22097.47,170,MS-DRG,17677.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22747.39,175,MS-DRG,18197.912,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18197.91,140,MS-DRG,14558.33,other,140% of Medicare CMS MS-DRG,16248.14,125,MS-DRG,12998.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,12998.51,100,MS-DRG,10398.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12998.51,22747.39,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,inpatient,,,,,,11028.5,100,MS-DRG,8822.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9239.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15706.4,170,MS-DRG,12565.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16168.36,175,MS-DRG,12934.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12934.68,140,MS-DRG,10347.74,other,140% of Medicare CMS MS-DRG,11548.83,125,MS-DRG,9239.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,9239.06,100,MS-DRG,7391.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9239.06,16168.36,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,inpatient,,,,,,18427.5,100,MS-DRG,14742,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16919.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28763.58,170,MS-DRG,23010.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29609.56,175,MS-DRG,23687.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23687.65,140,MS-DRG,18950.12,other,140% of Medicare CMS MS-DRG,21149.69,125,MS-DRG,16919.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,16919.75,100,MS-DRG,13535.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16919.75,29609.56,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,inpatient,,,,,,10860.5,100,MS-DRG,8688.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9511.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16170.33,170,MS-DRG,12936.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16645.93,175,MS-DRG,13316.744,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13316.74,140,MS-DRG,10653.39,other,140% of Medicare CMS MS-DRG,11889.95,125,MS-DRG,9511.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,9511.96,100,MS-DRG,7609.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9511.96,16645.93,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,inpatient,,,,,,8754.9,100,MS-DRG,7003.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7951.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13516.9,170,MS-DRG,10813.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13914.46,175,MS-DRG,11131.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11131.57,140,MS-DRG,8905.26,other,140% of Medicare CMS MS-DRG,9938.9,125,MS-DRG,7951.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,7951.12,100,MS-DRG,6360.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7951.12,13914.46,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,inpatient,,,,,,17767.4,100,MS-DRG,14213.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15738.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26755.67,170,MS-DRG,21404.536,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27542.6,175,MS-DRG,22034.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22034.08,140,MS-DRG,17627.26,other,140% of Medicare CMS MS-DRG,19673.29,125,MS-DRG,15738.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,15738.63,100,MS-DRG,12590.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15738.63,27542.6,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,inpatient,,,,,,9667,100,MS-DRG,7733.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8035.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13659.65,170,MS-DRG,10927.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14061.41,175,MS-DRG,11249.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11249.13,140,MS-DRG,8999.3,other,140% of Medicare CMS MS-DRG,10043.86,125,MS-DRG,8035.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,8035.09,100,MS-DRG,6428.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8035.09,14061.41,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,inpatient,,,,,,6980.4,100,MS-DRG,5584.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6024.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10242.11,170,MS-DRG,8193.688,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10543.35,175,MS-DRG,8434.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8434.68,140,MS-DRG,6747.74,other,140% of Medicare CMS MS-DRG,7530.96,125,MS-DRG,6024.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,6024.77,100,MS-DRG,4819.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6024.77,10543.35,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,inpatient,,,,,,16499,100,MS-DRG,13199.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14818.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25190.7,170,MS-DRG,20152.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25931.61,175,MS-DRG,20745.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20745.28,140,MS-DRG,16596.22,other,140% of Medicare CMS MS-DRG,18522.58,125,MS-DRG,14818.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,14818.06,100,MS-DRG,11854.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14818.06,25931.61,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,inpatient,,,,,,10291.4,100,MS-DRG,8233.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8987.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15278.16,170,MS-DRG,12222.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15727.51,175,MS-DRG,12582.008,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12582.01,140,MS-DRG,10065.61,other,140% of Medicare CMS MS-DRG,11233.94,125,MS-DRG,8987.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,8987.15,100,MS-DRG,7189.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8987.15,15727.51,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,inpatient,,,,,,7714.7,100,MS-DRG,6171.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6847.17,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11640.19,170,MS-DRG,9312.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11982.55,175,MS-DRG,9586.04,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9586.04,140,MS-DRG,7668.83,other,140% of Medicare CMS MS-DRG,8558.96,125,MS-DRG,6847.17,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,6847.17,100,MS-DRG,5477.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6847.17,11982.55,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,inpatient,,,,,,20074.6,100,MS-DRG,16059.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18055.18,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30693.81,170,MS-DRG,24555.048,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31596.57,175,MS-DRG,25277.256,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25277.25,140,MS-DRG,20221.8,other,140% of Medicare CMS MS-DRG,22568.98,125,MS-DRG,18055.18,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,18055.18,100,MS-DRG,14444.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18055.18,31596.57,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,inpatient,,,,,,12264,100,MS-DRG,9811.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10606.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18030.23,170,MS-DRG,14424.184,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18560.54,175,MS-DRG,14848.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14848.43,140,MS-DRG,11878.74,other,140% of Medicare CMS MS-DRG,13257.53,125,MS-DRG,10606.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,10606.02,100,MS-DRG,8484.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10606.02,18560.54,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,inpatient,,,,,,9606.1,100,MS-DRG,7684.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8412.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14302.02,170,MS-DRG,11441.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14722.66,175,MS-DRG,11778.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11778.13,140,MS-DRG,9422.5,other,140% of Medicare CMS MS-DRG,10516.19,125,MS-DRG,8412.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,8412.95,100,MS-DRG,6730.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8412.95,14722.66,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,inpatient,,,,,,29557.5,100,MS-DRG,23646,other,Custom DRG with base of 7000. See MS-DRG rows for rates,26417.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44909.75,170,MS-DRG,35927.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46230.63,175,MS-DRG,36984.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,36984.5,140,MS-DRG,29587.6,other,140% of Medicare CMS MS-DRG,33021.88,125,MS-DRG,26417.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,26417.5,100,MS-DRG,21134,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26417.5,46230.63,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,inpatient,,,,,,15723.4,100,MS-DRG,12578.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13563.45,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23057.87,170,MS-DRG,18446.296,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23736.04,175,MS-DRG,18988.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18988.83,140,MS-DRG,15191.06,other,140% of Medicare CMS MS-DRG,16954.31,125,MS-DRG,13563.45,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,13563.45,100,MS-DRG,10850.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13563.45,23736.04,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,inpatient,,,,,,9710.4,100,MS-DRG,7768.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7909.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13446.58,170,MS-DRG,10757.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13842.06,175,MS-DRG,11073.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11073.65,140,MS-DRG,8858.92,other,140% of Medicare CMS MS-DRG,9887.19,125,MS-DRG,7909.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,7909.75,100,MS-DRG,6327.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7909.75,13842.06,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,inpatient,,,,,,12279.4,100,MS-DRG,9823.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10199.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17339.58,170,MS-DRG,13871.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17849.56,175,MS-DRG,14279.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14279.65,140,MS-DRG,11423.72,other,140% of Medicare CMS MS-DRG,12749.69,125,MS-DRG,10199.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,10199.75,100,MS-DRG,8159.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10199.75,17849.56,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,inpatient,,,,,,7154.7,100,MS-DRG,5723.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6101.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10373.32,170,MS-DRG,8298.656,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10678.41,175,MS-DRG,8542.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8542.73,140,MS-DRG,6834.18,other,140% of Medicare CMS MS-DRG,7627.44,125,MS-DRG,6101.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,6101.95,100,MS-DRG,4881.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6101.95,10678.41,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,inpatient,,,,,,5240.9,100,MS-DRG,4192.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4591.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7805.96,170,MS-DRG,6244.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8035.55,175,MS-DRG,6428.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6428.44,140,MS-DRG,5142.75,other,140% of Medicare CMS MS-DRG,5739.68,125,MS-DRG,4591.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,4591.74,100,MS-DRG,3673.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4591.74,8035.55,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,inpatient,,,,,,11842.6,100,MS-DRG,9474.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10790.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18344.07,170,MS-DRG,14675.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18883.6,175,MS-DRG,15106.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15106.88,140,MS-DRG,12085.5,other,140% of Medicare CMS MS-DRG,13488.29,125,MS-DRG,10790.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,10790.63,100,MS-DRG,8632.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10790.63,18883.6,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,inpatient,,,,,,7126,100,MS-DRG,5700.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6435.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10940.11,170,MS-DRG,8752.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11261.88,175,MS-DRG,9009.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9009.5,140,MS-DRG,7207.6,other,140% of Medicare CMS MS-DRG,8044.2,125,MS-DRG,6435.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,6435.36,100,MS-DRG,5148.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6435.36,11261.88,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,inpatient,,,,,,5082,100,MS-DRG,4065.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4423.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7520.48,170,MS-DRG,6016.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7741.67,175,MS-DRG,6193.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6193.33,140,MS-DRG,4954.66,other,140% of Medicare CMS MS-DRG,5529.76,125,MS-DRG,4423.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,4423.81,100,MS-DRG,3539.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4423.81,7741.67,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,inpatient,,,,,,13953.1,100,MS-DRG,11162.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12959.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22031.35,170,MS-DRG,17625.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22679.34,175,MS-DRG,18143.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18143.47,140,MS-DRG,14514.78,other,140% of Medicare CMS MS-DRG,16199.53,125,MS-DRG,12959.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,12959.62,100,MS-DRG,10367.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12959.62,22679.34,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,inpatient,,,,,,8432.2,100,MS-DRG,6745.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7398.53,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12577.5,170,MS-DRG,10062,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12947.43,175,MS-DRG,10357.944,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10357.94,140,MS-DRG,8286.35,other,140% of Medicare CMS MS-DRG,9248.16,125,MS-DRG,7398.53,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,7398.53,100,MS-DRG,5918.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7398.53,12947.43,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,inpatient,,,,,,6144.6,100,MS-DRG,4915.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5503.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9356.24,170,MS-DRG,7484.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9631.42,175,MS-DRG,7705.136,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7705.14,140,MS-DRG,6164.11,other,140% of Medicare CMS MS-DRG,6879.59,125,MS-DRG,5503.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,5503.67,100,MS-DRG,4402.94,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5503.67,9631.42,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,inpatient,,,,,,12446,100,MS-DRG,9956.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11053.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18791.21,170,MS-DRG,15032.968,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19343.89,175,MS-DRG,15475.112,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15475.11,140,MS-DRG,12380.09,other,140% of Medicare CMS MS-DRG,13817.06,125,MS-DRG,11053.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,11053.65,100,MS-DRG,8842.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11053.65,19343.89,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,inpatient,,,,,,6895,100,MS-DRG,5516,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6074.17,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10326.09,170,MS-DRG,8260.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10629.8,175,MS-DRG,8503.84,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8503.84,140,MS-DRG,6803.07,other,140% of Medicare CMS MS-DRG,7592.71,125,MS-DRG,6074.17,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,6074.17,100,MS-DRG,4859.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6074.17,10629.8,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,inpatient,,,,,,4436.6,100,MS-DRG,3549.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3909.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6646.15,170,MS-DRG,5316.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6841.63,175,MS-DRG,5473.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5473.3,140,MS-DRG,4378.64,other,140% of Medicare CMS MS-DRG,4886.88,125,MS-DRG,3909.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,3909.5,100,MS-DRG,3127.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3909.5,6841.63,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,inpatient,,,,,,13328.7,100,MS-DRG,10662.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12030.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20451.68,170,MS-DRG,16361.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21053.2,175,MS-DRG,16842.56,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16842.56,140,MS-DRG,13474.05,other,140% of Medicare CMS MS-DRG,15038,125,MS-DRG,12030.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,12030.4,100,MS-DRG,9624.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12030.4,21053.2,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,inpatient,,,,,,7388.5,100,MS-DRG,5910.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6624.9,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11262.33,170,MS-DRG,9009.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11593.58,175,MS-DRG,9274.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9274.86,140,MS-DRG,7419.89,other,140% of Medicare CMS MS-DRG,8281.13,125,MS-DRG,6624.9,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,6624.9,100,MS-DRG,5299.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6624.9,11593.58,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,inpatient,,,,,,5388.6,100,MS-DRG,4310.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4674.47,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7946.6,170,MS-DRG,6357.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8180.32,175,MS-DRG,6544.256,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6544.26,140,MS-DRG,5235.41,other,140% of Medicare CMS MS-DRG,5843.09,125,MS-DRG,4674.47,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,4674.47,100,MS-DRG,3739.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4674.47,8180.32,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,inpatient,,,,,,9520,100,MS-DRG,7616,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8632.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14675.68,170,MS-DRG,11740.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15107.31,175,MS-DRG,12085.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12085.85,140,MS-DRG,9668.68,other,140% of Medicare CMS MS-DRG,10790.94,125,MS-DRG,8632.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,8632.75,100,MS-DRG,6906.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8632.75,15107.31,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,inpatient,,,,,,6311.2,100,MS-DRG,5048.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5406.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9191.46,170,MS-DRG,7353.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9461.8,175,MS-DRG,7569.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7569.44,140,MS-DRG,6055.55,other,140% of Medicare CMS MS-DRG,6758.43,125,MS-DRG,5406.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,5406.74,100,MS-DRG,4325.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5406.74,9461.8,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,inpatient,,,,,,11400.9,100,MS-DRG,9120.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9674.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16446.38,170,MS-DRG,13157.104,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16930.1,175,MS-DRG,13544.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13544.08,140,MS-DRG,10835.26,other,140% of Medicare CMS MS-DRG,12092.93,125,MS-DRG,9674.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,9674.34,100,MS-DRG,7739.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9674.34,16930.1,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,inpatient,,,,,,6928.6,100,MS-DRG,5542.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5998.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10198.03,170,MS-DRG,8158.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10497.97,175,MS-DRG,8398.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8398.38,140,MS-DRG,6718.7,other,140% of Medicare CMS MS-DRG,7498.55,125,MS-DRG,5998.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,5998.84,100,MS-DRG,4799.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5998.84,10497.97,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,inpatient,,,,,,4841.2,100,MS-DRG,3872.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4223.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7180.39,170,MS-DRG,5744.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7391.58,175,MS-DRG,5913.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5913.26,140,MS-DRG,4730.61,other,140% of Medicare CMS MS-DRG,5279.7,125,MS-DRG,4223.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,4223.76,100,MS-DRG,3379.01,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4223.76,7391.58,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,inpatient,,,,,,10271.8,100,MS-DRG,8217.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8974.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15256.12,170,MS-DRG,12204.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15704.83,175,MS-DRG,12563.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12563.87,140,MS-DRG,10051.1,other,140% of Medicare CMS MS-DRG,11217.74,125,MS-DRG,8974.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,8974.19,100,MS-DRG,7179.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8974.19,15704.83,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,inpatient,,,,,,5649.7,100,MS-DRG,4519.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4917.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8359.1,170,MS-DRG,6687.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8604.96,175,MS-DRG,6883.968,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6883.97,140,MS-DRG,5507.18,other,140% of Medicare CMS MS-DRG,6146.4,125,MS-DRG,4917.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,4917.12,100,MS-DRG,3933.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4917.12,8604.96,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,inpatient,,,,,,3958.5,100,MS-DRG,3166.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3451.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5867.33,170,MS-DRG,4693.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6039.9,175,MS-DRG,4831.92,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4831.92,140,MS-DRG,3865.54,other,140% of Medicare CMS MS-DRG,4314.21,125,MS-DRG,3451.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,3451.37,100,MS-DRG,2761.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3451.37,6039.9,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,inpatient,,,,,,8988,100,MS-DRG,7190.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7876.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13389.9,170,MS-DRG,10711.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13783.72,175,MS-DRG,11026.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11026.97,140,MS-DRG,8821.58,other,140% of Medicare CMS MS-DRG,9845.51,125,MS-DRG,7876.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,7876.41,100,MS-DRG,6301.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7876.41,13783.72,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,inpatient,,,,,,5513.2,100,MS-DRG,4410.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4850.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8245.75,170,MS-DRG,6596.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8488.27,175,MS-DRG,6790.616,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6790.62,140,MS-DRG,5432.5,other,140% of Medicare CMS MS-DRG,6063.05,125,MS-DRG,4850.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,4850.44,100,MS-DRG,3880.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4850.44,8488.27,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,inpatient,,,,,,11279.1,100,MS-DRG,9023.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9999.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16999.52,170,MS-DRG,13599.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17499.51,175,MS-DRG,13999.608,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13999.61,140,MS-DRG,11199.69,other,140% of Medicare CMS MS-DRG,12499.65,125,MS-DRG,9999.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,9999.72,100,MS-DRG,7999.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9999.72,17499.51,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,inpatient,,,,,,6601,100,MS-DRG,5280.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5784.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9833.82,170,MS-DRG,7867.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10123.05,175,MS-DRG,8098.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8098.44,140,MS-DRG,6478.75,other,140% of Medicare CMS MS-DRG,7230.75,125,MS-DRG,5784.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,5784.6,100,MS-DRG,4627.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5784.6,10123.05,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,inpatient,,,,,,4514.3,100,MS-DRG,3611.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3997.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6796.24,170,MS-DRG,5436.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6996.13,175,MS-DRG,5596.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5596.91,140,MS-DRG,4477.53,other,140% of Medicare CMS MS-DRG,4997.24,125,MS-DRG,3997.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,3997.79,100,MS-DRG,3198.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3997.79,6996.13,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,13870.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23580.58,170,MS-DRG,18864.464,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24274.13,175,MS-DRG,19419.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19419.3,140,MS-DRG,15535.44,other,140% of Medicare CMS MS-DRG,17338.66,125,MS-DRG,13870.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,13870.93,100,MS-DRG,11096.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13870.93,24274.13,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,9343.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15883.78,170,MS-DRG,12707.024,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16350.95,175,MS-DRG,13080.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13080.76,140,MS-DRG,10464.61,other,140% of Medicare CMS MS-DRG,11679.25,125,MS-DRG,9343.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,9343.4,100,MS-DRG,7474.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9343.4,16350.95,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable per contract terms,6872.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11683.23,170,MS-DRG,9346.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12026.86,175,MS-DRG,9621.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9621.49,140,MS-DRG,7697.19,other,140% of Medicare CMS MS-DRG,8590.61,125,MS-DRG,6872.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6872.49,12026.86,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,inpatient,,,,,,38793.3,100,MS-DRG,31034.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,33990.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,57783.26,170,MS-DRG,46226.608,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59482.76,175,MS-DRG,47586.208,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,47586.21,140,MS-DRG,38068.97,other,140% of Medicare CMS MS-DRG,42487.69,125,MS-DRG,33990.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,33990.15,100,MS-DRG,27192.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33990.15,59482.76,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,inpatient,,,,,,20507.9,100,MS-DRG,16406.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17827.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30306.5,170,MS-DRG,24245.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31197.86,175,MS-DRG,24958.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24958.29,140,MS-DRG,19966.63,other,140% of Medicare CMS MS-DRG,22284.19,125,MS-DRG,17827.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,17827.35,100,MS-DRG,14261.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17827.35,31197.86,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,inpatient,,,,,,15579.9,100,MS-DRG,12463.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13280.68,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22577.16,170,MS-DRG,18061.728,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23241.19,175,MS-DRG,18592.952,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18592.95,140,MS-DRG,14874.36,other,140% of Medicare CMS MS-DRG,16600.85,125,MS-DRG,13280.68,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,13280.68,100,MS-DRG,10624.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13280.68,23241.19,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,inpatient,,,,,,25686.5,100,MS-DRG,20549.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22981.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39068.65,170,MS-DRG,31254.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40217.73,175,MS-DRG,32174.184,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32174.18,140,MS-DRG,25739.34,other,140% of Medicare CMS MS-DRG,28726.95,125,MS-DRG,22981.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,22981.56,100,MS-DRG,18385.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22981.56,40217.73,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,inpatient,,,,,,14919.8,100,MS-DRG,11935.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12084.73,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20544.04,170,MS-DRG,16435.232,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21148.28,175,MS-DRG,16918.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16918.62,140,MS-DRG,13534.9,other,140% of Medicare CMS MS-DRG,15105.91,125,MS-DRG,12084.73,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,12084.73,100,MS-DRG,9667.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12084.73,21148.28,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,inpatient,,,,,,11883.9,100,MS-DRG,9507.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9663.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16428.53,170,MS-DRG,13142.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16911.72,175,MS-DRG,13529.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13529.38,140,MS-DRG,10823.5,other,140% of Medicare CMS MS-DRG,12079.8,125,MS-DRG,9663.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,9663.84,100,MS-DRG,7731.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9663.84,16911.72,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,inpatient,,,,,,23647.4,100,MS-DRG,18917.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18772.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31912.42,170,MS-DRG,25529.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32851.02,175,MS-DRG,26280.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26280.81,140,MS-DRG,21024.65,other,140% of Medicare CMS MS-DRG,23465.01,125,MS-DRG,18772.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,18772.01,100,MS-DRG,15017.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18772.01,32851.02,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,inpatient,,,,,,16069.9,100,MS-DRG,12855.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12756.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21686.03,170,MS-DRG,17348.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22323.86,175,MS-DRG,17859.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17859.09,140,MS-DRG,14287.27,other,140% of Medicare CMS MS-DRG,15945.61,125,MS-DRG,12756.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,12756.49,100,MS-DRG,10205.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12756.49,22323.86,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,inpatient,,,,,,11342.8,100,MS-DRG,9074.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9320.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15844.94,170,MS-DRG,12675.952,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16310.96,175,MS-DRG,13048.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13048.77,140,MS-DRG,10439.02,other,140% of Medicare CMS MS-DRG,11650.69,125,MS-DRG,9320.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,9320.55,100,MS-DRG,7456.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9320.55,16310.96,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,inpatient,,,,,,24742.9,100,MS-DRG,19794.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21765.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37000.93,170,MS-DRG,29600.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38089.19,175,MS-DRG,30471.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30471.35,140,MS-DRG,24377.08,other,140% of Medicare CMS MS-DRG,27206.56,125,MS-DRG,21765.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,21765.25,100,MS-DRG,17412.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21765.25,38089.19,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,inpatient,,,,,,14000,100,MS-DRG,11200,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12198.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20738.23,170,MS-DRG,16590.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21348.18,175,MS-DRG,17078.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17078.54,140,MS-DRG,13662.83,other,140% of Medicare CMS MS-DRG,15248.7,125,MS-DRG,12198.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,12198.96,100,MS-DRG,9759.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12198.96,21348.18,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,inpatient,,,,,,9634.8,100,MS-DRG,7707.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8268.47,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14056.4,170,MS-DRG,11245.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14469.82,175,MS-DRG,11575.856,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11575.86,140,MS-DRG,9260.69,other,140% of Medicare CMS MS-DRG,10335.59,125,MS-DRG,8268.47,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,8268.47,100,MS-DRG,6614.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8268.47,14469.82,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,inpatient,,,,,,16643.9,100,MS-DRG,13315.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14310.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24327.92,170,MS-DRG,19462.336,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25043.45,175,MS-DRG,20034.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20034.76,140,MS-DRG,16027.81,other,140% of Medicare CMS MS-DRG,17888.18,125,MS-DRG,14310.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,14310.54,100,MS-DRG,11448.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14310.54,25043.45,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,inpatient,,,,,,11627,100,MS-DRG,9301.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10092.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17158,170,MS-DRG,13726.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17662.65,175,MS-DRG,14130.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14130.12,140,MS-DRG,11304.1,other,140% of Medicare CMS MS-DRG,12616.18,125,MS-DRG,10092.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,10092.94,100,MS-DRG,8074.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10092.94,17662.65,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,inpatient,,,,,,9135,100,MS-DRG,7308,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8107.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13783.52,170,MS-DRG,11026.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14188.91,175,MS-DRG,11351.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11351.13,140,MS-DRG,9080.9,other,140% of Medicare CMS MS-DRG,10134.94,125,MS-DRG,8107.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,8107.95,100,MS-DRG,6486.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8107.95,14188.91,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,inpatient,,,,,,22828.4,100,MS-DRG,18262.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19762.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33595.98,170,MS-DRG,26876.784,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34584.1,175,MS-DRG,27667.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27667.28,140,MS-DRG,22133.82,other,140% of Medicare CMS MS-DRG,24702.93,125,MS-DRG,19762.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,19762.34,100,MS-DRG,15809.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19762.34,34584.1,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,inpatient,,,,,,12681.2,100,MS-DRG,10144.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10555.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17944.16,170,MS-DRG,14355.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18471.93,175,MS-DRG,14777.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14777.55,140,MS-DRG,11822.04,other,140% of Medicare CMS MS-DRG,13194.24,125,MS-DRG,10555.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,10555.39,100,MS-DRG,8444.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10555.39,18471.93,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,inpatient,,,,,,9699.2,100,MS-DRG,7759.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8711.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14810.03,170,MS-DRG,11848.024,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15245.62,175,MS-DRG,12196.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12196.49,140,MS-DRG,9757.19,other,140% of Medicare CMS MS-DRG,10889.73,125,MS-DRG,8711.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,8711.78,100,MS-DRG,6969.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8711.78,15245.62,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,inpatient,,,,,,27523.3,100,MS-DRG,22018.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24146.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41049.27,170,MS-DRG,32839.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42256.6,175,MS-DRG,33805.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33805.28,140,MS-DRG,27044.22,other,140% of Medicare CMS MS-DRG,30183.29,125,MS-DRG,24146.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,24146.63,100,MS-DRG,19317.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24146.63,42256.6,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,inpatient,,,,,,16580.2,100,MS-DRG,13264.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13161.52,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22374.58,170,MS-DRG,17899.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23032.66,175,MS-DRG,18426.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18426.13,140,MS-DRG,14740.9,other,140% of Medicare CMS MS-DRG,16451.9,125,MS-DRG,13161.52,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13161.52,23032.66,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,inpatient,,,,,,10014.2,100,MS-DRG,8011.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9890.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16813.73,170,MS-DRG,13450.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17308.25,175,MS-DRG,13846.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13846.6,140,MS-DRG,11077.28,other,140% of Medicare CMS MS-DRG,12363.04,125,MS-DRG,9890.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,9890.43,100,MS-DRG,7912.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9890.43,17308.25,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,inpatient,,,,,,13217.4,100,MS-DRG,10573.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11829.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20110.56,170,MS-DRG,16088.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20702.05,175,MS-DRG,16561.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16561.64,140,MS-DRG,13249.31,other,140% of Medicare CMS MS-DRG,14787.18,125,MS-DRG,11829.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,11829.74,100,MS-DRG,9463.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11829.74,20702.05,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,inpatient,,,,,,7278.6,100,MS-DRG,5822.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6365.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10821.49,170,MS-DRG,8657.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11139.77,175,MS-DRG,8911.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8911.81,140,MS-DRG,7129.45,other,140% of Medicare CMS MS-DRG,7956.98,125,MS-DRG,6365.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,6365.58,100,MS-DRG,5092.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6365.58,11139.77,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,inpatient,,,,,,4393.9,100,MS-DRG,3515.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4133.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7027.15,170,MS-DRG,5621.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7233.84,175,MS-DRG,5787.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5787.07,140,MS-DRG,4629.66,other,140% of Medicare CMS MS-DRG,5167.03,125,MS-DRG,4133.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,4133.62,100,MS-DRG,3306.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4133.62,7233.84,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,inpatient,,,,,,12237.4,100,MS-DRG,9789.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10865.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18472.13,170,MS-DRG,14777.704,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19015.43,175,MS-DRG,15212.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15212.34,140,MS-DRG,12169.87,other,140% of Medicare CMS MS-DRG,13582.45,125,MS-DRG,10865.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,10865.96,100,MS-DRG,8692.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10865.96,19015.43,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,inpatient,,,,,,7702.8,100,MS-DRG,6162.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6795.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11553.08,170,MS-DRG,9242.464,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11892.88,175,MS-DRG,9514.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9514.3,140,MS-DRG,7611.44,other,140% of Medicare CMS MS-DRG,8494.91,125,MS-DRG,6795.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,6795.93,100,MS-DRG,5436.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6795.93,11892.88,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,inpatient,,,,,,5921.3,100,MS-DRG,4737.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5131.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8723.31,170,MS-DRG,6978.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8979.88,175,MS-DRG,7183.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7183.9,140,MS-DRG,5747.12,other,140% of Medicare CMS MS-DRG,6414.2,125,MS-DRG,5131.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,5131.36,100,MS-DRG,4105.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5131.36,8979.88,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,inpatient,,,,,,11601.8,100,MS-DRG,9281.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10303.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17515.93,170,MS-DRG,14012.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18031.11,175,MS-DRG,14424.888,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14424.89,140,MS-DRG,11539.91,other,140% of Medicare CMS MS-DRG,12879.36,125,MS-DRG,10303.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,10303.49,100,MS-DRG,8242.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10303.49,18031.11,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,inpatient,,,,,,6088.6,100,MS-DRG,4870.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5280.17,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8976.29,170,MS-DRG,7181.032,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9240.3,175,MS-DRG,7392.24,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7392.24,140,MS-DRG,5913.79,other,140% of Medicare CMS MS-DRG,6600.21,125,MS-DRG,5280.17,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,5280.17,100,MS-DRG,4224.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5280.17,9240.3,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,inpatient,,,,,,4244.8,100,MS-DRG,3395.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3800.83,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6461.41,170,MS-DRG,5169.128,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6651.45,175,MS-DRG,5321.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5321.16,140,MS-DRG,4256.93,other,140% of Medicare CMS MS-DRG,4751.04,125,MS-DRG,3800.83,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,3800.83,100,MS-DRG,3040.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3800.83,6651.45,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,inpatient,,,,,,13263.6,100,MS-DRG,10610.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11287.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19189.01,170,MS-DRG,15351.208,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19753.39,175,MS-DRG,15802.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15802.71,140,MS-DRG,12642.17,other,140% of Medicare CMS MS-DRG,14109.56,125,MS-DRG,11287.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,11287.65,100,MS-DRG,9030.12,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11287.65,19753.39,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,inpatient,,,,,,6622,100,MS-DRG,5297.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5874.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9987.06,170,MS-DRG,7989.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10280.8,175,MS-DRG,8224.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8224.64,140,MS-DRG,6579.71,other,140% of Medicare CMS MS-DRG,7343.43,125,MS-DRG,5874.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,5874.74,100,MS-DRG,4699.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5874.74,10280.8,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,inpatient,,,,,,4563.3,100,MS-DRG,3650.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4412.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7501.57,170,MS-DRG,6001.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7722.21,175,MS-DRG,6177.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6177.77,140,MS-DRG,4942.22,other,140% of Medicare CMS MS-DRG,5515.86,125,MS-DRG,4412.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,4412.69,100,MS-DRG,3530.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4412.69,7722.21,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,inpatient,,,,,,11652.9,100,MS-DRG,9322.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10083.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17142.27,170,MS-DRG,13713.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17646.46,175,MS-DRG,14117.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14117.17,140,MS-DRG,11293.74,other,140% of Medicare CMS MS-DRG,12604.61,125,MS-DRG,10083.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,10083.69,100,MS-DRG,8066.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10083.69,17646.46,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,inpatient,,,,,,7697.2,100,MS-DRG,6157.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6710.11,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11407.19,170,MS-DRG,9125.752,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11742.69,175,MS-DRG,9394.152,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9394.15,140,MS-DRG,7515.32,other,140% of Medicare CMS MS-DRG,8387.64,125,MS-DRG,6710.11,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,6710.11,100,MS-DRG,5368.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6710.11,11742.69,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,inpatient,,,,,,5681.9,100,MS-DRG,4545.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4948.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8412.64,170,MS-DRG,6730.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8660.07,175,MS-DRG,6928.056,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6928.05,140,MS-DRG,5542.44,other,140% of Medicare CMS MS-DRG,6185.76,125,MS-DRG,4948.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,4948.61,100,MS-DRG,3958.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4948.61,8660.07,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,inpatient,,,,,,64083.6,100,MS-DRG,51266.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,54711.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,93010.33,170,MS-DRG,74408.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,95745.93,175,MS-DRG,76596.744,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,76596.74,140,MS-DRG,61277.39,other,140% of Medicare CMS MS-DRG,68389.95,125,MS-DRG,54711.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,54711.96,100,MS-DRG,43769.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54711.96,95745.93,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,inpatient,,,,,,42636.3,100,MS-DRG,34109.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37763.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64197.42,170,MS-DRG,51357.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,66085.58,175,MS-DRG,52868.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52868.47,140,MS-DRG,42294.78,other,140% of Medicare CMS MS-DRG,47203.99,125,MS-DRG,37763.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,37763.19,100,MS-DRG,30210.55,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37763.19,66085.58,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,inpatient,,,,,,33516,100,MS-DRG,26812.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,28435.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48340.93,170,MS-DRG,38672.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,49762.72,175,MS-DRG,39810.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,39810.18,140,MS-DRG,31848.14,other,140% of Medicare CMS MS-DRG,35544.8,125,MS-DRG,28435.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,28435.84,100,MS-DRG,22748.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28435.84,49762.72,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,inpatient,,,,,,59144.4,100,MS-DRG,47315.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,52044.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,88476.01,170,MS-DRG,70780.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,91078.24,175,MS-DRG,72862.592,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,72862.59,140,MS-DRG,58290.07,other,140% of Medicare CMS MS-DRG,65055.89,125,MS-DRG,52044.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,52044.71,100,MS-DRG,41635.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52044.71,91078.24,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,inpatient,,,,,,42257.6,100,MS-DRG,33806.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37510.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63767.09,170,MS-DRG,51013.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65642.59,175,MS-DRG,52514.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52514.07,140,MS-DRG,42011.26,other,140% of Medicare CMS MS-DRG,46887.56,125,MS-DRG,37510.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,37510.05,100,MS-DRG,30008.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37510.05,65642.59,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,inpatient,,,,,,33691.7,100,MS-DRG,26953.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27975.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47557.93,170,MS-DRG,38046.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48956.69,175,MS-DRG,39165.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,39165.35,140,MS-DRG,31332.28,other,140% of Medicare CMS MS-DRG,34969.06,125,MS-DRG,27975.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,27975.25,100,MS-DRG,22380.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27975.25,48956.69,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,inpatient,,,,,,46431,100,MS-DRG,37144.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,40949.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,69613.42,170,MS-DRG,55690.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,71660.87,175,MS-DRG,57328.696,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,57328.7,140,MS-DRG,45862.96,other,140% of Medicare CMS MS-DRG,51186.34,125,MS-DRG,40949.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,40949.07,100,MS-DRG,32759.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40949.07,71660.87,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,inpatient,,,,,,26362,100,MS-DRG,21089.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22584.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38393.77,170,MS-DRG,30715.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39523,175,MS-DRG,31618.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31618.4,140,MS-DRG,25294.72,other,140% of Medicare CMS MS-DRG,28230.71,125,MS-DRG,22584.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,22584.57,100,MS-DRG,18067.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22584.57,39523,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,inpatient,,,,,,44906.4,100,MS-DRG,35925.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,42098.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,71567.81,170,MS-DRG,57254.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,73672.74,175,MS-DRG,58938.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,58938.19,140,MS-DRG,47150.55,other,140% of Medicare CMS MS-DRG,52623.39,125,MS-DRG,42098.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,42098.71,100,MS-DRG,33678.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42098.71,73672.74,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,inpatient,,,,,,20899.2,100,MS-DRG,16719.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17573.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29875.1,170,MS-DRG,23900.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30753.78,175,MS-DRG,24603.024,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24603.03,140,MS-DRG,19682.42,other,140% of Medicare CMS MS-DRG,21966.99,125,MS-DRG,17573.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,17573.59,100,MS-DRG,14058.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17573.59,30753.78,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,inpatient,,,,,,36691.2,100,MS-DRG,29352.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,34968.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59446.88,170,MS-DRG,47557.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,61195.31,175,MS-DRG,48956.248,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,48956.25,140,MS-DRG,39165,other,140% of Medicare CMS MS-DRG,43710.94,125,MS-DRG,34968.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,34968.75,100,MS-DRG,27975,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34968.75,61195.31,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,inpatient,,,,,,20910.4,100,MS-DRG,16728.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18531.21,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31503.06,170,MS-DRG,25202.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32429.62,175,MS-DRG,25943.696,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25943.69,140,MS-DRG,20754.95,other,140% of Medicare CMS MS-DRG,23164.01,125,MS-DRG,18531.21,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,18531.21,100,MS-DRG,14824.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18531.21,32429.62,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,inpatient,,,,,,13948.9,100,MS-DRG,11159.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11550.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19636.14,170,MS-DRG,15708.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20213.67,175,MS-DRG,16170.936,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16170.94,140,MS-DRG,12936.75,other,140% of Medicare CMS MS-DRG,14438.34,125,MS-DRG,11550.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,11550.67,100,MS-DRG,9240.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11550.67,20213.67,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,inpatient,,,,,,36715.7,100,MS-DRG,29372.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,32023.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54439.19,170,MS-DRG,43551.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,56040.34,175,MS-DRG,44832.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,44832.27,140,MS-DRG,35865.82,other,140% of Medicare CMS MS-DRG,40028.81,125,MS-DRG,32023.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,32023.05,100,MS-DRG,25618.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32023.05,56040.34,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,inpatient,,,,,,25381.3,100,MS-DRG,20305.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21525.08,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36592.64,170,MS-DRG,29274.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37668.89,175,MS-DRG,30135.112,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30135.11,140,MS-DRG,24108.09,other,140% of Medicare CMS MS-DRG,26906.35,125,MS-DRG,21525.08,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,21525.08,100,MS-DRG,17220.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21525.08,37668.89,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,inpatient,,,,,,19525.1,100,MS-DRG,15620.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16482.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28020.45,170,MS-DRG,22416.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28844.59,175,MS-DRG,23075.672,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23075.67,140,MS-DRG,18460.54,other,140% of Medicare CMS MS-DRG,20603.28,125,MS-DRG,16482.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,16482.62,100,MS-DRG,13186.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16482.62,28844.59,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,inpatient,,,,,,22619.8,100,MS-DRG,18095.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20558.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34949.98,170,MS-DRG,27959.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35977.92,175,MS-DRG,28782.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28782.33,140,MS-DRG,23025.86,other,140% of Medicare CMS MS-DRG,25698.51,125,MS-DRG,20558.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,20558.81,100,MS-DRG,16447.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20558.81,35977.92,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,inpatient,,,,,,13383.3,100,MS-DRG,10706.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11617.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19750.55,170,MS-DRG,15800.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20331.45,175,MS-DRG,16265.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16265.16,140,MS-DRG,13012.13,other,140% of Medicare CMS MS-DRG,14522.46,125,MS-DRG,11617.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,11617.97,100,MS-DRG,9294.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11617.97,20331.45,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,inpatient,,,,,,35259,100,MS-DRG,28207.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,30370.83,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,51630.41,170,MS-DRG,41304.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,53148.95,175,MS-DRG,42519.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42519.16,140,MS-DRG,34015.33,other,140% of Medicare CMS MS-DRG,37963.54,125,MS-DRG,30370.83,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,30370.83,100,MS-DRG,24296.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30370.83,53148.95,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,inpatient,,,,,,21497,100,MS-DRG,17197.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18247.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31020.22,170,MS-DRG,24816.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31932.58,175,MS-DRG,25546.064,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25546.07,140,MS-DRG,20436.86,other,140% of Medicare CMS MS-DRG,22808.99,125,MS-DRG,18247.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,18247.19,100,MS-DRG,14597.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18247.19,31932.58,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,inpatient,,,,,,17745.7,100,MS-DRG,14196.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15192.2,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25826.74,170,MS-DRG,20661.392,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26586.35,175,MS-DRG,21269.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21269.08,140,MS-DRG,17015.26,other,140% of Medicare CMS MS-DRG,18990.25,125,MS-DRG,15192.2,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,15192.2,100,MS-DRG,12153.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15192.2,26586.35,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,inpatient,,,,,,28678.3,100,MS-DRG,22942.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,26566.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,45162.69,170,MS-DRG,36130.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46491.01,175,MS-DRG,37192.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37192.81,140,MS-DRG,29754.25,other,140% of Medicare CMS MS-DRG,33207.86,125,MS-DRG,26566.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,26566.29,100,MS-DRG,21253.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26566.29,46491.01,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,inpatient,,,,,,15548.4,100,MS-DRG,12438.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13241.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22511.04,170,MS-DRG,18008.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23173.13,175,MS-DRG,18538.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18538.51,140,MS-DRG,14830.81,other,140% of Medicare CMS MS-DRG,16552.24,125,MS-DRG,13241.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,13241.79,100,MS-DRG,10593.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13241.79,23173.13,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,inpatient,,,,,,8592.5,100,MS-DRG,6874,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7266.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12352.9,170,MS-DRG,9882.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12716.22,175,MS-DRG,10172.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10172.97,140,MS-DRG,8138.38,other,140% of Medicare CMS MS-DRG,9083.01,125,MS-DRG,7266.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,7266.41,100,MS-DRG,5813.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7266.41,12716.22,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,inpatient,,,,,,23819.6,100,MS-DRG,19055.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20800.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35361.43,170,MS-DRG,28289.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36401.47,175,MS-DRG,29121.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29121.18,140,MS-DRG,23296.94,other,140% of Medicare CMS MS-DRG,26001.05,125,MS-DRG,20800.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,20800.84,100,MS-DRG,16640.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20800.84,36401.47,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,inpatient,,,,,,16442.3,100,MS-DRG,13153.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14717.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25019.6,170,MS-DRG,20015.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25755.47,175,MS-DRG,20604.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20604.37,140,MS-DRG,16483.5,other,140% of Medicare CMS MS-DRG,18396.76,125,MS-DRG,14717.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,14717.41,100,MS-DRG,11773.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14717.41,25755.47,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,inpatient,,,,,,12378.8,100,MS-DRG,9903.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11508.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19564.77,170,MS-DRG,15651.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20140.21,175,MS-DRG,16112.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16112.17,140,MS-DRG,12889.74,other,140% of Medicare CMS MS-DRG,14385.86,125,MS-DRG,11508.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,11508.69,100,MS-DRG,9206.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11508.69,20140.21,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,inpatient,,,,,,20762,100,MS-DRG,16609.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18207.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30952.02,170,MS-DRG,24761.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31862.37,175,MS-DRG,25489.896,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25489.9,140,MS-DRG,20391.92,other,140% of Medicare CMS MS-DRG,22758.84,125,MS-DRG,18207.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,18207.07,100,MS-DRG,14565.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18207.07,31862.37,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,inpatient,,,,,,14786.8,100,MS-DRG,11829.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12810.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21778.39,170,MS-DRG,17422.712,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22418.94,175,MS-DRG,17935.152,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17935.15,140,MS-DRG,14348.12,other,140% of Medicare CMS MS-DRG,16013.53,125,MS-DRG,12810.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,12810.82,100,MS-DRG,10248.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12810.82,22418.94,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,inpatient,,,,,,11522.7,100,MS-DRG,9218.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9807.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16672.05,170,MS-DRG,13337.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17162.41,175,MS-DRG,13729.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13729.93,140,MS-DRG,10983.94,other,140% of Medicare CMS MS-DRG,12258.86,125,MS-DRG,9807.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,9807.09,100,MS-DRG,7845.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9807.09,17162.41,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,inpatient,,,,,,16503.2,100,MS-DRG,13202.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15337.92,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26074.46,170,MS-DRG,20859.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26841.36,175,MS-DRG,21473.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21473.09,140,MS-DRG,17178.47,other,140% of Medicare CMS MS-DRG,19172.4,125,MS-DRG,15337.92,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,15337.92,100,MS-DRG,12270.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15337.92,26841.36,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,inpatient,,,,,,22757,100,MS-DRG,18205.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20337.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34574.21,170,MS-DRG,27659.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35591.1,175,MS-DRG,28472.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28472.88,140,MS-DRG,22778.3,other,140% of Medicare CMS MS-DRG,25422.21,125,MS-DRG,20337.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,20337.77,100,MS-DRG,16270.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20337.77,35591.1,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,inpatient,,,,,,14602,100,MS-DRG,11681.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12399.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21079.35,170,MS-DRG,16863.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21699.34,175,MS-DRG,17359.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17359.47,140,MS-DRG,13887.58,other,140% of Medicare CMS MS-DRG,15499.53,125,MS-DRG,12399.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,12399.62,100,MS-DRG,9919.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12399.62,21699.34,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,inpatient,,,,,,11228,100,MS-DRG,8982.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9538.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16215.45,170,MS-DRG,12972.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16692.38,175,MS-DRG,13353.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13353.9,140,MS-DRG,10683.12,other,140% of Medicare CMS MS-DRG,11923.13,125,MS-DRG,9538.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,9538.5,100,MS-DRG,7630.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9538.5,16692.38,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,inpatient,,,,,,15884.4,100,MS-DRG,12707.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13006.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22111.12,170,MS-DRG,17688.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22761.45,175,MS-DRG,18209.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18209.16,140,MS-DRG,14567.33,other,140% of Medicare CMS MS-DRG,16258.18,125,MS-DRG,13006.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,13006.54,100,MS-DRG,10405.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13006.54,22761.45,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,inpatient,,,,,,9306.5,100,MS-DRG,7445.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7641.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12991.04,170,MS-DRG,10392.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13373.13,175,MS-DRG,10698.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10698.51,140,MS-DRG,8558.81,other,140% of Medicare CMS MS-DRG,9552.24,125,MS-DRG,7641.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,7641.79,100,MS-DRG,6113.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7641.79,13373.13,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,inpatient,,,,,,24401.3,100,MS-DRG,19521.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21375.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36338.62,170,MS-DRG,29070.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37407.41,175,MS-DRG,29925.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29925.92,140,MS-DRG,23940.74,other,140% of Medicare CMS MS-DRG,26719.58,125,MS-DRG,21375.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,21375.66,100,MS-DRG,17100.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21375.66,37407.41,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,inpatient,,,,,,16630.6,100,MS-DRG,13304.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14828.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25208.54,170,MS-DRG,20166.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25949.96,175,MS-DRG,20759.968,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20759.97,140,MS-DRG,16607.98,other,140% of Medicare CMS MS-DRG,18535.69,125,MS-DRG,14828.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,14828.55,100,MS-DRG,11862.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14828.55,25949.96,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,inpatient,,,,,,13221.6,100,MS-DRG,10577.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11540.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19619.34,170,MS-DRG,15695.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20196.38,175,MS-DRG,16157.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16157.11,140,MS-DRG,12925.69,other,140% of Medicare CMS MS-DRG,14425.99,125,MS-DRG,11540.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,11540.79,100,MS-DRG,9232.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11540.79,20196.38,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,inpatient,,,,,,26000.8,100,MS-DRG,20800.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22111,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37588.7,170,MS-DRG,30070.96,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38694.25,175,MS-DRG,30955.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30955.4,140,MS-DRG,24764.32,other,140% of Medicare CMS MS-DRG,27638.75,125,MS-DRG,22111,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,22111,100,MS-DRG,17688.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22111,38694.25,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,inpatient,,,,,,14697.9,100,MS-DRG,11758.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12271.2,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20861.04,170,MS-DRG,16688.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21474.6,175,MS-DRG,17179.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17179.68,140,MS-DRG,13743.74,other,140% of Medicare CMS MS-DRG,15339,125,MS-DRG,12271.2,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,12271.2,100,MS-DRG,9816.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12271.2,21474.6,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,inpatient,,,,,,10651.9,100,MS-DRG,8521.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8813.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14982.17,170,MS-DRG,11985.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15422.82,175,MS-DRG,12338.256,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12338.26,140,MS-DRG,9870.61,other,140% of Medicare CMS MS-DRG,11016.3,125,MS-DRG,8813.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,8813.04,100,MS-DRG,7050.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8813.04,15422.82,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,inpatient,,,,,,17941.7,100,MS-DRG,14353.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16120.8,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27405.36,170,MS-DRG,21924.288,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28211.4,175,MS-DRG,22569.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22569.12,140,MS-DRG,18055.3,other,140% of Medicare CMS MS-DRG,20151,125,MS-DRG,16120.8,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,16120.8,100,MS-DRG,12896.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16120.8,28211.4,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,inpatient,,,,,,9230.9,100,MS-DRG,7384.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7963.47,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13537.9,170,MS-DRG,10830.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13936.07,175,MS-DRG,11148.856,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11148.86,140,MS-DRG,8919.09,other,140% of Medicare CMS MS-DRG,9954.34,125,MS-DRG,7963.47,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,7963.47,100,MS-DRG,6370.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7963.47,13936.07,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,inpatient,,,,,,22431.5,100,MS-DRG,17945.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20021.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34036.82,170,MS-DRG,27229.456,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35037.91,175,MS-DRG,28030.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28030.32,140,MS-DRG,22424.26,other,140% of Medicare CMS MS-DRG,25027.08,125,MS-DRG,20021.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,20021.66,100,MS-DRG,16017.33,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20021.66,35037.91,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,inpatient,,,,,,12304.6,100,MS-DRG,9843.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10716.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18218.12,170,MS-DRG,14574.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18753.95,175,MS-DRG,15003.16,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15003.16,140,MS-DRG,12002.53,other,140% of Medicare CMS MS-DRG,13395.68,125,MS-DRG,10716.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,10716.54,100,MS-DRG,8573.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10716.54,18753.95,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,inpatient,,,,,,9621.5,100,MS-DRG,7697.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8537.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14512.99,170,MS-DRG,11610.392,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14939.84,175,MS-DRG,11951.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11951.87,140,MS-DRG,9561.5,other,140% of Medicare CMS MS-DRG,10671.31,125,MS-DRG,8537.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,8537.05,100,MS-DRG,6829.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8537.05,14939.84,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,inpatient,,,,,,17733.1,100,MS-DRG,14186.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16558.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28149.55,170,MS-DRG,22519.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28977.48,175,MS-DRG,23181.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23181.98,140,MS-DRG,18545.58,other,140% of Medicare CMS MS-DRG,20698.2,125,MS-DRG,16558.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,16558.56,100,MS-DRG,13246.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16558.56,28977.48,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,inpatient,,,,,,12423.6,100,MS-DRG,9938.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10663.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18127.85,170,MS-DRG,14502.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18661.02,175,MS-DRG,14928.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14928.82,140,MS-DRG,11943.06,other,140% of Medicare CMS MS-DRG,13329.3,125,MS-DRG,10663.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,10663.44,100,MS-DRG,8530.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10663.44,18661.02,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,inpatient,,,,,,12367.6,100,MS-DRG,9894.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10531.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17903.23,170,MS-DRG,14322.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18429.79,175,MS-DRG,14743.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14743.83,140,MS-DRG,11795.06,other,140% of Medicare CMS MS-DRG,13164.14,125,MS-DRG,10531.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,10531.31,100,MS-DRG,8425.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10531.31,18429.79,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,inpatient,,,,,,9868.6,100,MS-DRG,7894.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9030.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15351.63,170,MS-DRG,12281.304,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15803.15,175,MS-DRG,12642.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12642.52,140,MS-DRG,10114.02,other,140% of Medicare CMS MS-DRG,11287.96,125,MS-DRG,9030.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,9030.37,100,MS-DRG,7224.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9030.37,15803.15,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,inpatient,,,,,,12983.6,100,MS-DRG,10386.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13161.52,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22374.58,170,MS-DRG,17899.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23032.66,175,MS-DRG,18426.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18426.13,140,MS-DRG,14740.9,other,140% of Medicare CMS MS-DRG,16451.9,125,MS-DRG,13161.52,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,13161.52,100,MS-DRG,10529.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12983.6,23032.66,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,inpatient,,,,,,10137.4,100,MS-DRG,8109.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8853.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15051.43,170,MS-DRG,12041.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15494.12,175,MS-DRG,12395.296,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12395.29,140,MS-DRG,9916.23,other,140% of Medicare CMS MS-DRG,11067.23,125,MS-DRG,8853.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,8853.78,100,MS-DRG,7083.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8853.78,15494.12,
ARTHROSCOPY,509,MS-DRG,,,,,inpatient,,,,,,10625.3,100,MS-DRG,8500.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8434.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14338.75,170,MS-DRG,11471,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14760.48,175,MS-DRG,11808.384,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11808.38,140,MS-DRG,9446.7,other,140% of Medicare CMS MS-DRG,10543.2,125,MS-DRG,8434.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,8434.56,100,MS-DRG,6747.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8434.56,14760.48,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,inpatient,,,,,,20216.7,100,MS-DRG,16173.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16797.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28555.75,170,MS-DRG,22844.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29395.63,175,MS-DRG,23516.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23516.5,140,MS-DRG,18813.2,other,140% of Medicare CMS MS-DRG,20996.88,125,MS-DRG,16797.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,16797.5,100,MS-DRG,13438,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16797.5,29395.63,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,inpatient,,,,,,13853,100,MS-DRG,11082.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12310.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20927.17,170,MS-DRG,16741.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21542.68,175,MS-DRG,17234.144,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17234.14,140,MS-DRG,13787.31,other,140% of Medicare CMS MS-DRG,15387.63,125,MS-DRG,12310.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,12310.1,100,MS-DRG,9848.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12310.1,21542.68,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,inpatient,,,,,,11245.5,100,MS-DRG,8996.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9963.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16938.65,170,MS-DRG,13550.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17436.84,175,MS-DRG,13949.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13949.47,140,MS-DRG,11159.58,other,140% of Medicare CMS MS-DRG,12454.89,125,MS-DRG,9963.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,9963.91,100,MS-DRG,7971.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9963.91,17436.84,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,inpatient,,,,,,11158,100,MS-DRG,8926.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10008.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17014.21,170,MS-DRG,13611.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17514.63,175,MS-DRG,14011.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14011.7,140,MS-DRG,11209.36,other,140% of Medicare CMS MS-DRG,12510.45,125,MS-DRG,10008.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10008.36,17514.63,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,inpatient,,,,,,7228.9,100,MS-DRG,5783.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6430.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10931.71,170,MS-DRG,8745.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11253.24,175,MS-DRG,9002.592,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9002.59,140,MS-DRG,7202.07,other,140% of Medicare CMS MS-DRG,8038.03,125,MS-DRG,6430.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,6430.42,100,MS-DRG,5144.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6430.42,11253.24,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,inpatient,,,,,,21824.6,100,MS-DRG,17459.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19519.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33183.49,170,MS-DRG,26546.792,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34159.48,175,MS-DRG,27327.584,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27327.58,140,MS-DRG,21862.06,other,140% of Medicare CMS MS-DRG,24399.63,125,MS-DRG,19519.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,19519.7,100,MS-DRG,15615.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19519.7,34159.48,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,inpatient,,,,,,14236.6,100,MS-DRG,11389.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12600.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21420.48,170,MS-DRG,17136.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22050.49,175,MS-DRG,17640.392,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17640.39,140,MS-DRG,14112.31,other,140% of Medicare CMS MS-DRG,15750.35,125,MS-DRG,12600.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,12600.28,100,MS-DRG,10080.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12600.28,22050.49,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,inpatient,,,,,,10569.3,100,MS-DRG,8455.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9226.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15685.39,170,MS-DRG,12548.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16146.73,175,MS-DRG,12917.384,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12917.38,140,MS-DRG,10333.9,other,140% of Medicare CMS MS-DRG,11533.38,125,MS-DRG,9226.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,9226.7,100,MS-DRG,7381.36,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9226.7,16146.73,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,inpatient,,,,,,26093.9,100,MS-DRG,20875.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22546.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38329.75,170,MS-DRG,30663.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39457.09,175,MS-DRG,31565.672,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31565.67,140,MS-DRG,25252.54,other,140% of Medicare CMS MS-DRG,28183.64,125,MS-DRG,22546.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,22546.91,100,MS-DRG,18037.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22546.91,39457.09,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,inpatient,,,,,,13995.1,100,MS-DRG,11196.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12154.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20662.67,170,MS-DRG,16530.136,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21270.39,175,MS-DRG,17016.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17016.31,140,MS-DRG,13613.05,other,140% of Medicare CMS MS-DRG,15193.14,125,MS-DRG,12154.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,12154.51,100,MS-DRG,9723.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12154.51,21270.39,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,inpatient,,,,,,10358.6,100,MS-DRG,8286.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8838.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15025.2,170,MS-DRG,12020.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15467.11,175,MS-DRG,12373.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12373.69,140,MS-DRG,9898.95,other,140% of Medicare CMS MS-DRG,11047.94,125,MS-DRG,8838.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,8838.35,100,MS-DRG,7070.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8838.35,15467.11,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,inpatient,,,,,,21134.4,100,MS-DRG,16907.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18486.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31427.48,170,MS-DRG,25141.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32351.81,175,MS-DRG,25881.448,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25881.45,140,MS-DRG,20705.16,other,140% of Medicare CMS MS-DRG,23108.44,125,MS-DRG,18486.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,18486.75,100,MS-DRG,14789.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18486.75,32351.81,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,inpatient,,,,,,15210.3,100,MS-DRG,12168.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13041.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22169.9,170,MS-DRG,17735.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22821.96,175,MS-DRG,18257.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18257.57,140,MS-DRG,14606.06,other,140% of Medicare CMS MS-DRG,16301.4,125,MS-DRG,13041.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,13041.12,100,MS-DRG,10432.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13041.12,22821.96,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,inpatient,,,,,,9984.1,100,MS-DRG,7987.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10072.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17123.37,170,MS-DRG,13698.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17627,175,MS-DRG,14101.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14101.6,140,MS-DRG,11281.28,other,140% of Medicare CMS MS-DRG,12590.71,125,MS-DRG,10072.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,10072.57,100,MS-DRG,8058.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9984.1,17627,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,inpatient,,,,,,5571.3,100,MS-DRG,4457.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5001.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8501.85,170,MS-DRG,6801.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8751.91,175,MS-DRG,7001.528,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7001.53,140,MS-DRG,5601.22,other,140% of Medicare CMS MS-DRG,6251.36,125,MS-DRG,5001.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,5001.09,100,MS-DRG,4000.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5001.09,8751.91,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,inpatient,,,,,,9026.5,100,MS-DRG,7221.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8006.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13610.32,170,MS-DRG,10888.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14010.62,175,MS-DRG,11208.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11208.5,140,MS-DRG,8966.8,other,140% of Medicare CMS MS-DRG,10007.59,125,MS-DRG,8006.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,8006.07,100,MS-DRG,6404.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8006.07,14010.62,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,inpatient,,,,,,5439.7,100,MS-DRG,4351.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4859.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8261.49,170,MS-DRG,6609.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8504.48,175,MS-DRG,6803.584,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6803.58,140,MS-DRG,5442.86,other,140% of Medicare CMS MS-DRG,6074.63,125,MS-DRG,4859.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,4859.7,100,MS-DRG,3887.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4859.7,8504.48,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,inpatient,,,,,,6953.8,100,MS-DRG,5563.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5970.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10149.75,170,MS-DRG,8119.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10448.27,175,MS-DRG,8358.616,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8358.62,140,MS-DRG,6686.9,other,140% of Medicare CMS MS-DRG,7463.05,125,MS-DRG,5970.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,5970.44,100,MS-DRG,4776.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5970.44,10448.27,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,inpatient,,,,,,4873.4,100,MS-DRG,3898.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4378.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7442.8,170,MS-DRG,5954.24,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7661.71,175,MS-DRG,6129.368,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6129.37,140,MS-DRG,4903.5,other,140% of Medicare CMS MS-DRG,5472.65,125,MS-DRG,4378.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,4378.12,100,MS-DRG,3502.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4378.12,7661.71,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,inpatient,,,,,,13971.3,100,MS-DRG,11177.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12252.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20828.5,170,MS-DRG,16662.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21441.11,175,MS-DRG,17152.888,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17152.88,140,MS-DRG,13722.3,other,140% of Medicare CMS MS-DRG,15315.08,125,MS-DRG,12252.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,12252.06,100,MS-DRG,9801.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12252.06,21441.11,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,inpatient,,,,,,9426.2,100,MS-DRG,7540.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8015.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13626.06,170,MS-DRG,10900.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14026.83,175,MS-DRG,11221.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11221.46,140,MS-DRG,8977.17,other,140% of Medicare CMS MS-DRG,10019.16,125,MS-DRG,8015.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,8015.33,100,MS-DRG,6412.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8015.33,14026.83,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,inpatient,,,,,,5726,100,MS-DRG,4580.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5296.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9004.63,170,MS-DRG,7203.704,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9269.47,175,MS-DRG,7415.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7415.58,140,MS-DRG,5932.46,other,140% of Medicare CMS MS-DRG,6621.05,125,MS-DRG,5296.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,5296.84,100,MS-DRG,4237.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5296.84,9269.47,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,inpatient,,,,,,12796,100,MS-DRG,10236.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11259.87,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19141.78,170,MS-DRG,15313.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19704.77,175,MS-DRG,15763.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15763.82,140,MS-DRG,12611.06,other,140% of Medicare CMS MS-DRG,14074.84,125,MS-DRG,11259.87,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,11259.87,100,MS-DRG,9007.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11259.87,19704.77,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,inpatient,,,,,,7623,100,MS-DRG,6098.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6734.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11448.12,170,MS-DRG,9158.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11784.83,175,MS-DRG,9427.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9427.87,140,MS-DRG,7542.3,other,140% of Medicare CMS MS-DRG,8417.74,125,MS-DRG,6734.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,6734.19,100,MS-DRG,5387.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6734.19,11784.83,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,inpatient,,,,,,5446.7,100,MS-DRG,4357.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4738.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8055.77,170,MS-DRG,6444.616,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8292.71,175,MS-DRG,6634.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6634.17,140,MS-DRG,5307.34,other,140% of Medicare CMS MS-DRG,5923.36,125,MS-DRG,4738.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,4738.69,100,MS-DRG,3790.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4738.69,8292.71,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,inpatient,,,,,,17560.2,100,MS-DRG,14048.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15393.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26168.93,170,MS-DRG,20935.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26938.61,175,MS-DRG,21550.888,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21550.89,140,MS-DRG,17240.71,other,140% of Medicare CMS MS-DRG,19241.86,125,MS-DRG,15393.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,15393.49,100,MS-DRG,12314.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15393.49,26938.61,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,inpatient,,,,,,8439.2,100,MS-DRG,6751.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7404.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12588.01,170,MS-DRG,10070.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12958.24,175,MS-DRG,10366.592,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10366.59,140,MS-DRG,8293.27,other,140% of Medicare CMS MS-DRG,9255.89,125,MS-DRG,7404.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,7404.71,100,MS-DRG,5923.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7404.71,12958.24,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,inpatient,,,,,,6403.6,100,MS-DRG,5122.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5083.21,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8641.46,170,MS-DRG,6913.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8895.62,175,MS-DRG,7116.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7116.49,140,MS-DRG,5693.19,other,140% of Medicare CMS MS-DRG,6354.01,125,MS-DRG,5083.21,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,5083.21,100,MS-DRG,4066.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5083.21,8895.62,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,inpatient,,,,,,13579.3,100,MS-DRG,10863.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12038.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20465.33,170,MS-DRG,16372.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21067.25,175,MS-DRG,16853.8,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16853.8,140,MS-DRG,13483.04,other,140% of Medicare CMS MS-DRG,15048.04,125,MS-DRG,12038.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,12038.43,100,MS-DRG,9630.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12038.43,21067.25,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,inpatient,,,,,,8481.9,100,MS-DRG,6785.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7447.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12660.43,170,MS-DRG,10128.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13032.79,175,MS-DRG,10426.232,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10426.23,140,MS-DRG,8340.98,other,140% of Medicare CMS MS-DRG,9309.14,125,MS-DRG,7447.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,7447.31,100,MS-DRG,5957.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7447.31,13032.79,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,inpatient,,,,,,7338.1,100,MS-DRG,5870.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5825.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9903.1,170,MS-DRG,7922.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10194.36,175,MS-DRG,8155.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8155.49,140,MS-DRG,6524.39,other,140% of Medicare CMS MS-DRG,7281.69,125,MS-DRG,5825.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,5825.35,100,MS-DRG,4660.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5825.35,10194.36,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,inpatient,,,,,,11713.8,100,MS-DRG,9371.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10507.85,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17863.35,170,MS-DRG,14290.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18388.74,175,MS-DRG,14710.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14710.99,140,MS-DRG,11768.79,other,140% of Medicare CMS MS-DRG,13134.81,125,MS-DRG,10507.85,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,10507.85,100,MS-DRG,8406.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10507.85,18388.74,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,inpatient,,,,,,6723.5,100,MS-DRG,5378.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5966.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10142.4,170,MS-DRG,8113.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10440.71,175,MS-DRG,8352.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8352.57,140,MS-DRG,6682.06,other,140% of Medicare CMS MS-DRG,7457.65,125,MS-DRG,5966.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,5966.12,100,MS-DRG,4772.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5966.12,10440.71,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,inpatient,,,,,,9281.3,100,MS-DRG,7425.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8344.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14185.51,170,MS-DRG,11348.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14602.74,175,MS-DRG,11682.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11682.19,140,MS-DRG,9345.75,other,140% of Medicare CMS MS-DRG,10430.53,125,MS-DRG,8344.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,8344.42,100,MS-DRG,6675.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8344.42,14602.74,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,inpatient,,,,,,5741.4,100,MS-DRG,4593.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5073.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8625.7,170,MS-DRG,6900.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8879.4,175,MS-DRG,7103.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7103.52,140,MS-DRG,5682.82,other,140% of Medicare CMS MS-DRG,6342.43,125,MS-DRG,5073.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,5073.94,100,MS-DRG,4059.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5073.94,8879.4,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,inpatient,,,,,,9318.4,100,MS-DRG,7454.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8637.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14684.07,170,MS-DRG,11747.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15115.96,175,MS-DRG,12092.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12092.77,140,MS-DRG,9674.22,other,140% of Medicare CMS MS-DRG,10797.11,125,MS-DRG,8637.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,8637.69,100,MS-DRG,6910.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8637.69,15115.96,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,inpatient,,,,,,5656,100,MS-DRG,4524.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5090,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8653,170,MS-DRG,6922.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8907.5,175,MS-DRG,7126,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7126,140,MS-DRG,5700.8,other,140% of Medicare CMS MS-DRG,6362.5,125,MS-DRG,5090,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,5090,100,MS-DRG,4072,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5090,8907.5,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,inpatient,,,,,,10023.3,100,MS-DRG,8018.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9611.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16340.37,170,MS-DRG,13072.296,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16820.97,175,MS-DRG,13456.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13456.77,140,MS-DRG,10765.42,other,140% of Medicare CMS MS-DRG,12014.98,125,MS-DRG,9611.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,9611.98,100,MS-DRG,7689.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9611.98,16820.97,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,inpatient,,,,,,6083,100,MS-DRG,4866.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5423.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9219.8,170,MS-DRG,7375.84,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9490.97,175,MS-DRG,7592.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7592.77,140,MS-DRG,6074.22,other,140% of Medicare CMS MS-DRG,6779.26,125,MS-DRG,5423.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,5423.41,100,MS-DRG,4338.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5423.41,9490.97,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,inpatient,,,,,,12495,100,MS-DRG,9996,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11425.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19423.06,170,MS-DRG,15538.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19994.33,175,MS-DRG,15995.464,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15995.46,140,MS-DRG,12796.37,other,140% of Medicare CMS MS-DRG,14281.66,125,MS-DRG,11425.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,11425.33,100,MS-DRG,9140.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11425.33,19994.33,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,inpatient,,,,,,7669.2,100,MS-DRG,6135.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6989.8,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11882.66,170,MS-DRG,9506.128,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12232.15,175,MS-DRG,9785.72,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9785.72,140,MS-DRG,7828.58,other,140% of Medicare CMS MS-DRG,8737.25,125,MS-DRG,6989.8,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,6989.8,100,MS-DRG,5591.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6989.8,12232.15,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,inpatient,,,,,,5531.4,100,MS-DRG,4425.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4817.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8189.07,170,MS-DRG,6551.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8429.93,175,MS-DRG,6743.944,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6743.94,140,MS-DRG,5395.15,other,140% of Medicare CMS MS-DRG,6021.38,125,MS-DRG,4817.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,4817.1,100,MS-DRG,3853.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4817.1,8429.93,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,inpatient,,,,,,10239.6,100,MS-DRG,8191.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9389.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15961.45,170,MS-DRG,12769.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16430.91,175,MS-DRG,13144.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13144.73,140,MS-DRG,10515.78,other,140% of Medicare CMS MS-DRG,11736.36,125,MS-DRG,9389.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,9389.09,100,MS-DRG,7511.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9389.09,16430.91,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,inpatient,,,,,,6028.4,100,MS-DRG,4822.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5529.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9400.34,170,MS-DRG,7520.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9676.82,175,MS-DRG,7741.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7741.45,140,MS-DRG,6193.16,other,140% of Medicare CMS MS-DRG,6912.01,125,MS-DRG,5529.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,5529.61,100,MS-DRG,4423.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5529.61,9676.82,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,inpatient,,,,,,10873.1,100,MS-DRG,8698.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9643.47,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16393.9,170,MS-DRG,13115.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16876.07,175,MS-DRG,13500.856,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13500.86,140,MS-DRG,10800.69,other,140% of Medicare CMS MS-DRG,12054.34,125,MS-DRG,9643.47,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,9643.47,100,MS-DRG,7714.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9643.47,16876.07,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,inpatient,,,,,,6911.8,100,MS-DRG,5529.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6170.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10489.83,170,MS-DRG,8391.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10798.36,175,MS-DRG,8638.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8638.69,140,MS-DRG,6910.95,other,140% of Medicare CMS MS-DRG,7713.11,125,MS-DRG,6170.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,6170.49,100,MS-DRG,4936.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6170.49,10798.36,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,inpatient,,,,,,5198.9,100,MS-DRG,4159.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4633.73,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7877.34,170,MS-DRG,6301.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8109.03,175,MS-DRG,6487.224,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6487.22,140,MS-DRG,5189.78,other,140% of Medicare CMS MS-DRG,5792.16,125,MS-DRG,4633.73,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,4633.73,100,MS-DRG,3706.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4633.73,8109.03,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,inpatient,,,,,,20419.7,100,MS-DRG,16335.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18042.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30671.77,170,MS-DRG,24537.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31573.89,175,MS-DRG,25259.112,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25259.11,140,MS-DRG,20207.29,other,140% of Medicare CMS MS-DRG,22552.78,125,MS-DRG,18042.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,18042.22,100,MS-DRG,14433.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18042.22,31573.89,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,inpatient,,,,,,11540.2,100,MS-DRG,9232.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10446.11,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17758.39,170,MS-DRG,14206.712,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18280.69,175,MS-DRG,14624.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14624.55,140,MS-DRG,11699.64,other,140% of Medicare CMS MS-DRG,13057.64,125,MS-DRG,10446.11,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,10446.11,100,MS-DRG,8356.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10446.11,18280.69,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,inpatient,,,,,,8425.2,100,MS-DRG,6740.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7036.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11961.37,170,MS-DRG,9569.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12313.18,175,MS-DRG,9850.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9850.54,140,MS-DRG,7880.43,other,140% of Medicare CMS MS-DRG,8795.13,125,MS-DRG,7036.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,7036.1,100,MS-DRG,5628.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7036.1,12313.18,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,inpatient,,,,,,41093.5,100,MS-DRG,32874.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,38391.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65265.92,170,MS-DRG,52212.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,67185.51,175,MS-DRG,53748.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,53748.41,140,MS-DRG,42998.73,other,140% of Medicare CMS MS-DRG,47989.65,125,MS-DRG,38391.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,38391.72,100,MS-DRG,30713.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38391.72,67185.51,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,inpatient,,,,,,25232.2,100,MS-DRG,20185.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21028.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35747.69,170,MS-DRG,28598.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36799.09,175,MS-DRG,29439.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29439.27,140,MS-DRG,23551.42,other,140% of Medicare CMS MS-DRG,26285.06,125,MS-DRG,21028.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,21028.05,100,MS-DRG,16822.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21028.05,36799.09,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,inpatient,,,,,,14347.2,100,MS-DRG,11477.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12632.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21475.06,170,MS-DRG,17180.048,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22106.68,175,MS-DRG,17685.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17685.35,140,MS-DRG,14148.28,other,140% of Medicare CMS MS-DRG,15790.49,125,MS-DRG,12632.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,12632.39,100,MS-DRG,10105.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12632.39,22106.68,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,inpatient,,,,,,39543,100,MS-DRG,31634.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,35088.53,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,59650.5,170,MS-DRG,47720.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,61404.93,175,MS-DRG,49123.944,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,49123.94,140,MS-DRG,39299.15,other,140% of Medicare CMS MS-DRG,43860.66,125,MS-DRG,35088.53,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,35088.53,100,MS-DRG,28070.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35088.53,61404.93,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,inpatient,,,,,,18330.9,100,MS-DRG,14664.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16356.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27805.29,170,MS-DRG,22244.232,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28623.09,175,MS-DRG,22898.472,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22898.47,140,MS-DRG,18318.78,other,140% of Medicare CMS MS-DRG,20445.06,125,MS-DRG,16356.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,16356.05,100,MS-DRG,13084.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16356.05,28623.09,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,inpatient,,,,,,11987.5,100,MS-DRG,9590,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9943.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16904.02,170,MS-DRG,13523.216,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17401.2,175,MS-DRG,13920.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13920.96,140,MS-DRG,11136.77,other,140% of Medicare CMS MS-DRG,12429.43,125,MS-DRG,9943.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,9943.54,100,MS-DRG,7954.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9943.54,17401.2,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,inpatient,,,,,,22061.9,100,MS-DRG,17649.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20635.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35080.13,170,MS-DRG,28064.104,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36111.9,175,MS-DRG,28889.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28889.52,140,MS-DRG,23111.62,other,140% of Medicare CMS MS-DRG,25794.21,125,MS-DRG,20635.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,20635.37,100,MS-DRG,16508.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20635.37,36111.9,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,inpatient,,,,,,12153.4,100,MS-DRG,9722.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10783.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18332.53,170,MS-DRG,14666.024,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18871.72,175,MS-DRG,15097.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15097.38,140,MS-DRG,12077.9,other,140% of Medicare CMS MS-DRG,13479.8,125,MS-DRG,10783.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,10783.84,100,MS-DRG,8627.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10783.84,18871.72,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,inpatient,,,,,,9880.5,100,MS-DRG,7904.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8314.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14135.11,170,MS-DRG,11308.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14550.85,175,MS-DRG,11640.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11640.68,140,MS-DRG,9312.54,other,140% of Medicare CMS MS-DRG,10393.46,125,MS-DRG,8314.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,8314.77,100,MS-DRG,6651.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8314.77,14550.85,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,inpatient,,,,,,13543.6,100,MS-DRG,10834.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10751.11,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18276.89,170,MS-DRG,14621.512,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18814.44,175,MS-DRG,15051.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15051.55,140,MS-DRG,12041.24,other,140% of Medicare CMS MS-DRG,13438.89,125,MS-DRG,10751.11,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,10751.11,100,MS-DRG,8600.89,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10751.11,18814.44,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,inpatient,,,,,,10575.6,100,MS-DRG,8460.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9396.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15974.05,170,MS-DRG,12779.24,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16443.88,175,MS-DRG,13155.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13155.1,140,MS-DRG,10524.08,other,140% of Medicare CMS MS-DRG,11745.63,125,MS-DRG,9396.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,9396.5,100,MS-DRG,7517.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9396.5,16443.88,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,inpatient,,,,,,14950.6,100,MS-DRG,11960.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12092.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20557.69,170,MS-DRG,16446.152,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21162.33,175,MS-DRG,16929.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16929.86,140,MS-DRG,13543.89,other,140% of Medicare CMS MS-DRG,15115.95,125,MS-DRG,12092.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,12092.76,100,MS-DRG,9674.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12092.76,21162.33,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,inpatient,,,,,,12887.7,100,MS-DRG,10310.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10397.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17675.48,170,MS-DRG,14140.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18195.35,175,MS-DRG,14556.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14556.28,140,MS-DRG,11645.02,other,140% of Medicare CMS MS-DRG,12996.68,125,MS-DRG,10397.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,10397.34,100,MS-DRG,8317.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10397.34,18195.35,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,inpatient,,,,,,12488,100,MS-DRG,9990.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12904.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21937.94,170,MS-DRG,17550.352,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22583.17,175,MS-DRG,18066.536,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18066.54,140,MS-DRG,14453.23,other,140% of Medicare CMS MS-DRG,16130.84,125,MS-DRG,12904.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,12904.67,100,MS-DRG,10323.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12488,22583.17,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,inpatient,,,,,,8063.3,100,MS-DRG,6450.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7470.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12699.27,170,MS-DRG,10159.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13072.78,175,MS-DRG,10458.224,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10458.22,140,MS-DRG,8366.58,other,140% of Medicare CMS MS-DRG,9337.7,125,MS-DRG,7470.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,7470.16,100,MS-DRG,5976.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7470.16,13072.78,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,inpatient,,,,,,5417.3,100,MS-DRG,4333.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4861.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8264.64,170,MS-DRG,6611.712,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8507.71,175,MS-DRG,6806.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6806.17,140,MS-DRG,5444.94,other,140% of Medicare CMS MS-DRG,6076.94,125,MS-DRG,4861.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,4861.55,100,MS-DRG,3889.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4861.55,8507.71,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,inpatient,,,,,,14989.8,100,MS-DRG,11991.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13428.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22829.06,170,MS-DRG,18263.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23500.51,175,MS-DRG,18800.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18800.4,140,MS-DRG,15040.32,other,140% of Medicare CMS MS-DRG,16786.08,125,MS-DRG,13428.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,13428.86,100,MS-DRG,10743.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13428.86,23500.51,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,inpatient,,,,,,7642.6,100,MS-DRG,6114.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6229.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10590.59,170,MS-DRG,8472.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10902.08,175,MS-DRG,8721.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8721.66,140,MS-DRG,6977.33,other,140% of Medicare CMS MS-DRG,7787.2,125,MS-DRG,6229.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,6229.76,100,MS-DRG,4983.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6229.76,10902.08,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,inpatient,,,,,,11788,100,MS-DRG,9430.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9881.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16799.04,170,MS-DRG,13439.232,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17293.13,175,MS-DRG,13834.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13834.51,140,MS-DRG,11067.61,other,140% of Medicare CMS MS-DRG,12352.24,125,MS-DRG,9881.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,9881.79,100,MS-DRG,7905.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9881.79,17293.13,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,inpatient,,,,,,7476.7,100,MS-DRG,5981.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7401.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12582.75,170,MS-DRG,10066.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12952.84,175,MS-DRG,10362.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10362.27,140,MS-DRG,8289.82,other,140% of Medicare CMS MS-DRG,9252.03,125,MS-DRG,7401.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,7401.62,100,MS-DRG,5921.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7401.62,12952.84,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,inpatient,,,,,,5233.2,100,MS-DRG,4186.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4154,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7061.8,170,MS-DRG,5649.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7269.5,175,MS-DRG,5815.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5815.6,140,MS-DRG,4652.48,other,140% of Medicare CMS MS-DRG,5192.5,125,MS-DRG,4154,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,4154,100,MS-DRG,3323.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4154,7269.5,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,inpatient,,,,,,7287.7,100,MS-DRG,5830.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6331.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10763.77,170,MS-DRG,8611.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11080.35,175,MS-DRG,8864.28,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8864.28,140,MS-DRG,7091.42,other,140% of Medicare CMS MS-DRG,7914.54,125,MS-DRG,6331.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,6331.63,100,MS-DRG,5065.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6331.63,11080.35,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,inpatient,,,,,,4927.3,100,MS-DRG,3941.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3911.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6649.3,170,MS-DRG,5319.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6844.86,175,MS-DRG,5475.888,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5475.89,140,MS-DRG,4380.71,other,140% of Medicare CMS MS-DRG,4889.19,125,MS-DRG,3911.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,3911.35,100,MS-DRG,3129.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3911.35,6844.86,
CELLULITIS WITH MCC,602,MS-DRG,,,,,inpatient,,,,,,10088.4,100,MS-DRG,8070.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9184.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15612.97,170,MS-DRG,12490.376,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16072.18,175,MS-DRG,12857.744,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12857.74,140,MS-DRG,10286.19,other,140% of Medicare CMS MS-DRG,11480.13,125,MS-DRG,9184.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,9184.1,100,MS-DRG,7347.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9184.1,16072.18,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,inpatient,,,,,,6172.6,100,MS-DRG,4938.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5462.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9285.93,170,MS-DRG,7428.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9559.04,175,MS-DRG,7647.232,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7647.23,140,MS-DRG,6117.78,other,140% of Medicare CMS MS-DRG,6827.89,125,MS-DRG,5462.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,5462.31,100,MS-DRG,4369.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5462.31,9559.04,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,inpatient,,,,,,10564.4,100,MS-DRG,8451.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9299.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15809.27,170,MS-DRG,12647.416,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16274.25,175,MS-DRG,13019.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13019.4,140,MS-DRG,10415.52,other,140% of Medicare CMS MS-DRG,11624.46,125,MS-DRG,9299.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,9299.57,100,MS-DRG,7439.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9299.57,16274.25,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,inpatient,,,,,,6372.8,100,MS-DRG,5098.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5611.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9538.87,170,MS-DRG,7631.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9819.43,175,MS-DRG,7855.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7855.54,140,MS-DRG,6284.43,other,140% of Medicare CMS MS-DRG,7013.88,125,MS-DRG,5611.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,5611.1,100,MS-DRG,4488.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5611.1,9819.43,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,inpatient,,,,,,10744.3,100,MS-DRG,8595.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9791.03,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16644.75,170,MS-DRG,13315.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17134.3,175,MS-DRG,13707.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13707.44,140,MS-DRG,10965.95,other,140% of Medicare CMS MS-DRG,12238.79,125,MS-DRG,9791.03,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,9791.03,100,MS-DRG,7832.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9791.03,17134.3,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,inpatient,,,,,,5937.4,100,MS-DRG,4749.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5516.64,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9378.29,170,MS-DRG,7502.632,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9654.12,175,MS-DRG,7723.296,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7723.3,140,MS-DRG,6178.64,other,140% of Medicare CMS MS-DRG,6895.8,125,MS-DRG,5516.64,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,5516.64,100,MS-DRG,4413.31,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5516.64,9654.12,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,inpatient,,,,,,16449.3,100,MS-DRG,13159.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13906.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23641.46,170,MS-DRG,18913.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24336.8,175,MS-DRG,19469.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19469.44,140,MS-DRG,15575.55,other,140% of Medicare CMS MS-DRG,17383.43,125,MS-DRG,13906.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,13906.74,100,MS-DRG,11125.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13906.74,24336.8,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,inpatient,,,,,,10330.6,100,MS-DRG,8264.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9082.85,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15440.85,170,MS-DRG,12352.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15894.99,175,MS-DRG,12715.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12715.99,140,MS-DRG,10172.79,other,140% of Medicare CMS MS-DRG,11353.56,125,MS-DRG,9082.85,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,9082.85,100,MS-DRG,7266.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9082.85,15894.99,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,inpatient,,,,,,26351.5,100,MS-DRG,21081.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24435.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41540.5,170,MS-DRG,33232.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42762.28,175,MS-DRG,34209.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34209.83,140,MS-DRG,27367.86,other,140% of Medicare CMS MS-DRG,30544.49,125,MS-DRG,24435.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,24435.59,100,MS-DRG,19548.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24435.59,42762.28,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,inpatient,,,,,,13608,100,MS-DRG,10886.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12252.68,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20829.56,170,MS-DRG,16663.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21442.19,175,MS-DRG,17153.752,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17153.75,140,MS-DRG,13723,other,140% of Medicare CMS MS-DRG,15315.85,125,MS-DRG,12252.68,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,12252.68,100,MS-DRG,9802.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12252.68,21442.19,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,inpatient,,,,,,8210.3,100,MS-DRG,6568.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7171.32,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12191.24,170,MS-DRG,9752.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12549.81,175,MS-DRG,10039.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10039.85,140,MS-DRG,8031.88,other,140% of Medicare CMS MS-DRG,8964.15,125,MS-DRG,7171.32,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,7171.32,100,MS-DRG,5737.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7171.32,12549.81,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,inpatient,,,,,,20241.9,100,MS-DRG,16193.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16068.32,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27316.14,170,MS-DRG,21852.912,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28119.56,175,MS-DRG,22495.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22495.65,140,MS-DRG,17996.52,other,140% of Medicare CMS MS-DRG,20085.4,125,MS-DRG,16068.32,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,16068.32,100,MS-DRG,12854.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16068.32,28119.56,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,inpatient,,,,,,11799.2,100,MS-DRG,9439.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10015.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17026.81,170,MS-DRG,13621.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17527.6,175,MS-DRG,14022.08,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14022.08,140,MS-DRG,11217.66,other,140% of Medicare CMS MS-DRG,12519.71,125,MS-DRG,10015.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,10015.77,100,MS-DRG,8012.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10015.77,17527.6,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,inpatient,,,,,,10885,100,MS-DRG,8708,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9368.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15925.75,170,MS-DRG,12740.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16394.16,175,MS-DRG,13115.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13115.33,140,MS-DRG,10492.26,other,140% of Medicare CMS MS-DRG,11710.11,125,MS-DRG,9368.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,9368.09,100,MS-DRG,7494.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9368.09,16394.16,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,inpatient,,,,,,25347.7,100,MS-DRG,20278.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23619.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40153.97,170,MS-DRG,32123.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41334.97,175,MS-DRG,33067.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33067.97,140,MS-DRG,26454.38,other,140% of Medicare CMS MS-DRG,29524.98,125,MS-DRG,23619.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,23619.98,100,MS-DRG,18895.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23619.98,41334.97,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,inpatient,,,,,,13192.2,100,MS-DRG,10553.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11492.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19537.47,170,MS-DRG,15629.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20112.1,175,MS-DRG,16089.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16089.68,140,MS-DRG,12871.74,other,140% of Medicare CMS MS-DRG,14365.79,125,MS-DRG,11492.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,11492.63,100,MS-DRG,9194.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11492.63,20112.1,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,inpatient,,,,,,6923,100,MS-DRG,5538.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6881.13,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11697.92,170,MS-DRG,9358.336,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12041.98,175,MS-DRG,9633.584,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9633.58,140,MS-DRG,7706.86,other,140% of Medicare CMS MS-DRG,8601.41,125,MS-DRG,6881.13,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,6881.13,100,MS-DRG,5504.9,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6881.13,12041.98,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,inpatient,,,,,,20140.4,100,MS-DRG,16112.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18036.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30661.27,170,MS-DRG,24529.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31563.07,175,MS-DRG,25250.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25250.46,140,MS-DRG,20200.37,other,140% of Medicare CMS MS-DRG,22545.05,125,MS-DRG,18036.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,18036.04,100,MS-DRG,14428.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18036.04,31563.07,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,inpatient,,,,,,11334.4,100,MS-DRG,9067.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9211.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15659.16,170,MS-DRG,12527.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16119.72,175,MS-DRG,12895.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12895.78,140,MS-DRG,10316.62,other,140% of Medicare CMS MS-DRG,11514.09,125,MS-DRG,9211.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,9211.27,100,MS-DRG,7369.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9211.27,16119.72,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,inpatient,,,,,,8931.3,100,MS-DRG,7145.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7631.3,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12973.21,170,MS-DRG,10378.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13354.78,175,MS-DRG,10683.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10683.82,140,MS-DRG,8547.06,other,140% of Medicare CMS MS-DRG,9539.13,125,MS-DRG,7631.3,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,7631.3,100,MS-DRG,6105.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7631.3,13354.78,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,inpatient,,,,,,25513.6,100,MS-DRG,20410.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24786.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42136.68,170,MS-DRG,33709.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43375.99,175,MS-DRG,34700.792,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34700.79,140,MS-DRG,27760.63,other,140% of Medicare CMS MS-DRG,30982.85,125,MS-DRG,24786.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,24786.28,100,MS-DRG,19829.02,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24786.28,43375.99,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,inpatient,,,,,,15706.6,100,MS-DRG,12565.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13970.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23750.62,170,MS-DRG,19000.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24449.16,175,MS-DRG,19559.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19559.33,140,MS-DRG,15647.46,other,140% of Medicare CMS MS-DRG,17463.69,125,MS-DRG,13970.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,13970.95,100,MS-DRG,11176.76,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13970.95,24449.16,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,inpatient,,,,,,9829.4,100,MS-DRG,7863.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8621.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14655.73,170,MS-DRG,11724.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15086.79,175,MS-DRG,12069.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12069.43,140,MS-DRG,9655.54,other,140% of Medicare CMS MS-DRG,10776.28,125,MS-DRG,8621.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,8621.02,100,MS-DRG,6896.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8621.02,15086.79,
DIABETES WITH MCC,637,MS-DRG,,,,,inpatient,,,,,,9769.9,100,MS-DRG,7815.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8948.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15212.03,170,MS-DRG,12169.624,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15659.44,175,MS-DRG,12527.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12527.55,140,MS-DRG,10022.04,other,140% of Medicare CMS MS-DRG,11185.31,125,MS-DRG,8948.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,8948.25,100,MS-DRG,7158.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8948.25,15659.44,
DIABETES WITH CC,638,MS-DRG,,,,,inpatient,,,,,,6132,100,MS-DRG,4905.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5553.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9440.22,170,MS-DRG,7552.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9717.87,175,MS-DRG,7774.296,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7774.3,140,MS-DRG,6219.44,other,140% of Medicare CMS MS-DRG,6941.34,125,MS-DRG,5553.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,5553.07,100,MS-DRG,4442.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5553.07,9717.87,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,inpatient,,,,,,4205.6,100,MS-DRG,3364.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3843.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6533.85,170,MS-DRG,5227.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6726.02,175,MS-DRG,5380.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5380.82,140,MS-DRG,4304.66,other,140% of Medicare CMS MS-DRG,4804.3,125,MS-DRG,3843.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,3843.44,100,MS-DRG,3074.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3843.44,6726.02,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,inpatient,,,,,,8857.1,100,MS-DRG,7085.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8120.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13804.49,170,MS-DRG,11043.592,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14210.51,175,MS-DRG,11368.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11368.41,140,MS-DRG,9094.73,other,140% of Medicare CMS MS-DRG,10150.36,125,MS-DRG,8120.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,8120.29,100,MS-DRG,6496.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8120.29,14210.51,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,inpatient,,,,,,5391.4,100,MS-DRG,4313.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4824.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8201.67,170,MS-DRG,6561.336,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8442.89,175,MS-DRG,6754.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6754.31,140,MS-DRG,5403.45,other,140% of Medicare CMS MS-DRG,6030.64,125,MS-DRG,4824.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,4824.51,100,MS-DRG,3859.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4824.51,8442.89,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,inpatient,,,,,,9823.1,100,MS-DRG,7858.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8046.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13679.59,170,MS-DRG,10943.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14081.94,175,MS-DRG,11265.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11265.55,140,MS-DRG,9012.44,other,140% of Medicare CMS MS-DRG,10058.53,125,MS-DRG,8046.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,8046.82,100,MS-DRG,6437.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8046.82,14081.94,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,inpatient,,,,,,11505.9,100,MS-DRG,9204.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10157.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17267.17,170,MS-DRG,13813.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17775.03,175,MS-DRG,14220.024,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14220.02,140,MS-DRG,11376.02,other,140% of Medicare CMS MS-DRG,12696.45,125,MS-DRG,10157.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,10157.16,100,MS-DRG,8125.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10157.16,17775.03,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,inpatient,,,,,,7133.7,100,MS-DRG,5706.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6555.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11143.74,170,MS-DRG,8914.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11471.5,175,MS-DRG,9177.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9177.2,140,MS-DRG,7341.76,other,140% of Medicare CMS MS-DRG,8193.93,125,MS-DRG,6555.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,6555.14,100,MS-DRG,5244.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6555.14,11471.5,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,inpatient,,,,,,5198.2,100,MS-DRG,4158.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4697.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7986.5,170,MS-DRG,6389.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8221.4,175,MS-DRG,6577.12,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6577.12,140,MS-DRG,5261.7,other,140% of Medicare CMS MS-DRG,5872.43,125,MS-DRG,4697.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,4697.94,100,MS-DRG,3758.35,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4697.94,8221.4,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,inpatient,,,,,,32507.3,100,MS-DRG,26005.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27768.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47206.3,170,MS-DRG,37765.04,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48594.72,175,MS-DRG,38875.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38875.77,140,MS-DRG,31100.62,other,140% of Medicare CMS MS-DRG,34710.51,125,MS-DRG,27768.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,27768.41,100,MS-DRG,22214.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27768.41,48594.72,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,inpatient,,,,,,24823.4,100,MS-DRG,19858.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21352.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36299.78,170,MS-DRG,29039.824,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37367.42,175,MS-DRG,29893.936,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29893.93,140,MS-DRG,23915.14,other,140% of Medicare CMS MS-DRG,26691.01,125,MS-DRG,21352.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,21352.81,100,MS-DRG,17082.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21352.81,37367.42,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,inpatient,,,,,,21595.7,100,MS-DRG,17276.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18549.73,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31534.54,170,MS-DRG,25227.632,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32462.03,175,MS-DRG,25969.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25969.62,140,MS-DRG,20775.7,other,140% of Medicare CMS MS-DRG,23187.16,125,MS-DRG,18549.73,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,18549.73,100,MS-DRG,14839.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18549.73,32462.03,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,inpatient,,,,,,38896.9,100,MS-DRG,31117.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,33424.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,56821.8,170,MS-DRG,45457.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,58493.03,175,MS-DRG,46794.424,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,46794.43,140,MS-DRG,37435.54,other,140% of Medicare CMS MS-DRG,41780.74,125,MS-DRG,33424.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,33424.59,100,MS-DRG,26739.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33424.59,58493.03,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,inpatient,,,,,,19897.5,100,MS-DRG,15918,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16901.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28733.13,170,MS-DRG,22986.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29578.22,175,MS-DRG,23662.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23662.58,140,MS-DRG,18930.06,other,140% of Medicare CMS MS-DRG,21127.3,125,MS-DRG,16901.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,16901.84,100,MS-DRG,13521.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16901.84,29578.22,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,inpatient,,,,,,15110.9,100,MS-DRG,12088.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13013.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22123.73,170,MS-DRG,17698.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22774.43,175,MS-DRG,18219.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18219.54,140,MS-DRG,14575.63,other,140% of Medicare CMS MS-DRG,16267.45,125,MS-DRG,13013.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,13013.96,100,MS-DRG,10411.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13013.96,22774.43,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,inpatient,,,,,,23137.1,100,MS-DRG,18509.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19372.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32932.64,170,MS-DRG,26346.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33901.25,175,MS-DRG,27121,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27121,140,MS-DRG,21696.8,other,140% of Medicare CMS MS-DRG,24215.18,125,MS-DRG,19372.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,19372.14,100,MS-DRG,15497.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19372.14,33901.25,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,inpatient,,,,,,13146,100,MS-DRG,10516.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11386.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19356.95,170,MS-DRG,15485.56,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19926.27,175,MS-DRG,15941.016,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15941.02,140,MS-DRG,12752.82,other,140% of Medicare CMS MS-DRG,14233.05,125,MS-DRG,11386.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,11386.44,100,MS-DRG,9109.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11386.44,19926.27,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,inpatient,,,,,,11053,100,MS-DRG,8842.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9140.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15538.46,170,MS-DRG,12430.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15995.47,175,MS-DRG,12796.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12796.38,140,MS-DRG,10237.1,other,140% of Medicare CMS MS-DRG,11425.34,125,MS-DRG,9140.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,9140.27,100,MS-DRG,7312.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9140.27,15995.47,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,inpatient,,,,,,18038.3,100,MS-DRG,14430.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15984.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27173.4,170,MS-DRG,21738.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27972.61,175,MS-DRG,22378.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22378.09,140,MS-DRG,17902.47,other,140% of Medicare CMS MS-DRG,19980.44,125,MS-DRG,15984.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,15984.35,100,MS-DRG,12787.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15984.35,27972.61,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,inpatient,,,,,,9878.4,100,MS-DRG,7902.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8309.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14126.73,170,MS-DRG,11301.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14542.22,175,MS-DRG,11633.776,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11633.78,140,MS-DRG,9307.02,other,140% of Medicare CMS MS-DRG,10387.3,125,MS-DRG,8309.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,8309.84,100,MS-DRG,6647.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8309.84,14542.22,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,inpatient,,,,,,7545.3,100,MS-DRG,6036.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6473.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11004.13,170,MS-DRG,8803.304,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11327.79,175,MS-DRG,9062.232,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9062.23,140,MS-DRG,7249.78,other,140% of Medicare CMS MS-DRG,8091.28,125,MS-DRG,6473.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,6473.02,100,MS-DRG,5178.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6473.02,11327.79,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,inpatient,,,,,,21270.9,100,MS-DRG,17016.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18502.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31453.72,170,MS-DRG,25162.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32378.83,175,MS-DRG,25903.064,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25903.07,140,MS-DRG,20722.46,other,140% of Medicare CMS MS-DRG,23127.74,125,MS-DRG,18502.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,18502.19,100,MS-DRG,14801.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18502.19,32378.83,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,inpatient,,,,,,10675,100,MS-DRG,8540,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9008.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15313.84,170,MS-DRG,12251.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15764.25,175,MS-DRG,12611.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12611.4,140,MS-DRG,10089.12,other,140% of Medicare CMS MS-DRG,11260.18,125,MS-DRG,9008.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,9008.14,100,MS-DRG,7206.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9008.14,15764.25,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,inpatient,,,,,,7886.9,100,MS-DRG,6309.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6554.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11142.67,170,MS-DRG,8914.136,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11470.39,175,MS-DRG,9176.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9176.31,140,MS-DRG,7341.05,other,140% of Medicare CMS MS-DRG,8193.14,125,MS-DRG,6554.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,6554.51,100,MS-DRG,5243.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6554.51,11470.39,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,inpatient,,,,,,21422.1,100,MS-DRG,17137.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19072.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32423.57,170,MS-DRG,25938.856,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33377.21,175,MS-DRG,26701.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26701.77,140,MS-DRG,21361.42,other,140% of Medicare CMS MS-DRG,23840.86,125,MS-DRG,19072.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,19072.69,100,MS-DRG,15258.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19072.69,33377.21,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,inpatient,,,,,,12053.3,100,MS-DRG,9642.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10603.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18026.04,170,MS-DRG,14420.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18556.21,175,MS-DRG,14844.968,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14844.97,140,MS-DRG,11875.98,other,140% of Medicare CMS MS-DRG,13254.44,125,MS-DRG,10603.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,10603.55,100,MS-DRG,8482.84,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10603.55,18556.21,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,inpatient,,,,,,6887.3,100,MS-DRG,5509.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6480.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11016.73,170,MS-DRG,8813.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11340.75,175,MS-DRG,9072.6,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9072.6,140,MS-DRG,7258.08,other,140% of Medicare CMS MS-DRG,8100.54,125,MS-DRG,6480.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,6480.43,100,MS-DRG,5184.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6480.43,11340.75,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,inpatient,,,,,,19760.3,100,MS-DRG,15808.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17398.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29578.06,170,MS-DRG,23662.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30448.01,175,MS-DRG,24358.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24358.4,140,MS-DRG,19486.72,other,140% of Medicare CMS MS-DRG,21748.58,125,MS-DRG,17398.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,17398.86,100,MS-DRG,13919.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17398.86,30448.01,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,inpatient,,,,,,11019.4,100,MS-DRG,8815.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9474.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16107.35,170,MS-DRG,12885.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16581.09,175,MS-DRG,13264.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13264.87,140,MS-DRG,10611.9,other,140% of Medicare CMS MS-DRG,11843.64,125,MS-DRG,9474.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,9474.91,100,MS-DRG,7579.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9474.91,16581.09,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,inpatient,,,,,,6912.5,100,MS-DRG,5530,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5943.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10103.56,170,MS-DRG,8082.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10400.72,175,MS-DRG,8320.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8320.58,140,MS-DRG,6656.46,other,140% of Medicare CMS MS-DRG,7429.09,125,MS-DRG,5943.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,5943.27,100,MS-DRG,4754.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5943.27,10400.72,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,inpatient,,,,,,12820.5,100,MS-DRG,10256.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10569.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17968.32,170,MS-DRG,14374.656,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18496.8,175,MS-DRG,14797.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14797.44,140,MS-DRG,11837.95,other,140% of Medicare CMS MS-DRG,13212,125,MS-DRG,10569.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,10569.6,100,MS-DRG,8455.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10569.6,18496.8,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,inpatient,,,,,,7291.9,100,MS-DRG,5833.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5788.3,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9840.11,170,MS-DRG,7872.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10129.53,175,MS-DRG,8103.624,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8103.62,140,MS-DRG,6482.9,other,140% of Medicare CMS MS-DRG,7235.38,125,MS-DRG,5788.3,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,5788.3,100,MS-DRG,4630.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5788.3,10129.53,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,inpatient,,,,,,24458,100,MS-DRG,19566.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22832.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,38814.66,170,MS-DRG,31051.728,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39956.26,175,MS-DRG,31965.008,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31965.01,140,MS-DRG,25572.01,other,140% of Medicare CMS MS-DRG,28540.19,125,MS-DRG,22832.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,22832.15,100,MS-DRG,18265.72,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22832.15,39956.26,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,inpatient,,,,,,16593.5,100,MS-DRG,13274.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14708.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25003.86,170,MS-DRG,20003.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25739.26,175,MS-DRG,20591.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20591.41,140,MS-DRG,16473.13,other,140% of Medicare CMS MS-DRG,18385.19,125,MS-DRG,14708.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,14708.15,100,MS-DRG,11766.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14708.15,25739.26,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,inpatient,,,,,,11804.8,100,MS-DRG,9443.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9795.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16652.1,170,MS-DRG,13321.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17141.86,175,MS-DRG,13713.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13713.49,140,MS-DRG,10970.79,other,140% of Medicare CMS MS-DRG,12244.19,125,MS-DRG,9795.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,9795.35,100,MS-DRG,7836.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9795.35,17141.86,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,inpatient,,,,,,10406.2,100,MS-DRG,8324.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9266.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15752.57,170,MS-DRG,12602.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16215.89,175,MS-DRG,12972.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12972.71,140,MS-DRG,10378.17,other,140% of Medicare CMS MS-DRG,11582.78,125,MS-DRG,9266.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,9266.22,100,MS-DRG,7412.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9266.22,16215.89,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,inpatient,,,,,,6264.3,100,MS-DRG,5011.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5561.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9454.91,170,MS-DRG,7563.928,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9732.99,175,MS-DRG,7786.392,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7786.39,140,MS-DRG,6229.11,other,140% of Medicare CMS MS-DRG,6952.14,125,MS-DRG,5561.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,5561.71,100,MS-DRG,4449.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5561.71,9732.99,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,inpatient,,,,,,4233.6,100,MS-DRG,3386.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3756.99,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6386.88,170,MS-DRG,5109.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6574.73,175,MS-DRG,5259.784,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5259.79,140,MS-DRG,4207.83,other,140% of Medicare CMS MS-DRG,4696.24,125,MS-DRG,3756.99,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,3756.99,100,MS-DRG,3005.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3756.99,6574.73,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,inpatient,,,,,,11884.6,100,MS-DRG,9507.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11356.81,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19306.58,170,MS-DRG,15445.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19874.42,175,MS-DRG,15899.536,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15899.53,140,MS-DRG,12719.62,other,140% of Medicare CMS MS-DRG,14196.01,125,MS-DRG,11356.81,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,11356.81,100,MS-DRG,9085.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11356.81,19874.42,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,inpatient,,,,,,7278.6,100,MS-DRG,5822.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6453.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10971.6,170,MS-DRG,8777.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11294.29,175,MS-DRG,9035.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9035.43,140,MS-DRG,7228.34,other,140% of Medicare CMS MS-DRG,8067.35,125,MS-DRG,6453.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,6453.88,100,MS-DRG,5163.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6453.88,11294.29,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,inpatient,,,,,,6064.8,100,MS-DRG,4851.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4821.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8196.43,170,MS-DRG,6557.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8437.5,175,MS-DRG,6750,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6750,140,MS-DRG,5400,other,140% of Medicare CMS MS-DRG,6026.79,125,MS-DRG,4821.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,4821.43,100,MS-DRG,3857.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4821.43,8437.5,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,inpatient,,,,,,8029.7,100,MS-DRG,6423.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7250.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12326.65,170,MS-DRG,9861.32,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12689.2,175,MS-DRG,10151.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10151.36,140,MS-DRG,8121.09,other,140% of Medicare CMS MS-DRG,9063.71,125,MS-DRG,7250.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,7250.97,100,MS-DRG,5800.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7250.97,12689.2,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,inpatient,,,,,,5569.2,100,MS-DRG,4455.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4981.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8469.32,170,MS-DRG,6775.456,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8718.41,175,MS-DRG,6974.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6974.73,140,MS-DRG,5579.78,other,140% of Medicare CMS MS-DRG,6227.44,125,MS-DRG,4981.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,4981.95,100,MS-DRG,3985.56,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4981.95,8718.41,
URINARY STONES WITH MCC,693,MS-DRG,,,,,inpatient,,,,,,10015.6,100,MS-DRG,8012.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8744.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14865.65,170,MS-DRG,11892.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15302.88,175,MS-DRG,12242.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12242.3,140,MS-DRG,9793.84,other,140% of Medicare CMS MS-DRG,10930.63,125,MS-DRG,8744.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,8744.5,100,MS-DRG,6995.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8744.5,15302.88,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,inpatient,,,,,,5579.7,100,MS-DRG,4463.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4832.54,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8215.32,170,MS-DRG,6572.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8456.95,175,MS-DRG,6765.56,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6765.56,140,MS-DRG,5412.45,other,140% of Medicare CMS MS-DRG,6040.68,125,MS-DRG,4832.54,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,4832.54,100,MS-DRG,3866.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4832.54,8456.95,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,inpatient,,,,,,8038.1,100,MS-DRG,6430.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7384.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12553.36,170,MS-DRG,10042.688,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12922.58,175,MS-DRG,10338.064,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10338.06,140,MS-DRG,8270.45,other,140% of Medicare CMS MS-DRG,9230.41,125,MS-DRG,7384.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,7384.33,100,MS-DRG,5907.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7384.33,12922.58,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,inpatient,,,,,,4851,100,MS-DRG,3880.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4273.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7264.36,170,MS-DRG,5811.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7478.01,175,MS-DRG,5982.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5982.41,140,MS-DRG,4785.93,other,140% of Medicare CMS MS-DRG,5341.44,125,MS-DRG,4273.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,4273.15,100,MS-DRG,3418.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4273.15,7478.01,
URETHRAL STRICTURE,697,MS-DRG,,,,,inpatient,,,,,,6946.8,100,MS-DRG,5557.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6872.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11683.23,170,MS-DRG,9346.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12026.86,175,MS-DRG,9621.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9621.49,140,MS-DRG,7697.19,other,140% of Medicare CMS MS-DRG,8590.61,125,MS-DRG,6872.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,6872.49,100,MS-DRG,5497.99,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6872.49,12026.86,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,inpatient,,,,,,11217.5,100,MS-DRG,8974,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10214.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17364.77,170,MS-DRG,13891.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17875.5,175,MS-DRG,14300.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14300.4,140,MS-DRG,11440.32,other,140% of Medicare CMS MS-DRG,12768.21,125,MS-DRG,10214.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,10214.57,100,MS-DRG,8171.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10214.57,17875.5,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,inpatient,,,,,,7084.7,100,MS-DRG,5667.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6302.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10714.44,170,MS-DRG,8571.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11029.57,175,MS-DRG,8823.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8823.65,140,MS-DRG,7058.92,other,140% of Medicare CMS MS-DRG,7878.26,125,MS-DRG,6302.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,6302.61,100,MS-DRG,5042.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6302.61,11029.57,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,inpatient,,,,,,5185.6,100,MS-DRG,4148.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4373.18,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7434.41,170,MS-DRG,5947.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7653.07,175,MS-DRG,6122.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6122.45,140,MS-DRG,4897.96,other,140% of Medicare CMS MS-DRG,5466.48,125,MS-DRG,4373.18,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,4373.18,100,MS-DRG,3498.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4373.18,7653.07,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,inpatient,,,,,,13967.1,100,MS-DRG,11173.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12113.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20592.34,170,MS-DRG,16473.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21198,175,MS-DRG,16958.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16958.4,140,MS-DRG,13566.72,other,140% of Medicare CMS MS-DRG,15141.43,125,MS-DRG,12113.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,12113.14,100,MS-DRG,9690.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12113.14,21198,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,inpatient,,,,,,10392.9,100,MS-DRG,8314.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9005.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15308.59,170,MS-DRG,12246.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15758.84,175,MS-DRG,12607.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12607.07,140,MS-DRG,10085.66,other,140% of Medicare CMS MS-DRG,11256.31,125,MS-DRG,9005.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,9005.05,100,MS-DRG,7204.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9005.05,15758.84,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,inpatient,,,,,,16884,100,MS-DRG,13507.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13402.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22784.98,170,MS-DRG,18227.984,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23455.13,175,MS-DRG,18764.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18764.1,140,MS-DRG,15011.28,other,140% of Medicare CMS MS-DRG,16753.66,125,MS-DRG,13402.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,13402.93,100,MS-DRG,10722.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13402.93,23455.13,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,inpatient,,,,,,10089.8,100,MS-DRG,8071.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8009.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13616.63,170,MS-DRG,10893.304,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14017.12,175,MS-DRG,11213.696,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11213.69,140,MS-DRG,8970.95,other,140% of Medicare CMS MS-DRG,10012.23,125,MS-DRG,8009.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,8009.78,100,MS-DRG,6407.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8009.78,14017.12,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,inpatient,,,,,,14303.8,100,MS-DRG,11443.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13107.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22282.22,170,MS-DRG,17825.776,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22937.58,175,MS-DRG,18350.064,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18350.07,140,MS-DRG,14680.06,other,140% of Medicare CMS MS-DRG,16383.99,125,MS-DRG,13107.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,13107.19,100,MS-DRG,10485.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13107.19,22937.58,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,inpatient,,,,,,8691.2,100,MS-DRG,6952.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7337.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12473.6,170,MS-DRG,9978.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12840.47,175,MS-DRG,10272.376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10272.37,140,MS-DRG,8217.9,other,140% of Medicare CMS MS-DRG,9171.76,125,MS-DRG,7337.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,7337.41,100,MS-DRG,5869.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7337.41,12840.47,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,inpatient,,,,,,10373.3,100,MS-DRG,8298.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8956.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15226.71,170,MS-DRG,12181.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15674.56,175,MS-DRG,12539.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12539.65,140,MS-DRG,10031.72,other,140% of Medicare CMS MS-DRG,11196.11,125,MS-DRG,8956.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,8956.89,100,MS-DRG,7165.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8956.89,15674.56,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,inpatient,,,,,,6707.4,100,MS-DRG,5365.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5917.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10060.53,170,MS-DRG,8048.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10356.43,175,MS-DRG,8285.144,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8285.14,140,MS-DRG,6628.11,other,140% of Medicare CMS MS-DRG,7397.45,125,MS-DRG,5917.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,5917.96,100,MS-DRG,4734.37,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5917.96,10356.43,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,inpatient,,,,,,15632.4,100,MS-DRG,12505.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13629.52,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23170.18,170,MS-DRG,18536.144,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23851.66,175,MS-DRG,19081.328,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19081.33,140,MS-DRG,15265.06,other,140% of Medicare CMS MS-DRG,17036.9,125,MS-DRG,13629.52,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,13629.52,100,MS-DRG,10903.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13629.52,23851.66,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,inpatient,,,,,,9200.1,100,MS-DRG,7360.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8780.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14927.58,170,MS-DRG,11942.064,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15366.63,175,MS-DRG,12293.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12293.3,140,MS-DRG,9834.64,other,140% of Medicare CMS MS-DRG,10976.16,125,MS-DRG,8780.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,8780.93,100,MS-DRG,7024.74,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8780.93,15366.63,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,inpatient,,,,,,12392.1,100,MS-DRG,9913.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11198.13,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19036.82,170,MS-DRG,15229.456,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19596.73,175,MS-DRG,15677.384,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15677.38,140,MS-DRG,12541.9,other,140% of Medicare CMS MS-DRG,13997.66,125,MS-DRG,11198.13,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,11198.13,100,MS-DRG,8958.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11198.13,19596.73,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,inpatient,,,,,,8883,100,MS-DRG,7106.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7259.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12341.34,170,MS-DRG,9873.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12704.32,175,MS-DRG,10163.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10163.45,140,MS-DRG,8130.76,other,140% of Medicare CMS MS-DRG,9074.51,125,MS-DRG,7259.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,7259.61,100,MS-DRG,5807.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7259.61,12704.32,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,inpatient,,,,,,11883.9,100,MS-DRG,9507.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11575.37,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19678.13,170,MS-DRG,15742.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20256.9,175,MS-DRG,16205.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16205.52,140,MS-DRG,12964.42,other,140% of Medicare CMS MS-DRG,14469.21,125,MS-DRG,11575.37,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,11575.37,100,MS-DRG,9260.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11575.37,20256.9,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,inpatient,,,,,,8066.8,100,MS-DRG,6453.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6879.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11695.81,170,MS-DRG,9356.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12039.81,175,MS-DRG,9631.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9631.85,140,MS-DRG,7705.48,other,140% of Medicare CMS MS-DRG,8599.86,125,MS-DRG,6879.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,6879.89,100,MS-DRG,5503.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6879.89,12039.81,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,inpatient,,,,,,5355.7,100,MS-DRG,4284.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4998,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8496.6,170,MS-DRG,6797.28,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8746.5,175,MS-DRG,6997.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6997.2,140,MS-DRG,5597.76,other,140% of Medicare CMS MS-DRG,6247.5,125,MS-DRG,4998,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,4998,100,MS-DRG,3998.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4998,8746.5,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,inpatient,,,,,,8745.1,100,MS-DRG,6996.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7661.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13024.64,170,MS-DRG,10419.712,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13407.71,175,MS-DRG,10726.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10726.17,140,MS-DRG,8580.94,other,140% of Medicare CMS MS-DRG,9576.94,125,MS-DRG,7661.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,7661.55,100,MS-DRG,6129.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7661.55,13407.71,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,inpatient,,,,,,5401.2,100,MS-DRG,4320.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4512.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7671.61,170,MS-DRG,6137.288,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7897.24,175,MS-DRG,6317.792,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6317.79,140,MS-DRG,5054.23,other,140% of Medicare CMS MS-DRG,5640.89,125,MS-DRG,4512.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,4512.71,100,MS-DRG,3610.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4512.71,7897.24,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,inpatient,,,,,,10057.6,100,MS-DRG,8046.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10008.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17014.21,170,MS-DRG,13611.368,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17514.63,175,MS-DRG,14011.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14011.7,140,MS-DRG,11209.36,other,140% of Medicare CMS MS-DRG,12510.45,125,MS-DRG,10008.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,10008.36,100,MS-DRG,8006.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10008.36,17514.63,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,inpatient,,,,,,5751.9,100,MS-DRG,4601.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4939.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8397.95,170,MS-DRG,6718.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8644.95,175,MS-DRG,6915.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6915.96,140,MS-DRG,5532.77,other,140% of Medicare CMS MS-DRG,6174.96,125,MS-DRG,4939.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,4939.97,100,MS-DRG,3951.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4939.97,8644.95,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,inpatient,,,,,,7544.6,100,MS-DRG,6035.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6198.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10537.06,170,MS-DRG,8429.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10846.97,175,MS-DRG,8677.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8677.58,140,MS-DRG,6942.06,other,140% of Medicare CMS MS-DRG,7747.84,125,MS-DRG,6198.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,6198.27,100,MS-DRG,4958.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6198.27,10846.97,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,inpatient,,,,,,4590.6,100,MS-DRG,3672.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3837.87,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6524.38,170,MS-DRG,5219.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6716.27,175,MS-DRG,5373.016,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5373.02,140,MS-DRG,4298.42,other,140% of Medicare CMS MS-DRG,4797.34,125,MS-DRG,3837.87,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,3837.87,100,MS-DRG,3070.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3837.87,6716.27,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,inpatient,,,,,,15296.4,100,MS-DRG,12237.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13420.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22814.37,170,MS-DRG,18251.496,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23485.39,175,MS-DRG,18788.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18788.31,140,MS-DRG,15030.65,other,140% of Medicare CMS MS-DRG,16775.28,125,MS-DRG,13420.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,13420.22,100,MS-DRG,10736.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13420.22,23485.39,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,inpatient,,,,,,8905.4,100,MS-DRG,7124.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7780.71,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13227.21,170,MS-DRG,10581.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13616.24,175,MS-DRG,10892.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10892.99,140,MS-DRG,8714.39,other,140% of Medicare CMS MS-DRG,9725.89,125,MS-DRG,7780.71,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,7780.71,100,MS-DRG,6224.57,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7780.71,13616.24,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,inpatient,,,,,,29856.4,100,MS-DRG,23885.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24000.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40800.53,170,MS-DRG,32640.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42000.54,175,MS-DRG,33600.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33600.43,140,MS-DRG,26880.34,other,140% of Medicare CMS MS-DRG,30000.39,125,MS-DRG,24000.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,24000.31,100,MS-DRG,19200.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24000.31,42000.54,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,inpatient,,,,,,14164.5,100,MS-DRG,11331.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12186.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20717.24,170,MS-DRG,16573.792,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21326.57,175,MS-DRG,17061.256,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17061.25,140,MS-DRG,13649,other,140% of Medicare CMS MS-DRG,15233.26,125,MS-DRG,12186.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,12186.61,100,MS-DRG,9749.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12186.61,21326.57,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,inpatient,,,,,,9826.6,100,MS-DRG,7861.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8425.3,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14323.01,170,MS-DRG,11458.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14744.28,175,MS-DRG,11795.424,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11795.42,140,MS-DRG,9436.34,other,140% of Medicare CMS MS-DRG,10531.63,125,MS-DRG,8425.3,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,8425.3,100,MS-DRG,6740.24,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8425.3,14744.28,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,inpatient,,,,,,27316.1,100,MS-DRG,21852.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22327.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37957.12,170,MS-DRG,30365.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39073.51,175,MS-DRG,31258.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,31258.81,140,MS-DRG,25007.05,other,140% of Medicare CMS MS-DRG,27909.65,125,MS-DRG,22327.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,22327.72,100,MS-DRG,17862.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22327.72,39073.51,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,inpatient,,,,,,12616.8,100,MS-DRG,10093.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11033.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18756.58,170,MS-DRG,15005.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19308.24,175,MS-DRG,15446.592,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15446.59,140,MS-DRG,12357.27,other,140% of Medicare CMS MS-DRG,13791.6,125,MS-DRG,11033.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,11033.28,100,MS-DRG,8826.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11033.28,19308.24,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,inpatient,,,,,,9190.3,100,MS-DRG,7352.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8022.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13637.6,170,MS-DRG,10910.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14038.71,175,MS-DRG,11230.968,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11230.97,140,MS-DRG,8984.78,other,140% of Medicare CMS MS-DRG,10027.65,125,MS-DRG,8022.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,8022.12,100,MS-DRG,6417.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8022.12,14038.71,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,inpatient,,,,,,12614.7,100,MS-DRG,10091.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11001.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18703.03,170,MS-DRG,14962.424,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19253.12,175,MS-DRG,15402.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15402.49,140,MS-DRG,12321.99,other,140% of Medicare CMS MS-DRG,13752.23,125,MS-DRG,11001.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,11001.78,100,MS-DRG,8801.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11001.78,19253.12,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,inpatient,,,,,,8194.2,100,MS-DRG,6555.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7174.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12196.5,170,MS-DRG,9757.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12555.22,175,MS-DRG,10044.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10044.17,140,MS-DRG,8035.34,other,140% of Medicare CMS MS-DRG,8968.01,125,MS-DRG,7174.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,7174.41,100,MS-DRG,5739.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7174.41,12555.22,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,inpatient,,,,,,13288.1,100,MS-DRG,10630.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11622.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19757.89,170,MS-DRG,15806.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20339.01,175,MS-DRG,16271.208,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16271.21,140,MS-DRG,13016.97,other,140% of Medicare CMS MS-DRG,14527.86,125,MS-DRG,11622.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,11622.29,100,MS-DRG,9297.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11622.29,20339.01,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,inpatient,,,,,,8055.6,100,MS-DRG,6444.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6395.84,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10872.93,170,MS-DRG,8698.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11192.72,175,MS-DRG,8954.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8954.18,140,MS-DRG,7163.34,other,140% of Medicare CMS MS-DRG,7994.8,125,MS-DRG,6395.84,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,6395.84,100,MS-DRG,5116.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6395.84,11192.72,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,inpatient,,,,,,10943.8,100,MS-DRG,8755.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10348.56,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17592.55,170,MS-DRG,14074.04,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18109.98,175,MS-DRG,14487.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14487.98,140,MS-DRG,11590.38,other,140% of Medicare CMS MS-DRG,12935.7,125,MS-DRG,10348.56,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,10348.56,100,MS-DRG,8278.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10348.56,18109.98,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,inpatient,,,,,,6850.2,100,MS-DRG,5480.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5477.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9312.16,170,MS-DRG,7449.728,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9586.05,175,MS-DRG,7668.84,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7668.84,140,MS-DRG,6135.07,other,140% of Medicare CMS MS-DRG,6847.18,125,MS-DRG,5477.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,5477.74,100,MS-DRG,4382.19,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5477.74,9586.05,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,inpatient,,,,,,9920.4,100,MS-DRG,7936.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8674.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14746,170,MS-DRG,11796.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15179.71,175,MS-DRG,12143.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12143.77,140,MS-DRG,9715.02,other,140% of Medicare CMS MS-DRG,10842.65,125,MS-DRG,8674.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,8674.12,100,MS-DRG,6939.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8674.12,15179.71,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,inpatient,,,,,,17683.4,100,MS-DRG,14146.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15541.67,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26420.84,170,MS-DRG,21136.672,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27197.92,175,MS-DRG,21758.336,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21758.34,140,MS-DRG,17406.67,other,140% of Medicare CMS MS-DRG,19427.09,125,MS-DRG,15541.67,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,15541.67,100,MS-DRG,12433.34,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15541.67,27197.92,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,inpatient,,,,,,9989,100,MS-DRG,7991.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8396.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14274.71,170,MS-DRG,11419.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14694.56,175,MS-DRG,11755.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11755.65,140,MS-DRG,9404.52,other,140% of Medicare CMS MS-DRG,10496.11,125,MS-DRG,8396.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,8396.89,100,MS-DRG,6717.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8396.89,14694.56,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,inpatient,,,,,,12158.3,100,MS-DRG,9726.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11437.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19444.07,170,MS-DRG,15555.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20015.96,175,MS-DRG,16012.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16012.77,140,MS-DRG,12810.22,other,140% of Medicare CMS MS-DRG,14297.11,125,MS-DRG,11437.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,11437.69,100,MS-DRG,9150.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11437.69,20015.96,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,inpatient,,,,,,7567.7,100,MS-DRG,6054.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6697.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11385.14,170,MS-DRG,9108.112,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11720,175,MS-DRG,9376,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9376,140,MS-DRG,7500.8,other,140% of Medicare CMS MS-DRG,8371.43,125,MS-DRG,6697.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,6697.14,100,MS-DRG,5357.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6697.14,11720,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,inpatient,,,,,,6977.6,100,MS-DRG,5582.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6110.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10388,170,MS-DRG,8310.4,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10693.53,175,MS-DRG,8554.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8554.83,140,MS-DRG,6843.86,other,140% of Medicare CMS MS-DRG,7638.24,125,MS-DRG,6110.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,6110.59,100,MS-DRG,4888.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6110.59,10693.53,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,inpatient,,,,,,9605.4,100,MS-DRG,7684.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9209.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15656.01,170,MS-DRG,12524.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16116.49,175,MS-DRG,12893.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12893.19,140,MS-DRG,10314.55,other,140% of Medicare CMS MS-DRG,11511.78,125,MS-DRG,9209.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,9209.42,100,MS-DRG,7367.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9209.42,16116.49,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,inpatient,,,,,,6688.5,100,MS-DRG,5350.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6128.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10418.45,170,MS-DRG,8334.76,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10724.88,175,MS-DRG,8579.904,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8579.9,140,MS-DRG,6863.92,other,140% of Medicare CMS MS-DRG,7660.63,125,MS-DRG,6128.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,6128.5,100,MS-DRG,4902.8,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6128.5,10724.88,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,inpatient,,,,,,4342.8,100,MS-DRG,3474.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3989.76,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6782.59,170,MS-DRG,5426.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6982.08,175,MS-DRG,5585.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5585.66,140,MS-DRG,4468.53,other,140% of Medicare CMS MS-DRG,4987.2,125,MS-DRG,3989.76,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,3989.76,100,MS-DRG,3191.81,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3989.76,6982.08,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,inpatient,,,,,,6766.2,100,MS-DRG,5412.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6145.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10447.84,170,MS-DRG,8358.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10755.13,175,MS-DRG,8604.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8604.11,140,MS-DRG,6883.29,other,140% of Medicare CMS MS-DRG,7682.24,125,MS-DRG,6145.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,6145.79,100,MS-DRG,4916.63,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6145.79,10755.13,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,inpatient,,,,,,3959.9,100,MS-DRG,3167.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3739.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6356.45,170,MS-DRG,5085.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6543.41,175,MS-DRG,5234.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5234.73,140,MS-DRG,4187.78,other,140% of Medicare CMS MS-DRG,4673.86,125,MS-DRG,3739.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,3739.09,100,MS-DRG,2991.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3739.09,6543.41,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,inpatient,,,,,,8027.6,100,MS-DRG,6422.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7520.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12785.33,170,MS-DRG,10228.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13161.37,175,MS-DRG,10529.096,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10529.09,140,MS-DRG,8423.27,other,140% of Medicare CMS MS-DRG,9400.98,125,MS-DRG,7520.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,7520.78,100,MS-DRG,6016.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7520.78,13161.37,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,inpatient,,,,,,11629.1,100,MS-DRG,9303.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9532.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16204.96,170,MS-DRG,12963.968,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16681.58,175,MS-DRG,13345.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13345.26,140,MS-DRG,10676.21,other,140% of Medicare CMS MS-DRG,11915.41,125,MS-DRG,9532.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,9532.33,100,MS-DRG,7625.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9532.33,16681.58,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,inpatient,,,,,,6060.6,100,MS-DRG,4848.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4931.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8383.26,170,MS-DRG,6706.608,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8629.83,175,MS-DRG,6903.864,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6903.86,140,MS-DRG,5523.09,other,140% of Medicare CMS MS-DRG,6164.16,125,MS-DRG,4931.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,4931.33,100,MS-DRG,3945.06,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4931.33,8629.83,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,inpatient,,,,,,4879.7,100,MS-DRG,3903.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4425.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7522.57,170,MS-DRG,6018.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7743.82,175,MS-DRG,6195.056,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6195.06,140,MS-DRG,4956.05,other,140% of Medicare CMS MS-DRG,5531.3,125,MS-DRG,4425.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,4425.04,100,MS-DRG,3540.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4425.04,7743.82,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,inpatient,,,,,,7130.2,100,MS-DRG,5704.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6107.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10382.75,170,MS-DRG,8306.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10688.13,175,MS-DRG,8550.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8550.5,140,MS-DRG,6840.4,other,140% of Medicare CMS MS-DRG,7634.38,125,MS-DRG,6107.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,6107.5,100,MS-DRG,4886,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6107.5,10688.13,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,inpatient,,,,,,13507.9,100,MS-DRG,10806.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10939.43,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18597.03,170,MS-DRG,14877.624,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19144,175,MS-DRG,15315.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15315.2,140,MS-DRG,12252.16,other,140% of Medicare CMS MS-DRG,13674.29,125,MS-DRG,10939.43,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,10939.43,100,MS-DRG,8751.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10939.43,19144,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,inpatient,,,,,,7308,100,MS-DRG,5846.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6322.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10749.07,170,MS-DRG,8599.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11065.22,175,MS-DRG,8852.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8852.17,140,MS-DRG,7081.74,other,140% of Medicare CMS MS-DRG,7903.73,125,MS-DRG,6322.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,6322.98,100,MS-DRG,5058.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6322.98,11065.22,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,inpatient,,,,,,6384.7,100,MS-DRG,5107.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5348.7,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9092.79,170,MS-DRG,7274.232,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9360.23,175,MS-DRG,7488.184,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7488.18,140,MS-DRG,5990.54,other,140% of Medicare CMS MS-DRG,6685.88,125,MS-DRG,5348.7,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,5348.7,100,MS-DRG,4278.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5348.7,9360.23,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,inpatient,,,,,,11305,100,MS-DRG,9044,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10801.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18362.98,170,MS-DRG,14690.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18903.06,175,MS-DRG,15122.448,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15122.45,140,MS-DRG,12097.96,other,140% of Medicare CMS MS-DRG,13502.19,125,MS-DRG,10801.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,10801.75,100,MS-DRG,8641.4,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10801.75,18903.06,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,inpatient,,,,,,7457.1,100,MS-DRG,5965.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6489.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11032.47,170,MS-DRG,8825.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11356.96,175,MS-DRG,9085.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9085.57,140,MS-DRG,7268.46,other,140% of Medicare CMS MS-DRG,8112.11,125,MS-DRG,6489.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,6489.69,100,MS-DRG,5191.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6489.69,11356.96,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,inpatient,,,,,,6106.8,100,MS-DRG,4885.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5278.93,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8974.18,170,MS-DRG,7179.344,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9238.13,175,MS-DRG,7390.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7390.5,140,MS-DRG,5912.4,other,140% of Medicare CMS MS-DRG,6598.66,125,MS-DRG,5278.93,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,5278.93,100,MS-DRG,4223.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5278.93,9238.13,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,inpatient,,,,,,12780.6,100,MS-DRG,10224.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11233.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19096.63,170,MS-DRG,15277.304,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19658.29,175,MS-DRG,15726.632,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15726.63,140,MS-DRG,12581.3,other,140% of Medicare CMS MS-DRG,14041.64,125,MS-DRG,11233.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,11233.31,100,MS-DRG,8986.65,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11233.31,19658.29,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,inpatient,,,,,,42147.7,100,MS-DRG,33718.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37045.75,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,62977.78,170,MS-DRG,50382.224,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,64830.06,175,MS-DRG,51864.048,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,51864.05,140,MS-DRG,41491.24,other,140% of Medicare CMS MS-DRG,46307.19,125,MS-DRG,37045.75,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,37045.75,100,MS-DRG,29636.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37045.75,64830.06,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,inpatient,,,,,,28784.7,100,MS-DRG,23027.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,25299.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43009.95,170,MS-DRG,34407.96,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44274.95,175,MS-DRG,35419.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,35419.96,140,MS-DRG,28335.97,other,140% of Medicare CMS MS-DRG,31624.96,125,MS-DRG,25299.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,25299.97,100,MS-DRG,20239.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25299.97,44274.95,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,inpatient,,,,,,17368.4,100,MS-DRG,13894.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15265.68,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25951.66,170,MS-DRG,20761.328,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26714.94,175,MS-DRG,21371.952,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21371.95,140,MS-DRG,17097.56,other,140% of Medicare CMS MS-DRG,19082.1,125,MS-DRG,15265.68,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,15265.68,100,MS-DRG,12212.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15265.68,26714.94,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,inpatient,,,,,,29568,100,MS-DRG,23654.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,25989.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44181.32,170,MS-DRG,35345.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,45480.77,175,MS-DRG,36384.616,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,36384.61,140,MS-DRG,29107.69,other,140% of Medicare CMS MS-DRG,32486.26,125,MS-DRG,25989.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,25989.01,100,MS-DRG,20791.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25989.01,45480.77,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,inpatient,,,,,,10465.7,100,MS-DRG,8372.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9198.92,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15638.16,170,MS-DRG,12510.528,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16098.11,175,MS-DRG,12878.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12878.49,140,MS-DRG,10302.79,other,140% of Medicare CMS MS-DRG,11498.65,125,MS-DRG,9198.92,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,9198.92,100,MS-DRG,7359.14,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9198.92,16098.11,
NORMAL NEWBORN,795,MS-DRG,,,,,inpatient,,,,,,1416.8,100,MS-DRG,1133.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,1245.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,2117.08,170,MS-DRG,1693.664,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,2179.35,175,MS-DRG,1743.48,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,1743.48,140,MS-DRG,1394.78,other,140% of Medicare CMS MS-DRG,1556.68,125,MS-DRG,1245.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,1245.34,100,MS-DRG,996.27,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,1245.34,2179.35,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,inpatient,,,,,,9191,100,MS-DRG,7352.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8757.47,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14887.7,170,MS-DRG,11910.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15325.57,175,MS-DRG,12260.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12260.46,140,MS-DRG,9808.37,other,140% of Medicare CMS MS-DRG,10946.84,125,MS-DRG,8757.47,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,8757.47,100,MS-DRG,7005.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8757.47,15325.57,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,inpatient,,,,,,6495.3,100,MS-DRG,5196.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6148.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10453.1,170,MS-DRG,8362.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10760.54,175,MS-DRG,8608.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8608.43,140,MS-DRG,6886.74,other,140% of Medicare CMS MS-DRG,7686.1,125,MS-DRG,6148.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,6148.88,100,MS-DRG,4919.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6148.88,10760.54,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,inpatient,,,,,,6495.3,100,MS-DRG,5196.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5156.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8765.3,170,MS-DRG,7012.24,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9023.11,175,MS-DRG,7218.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7218.48,140,MS-DRG,5774.78,other,140% of Medicare CMS MS-DRG,6445.08,125,MS-DRG,5156.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,5156.06,100,MS-DRG,4124.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5156.06,9023.11,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,inpatient,,,,,,36453.9,100,MS-DRG,29163.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,30590.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52004.07,170,MS-DRG,41603.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,53533.6,175,MS-DRG,42826.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42826.88,140,MS-DRG,34261.5,other,140% of Medicare CMS MS-DRG,38238.29,125,MS-DRG,30590.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,30590.63,100,MS-DRG,24472.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30590.63,53533.6,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,inpatient,,,,,,18609.5,100,MS-DRG,14887.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17397.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29574.92,170,MS-DRG,23659.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30444.77,175,MS-DRG,24355.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24355.81,140,MS-DRG,19484.65,other,140% of Medicare CMS MS-DRG,21746.26,125,MS-DRG,17397.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,17397.01,100,MS-DRG,13917.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17397.01,30444.77,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,inpatient,,,,,,12572,100,MS-DRG,10057.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11049.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18784.92,170,MS-DRG,15027.936,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19337.41,175,MS-DRG,15469.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15469.93,140,MS-DRG,12375.94,other,140% of Medicare CMS MS-DRG,13812.44,125,MS-DRG,11049.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,11049.95,100,MS-DRG,8839.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11049.95,19337.41,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,inpatient,,,,,,26684,100,MS-DRG,21347.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,21182.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36010.08,170,MS-DRG,28808.064,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37069.2,175,MS-DRG,29655.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29655.36,140,MS-DRG,23724.29,other,140% of Medicare CMS MS-DRG,26478,125,MS-DRG,21182.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,21182.4,100,MS-DRG,16945.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21182.4,37069.2,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,inpatient,,,,,,14373.1,100,MS-DRG,11498.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11472.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19503.9,170,MS-DRG,15603.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20077.54,175,MS-DRG,16062.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16062.03,140,MS-DRG,12849.62,other,140% of Medicare CMS MS-DRG,14341.1,125,MS-DRG,11472.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,11472.88,100,MS-DRG,9178.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11472.88,20077.54,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,inpatient,,,,,,8832.6,100,MS-DRG,7066.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7473.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12704.49,170,MS-DRG,10163.592,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13078.15,175,MS-DRG,10462.52,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10462.52,140,MS-DRG,8370.02,other,140% of Medicare CMS MS-DRG,9341.54,125,MS-DRG,7473.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,7473.23,100,MS-DRG,5978.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7473.23,13078.15,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,inpatient,,,,,,7039.2,100,MS-DRG,5631.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6224.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10582.19,170,MS-DRG,8465.752,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10893.44,175,MS-DRG,8714.752,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8714.75,140,MS-DRG,6971.8,other,140% of Medicare CMS MS-DRG,7781.03,125,MS-DRG,6224.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,6224.82,100,MS-DRG,4979.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6224.82,10893.44,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,inpatient,,,,,,4884.6,100,MS-DRG,3907.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4610.26,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7837.44,170,MS-DRG,6269.952,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8067.96,175,MS-DRG,6454.368,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6454.36,140,MS-DRG,5163.49,other,140% of Medicare CMS MS-DRG,5762.83,125,MS-DRG,4610.26,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,4610.26,100,MS-DRG,3688.21,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4610.26,8067.96,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,inpatient,,,,,,4419.8,100,MS-DRG,3535.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4039.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6867.61,170,MS-DRG,5494.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7069.6,175,MS-DRG,5655.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5655.68,140,MS-DRG,4524.54,other,140% of Medicare CMS MS-DRG,5049.71,125,MS-DRG,4039.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,4039.77,100,MS-DRG,3231.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4039.77,7069.6,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,inpatient,,,,,,14987,100,MS-DRG,11989.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13522.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22987.55,170,MS-DRG,18390.04,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23663.66,175,MS-DRG,18930.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18930.93,140,MS-DRG,15144.74,other,140% of Medicare CMS MS-DRG,16902.61,125,MS-DRG,13522.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,13522.09,100,MS-DRG,10817.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13522.09,23663.66,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,inpatient,,,,,,8509.9,100,MS-DRG,6807.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7436.19,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12641.52,170,MS-DRG,10113.216,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13013.33,175,MS-DRG,10410.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10410.67,140,MS-DRG,8328.54,other,140% of Medicare CMS MS-DRG,9295.24,125,MS-DRG,7436.19,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,7436.19,100,MS-DRG,5948.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7436.19,13013.33,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,inpatient,,,,,,6571.6,100,MS-DRG,5257.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6201.97,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10543.35,170,MS-DRG,8434.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10853.45,175,MS-DRG,8682.76,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8682.76,140,MS-DRG,6946.21,other,140% of Medicare CMS MS-DRG,7752.46,125,MS-DRG,6201.97,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,6201.97,100,MS-DRG,4961.58,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6201.97,10853.45,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,inpatient,,,,,,9732.1,100,MS-DRG,7785.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8666.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14732.35,170,MS-DRG,11785.88,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15165.66,175,MS-DRG,12132.528,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12132.53,140,MS-DRG,9706.02,other,140% of Medicare CMS MS-DRG,10832.61,125,MS-DRG,8666.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,8666.09,100,MS-DRG,6932.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8666.09,15165.66,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,inpatient,,,,,,6286,100,MS-DRG,5028.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5561.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9453.85,170,MS-DRG,7563.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9731.91,175,MS-DRG,7785.528,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7785.53,140,MS-DRG,6228.42,other,140% of Medicare CMS MS-DRG,6951.36,125,MS-DRG,5561.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,5561.09,100,MS-DRG,4448.87,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5561.09,9731.91,
COAGULATION DISORDERS,813,MS-DRG,,,,,inpatient,,,,,,10955.7,100,MS-DRG,8764.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9631.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16373.96,170,MS-DRG,13099.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16855.55,175,MS-DRG,13484.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13484.44,140,MS-DRG,10787.55,other,140% of Medicare CMS MS-DRG,12039.68,125,MS-DRG,9631.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,9631.74,100,MS-DRG,7705.39,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9631.74,16855.55,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,inpatient,,,,,,13153.7,100,MS-DRG,10522.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13139.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22336.79,170,MS-DRG,17869.432,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22993.76,175,MS-DRG,18395.008,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18395.01,140,MS-DRG,14716.01,other,140% of Medicare CMS MS-DRG,16424.11,125,MS-DRG,13139.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,13139.29,100,MS-DRG,10511.43,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13139.29,22993.76,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,inpatient,,,,,,7217.7,100,MS-DRG,5774.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6138.38,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10435.25,170,MS-DRG,8348.2,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10742.17,175,MS-DRG,8593.736,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8593.73,140,MS-DRG,6874.98,other,140% of Medicare CMS MS-DRG,7672.98,125,MS-DRG,6138.38,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,6138.38,100,MS-DRG,4910.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6138.38,10742.17,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,inpatient,,,,,,5103,100,MS-DRG,4082.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4384.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7454.35,170,MS-DRG,5963.48,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7673.59,175,MS-DRG,6138.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6138.87,140,MS-DRG,4911.1,other,140% of Medicare CMS MS-DRG,5481.14,125,MS-DRG,4384.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,4384.91,100,MS-DRG,3507.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4384.91,7673.59,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,inpatient,,,,,,21908.6,100,MS-DRG,17526.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17391.46,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29565.48,170,MS-DRG,23652.384,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30435.06,175,MS-DRG,24348.048,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24348.04,140,MS-DRG,19478.43,other,140% of Medicare CMS MS-DRG,21739.33,125,MS-DRG,17391.46,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,17391.46,100,MS-DRG,13913.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17391.46,30435.06,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,inpatient,,,,,,11130.7,100,MS-DRG,8904.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8835.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15021.01,170,MS-DRG,12016.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15462.81,175,MS-DRG,12370.248,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12370.25,140,MS-DRG,9896.2,other,140% of Medicare CMS MS-DRG,11044.86,125,MS-DRG,8835.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,8835.89,100,MS-DRG,7068.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8835.89,15462.81,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,inpatient,,,,,,6219.5,100,MS-DRG,4975.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5601.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9522.07,170,MS-DRG,7617.656,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9802.14,175,MS-DRG,7841.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7841.71,140,MS-DRG,6273.37,other,140% of Medicare CMS MS-DRG,7001.53,125,MS-DRG,5601.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,5601.22,100,MS-DRG,4480.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5601.22,9802.14,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,inpatient,,,,,,37223.2,100,MS-DRG,29778.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37333.46,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63466.88,170,MS-DRG,50773.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65333.56,175,MS-DRG,52266.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52266.84,140,MS-DRG,41813.47,other,140% of Medicare CMS MS-DRG,46666.83,125,MS-DRG,37333.46,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,37333.46,100,MS-DRG,29866.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37223.2,65333.56,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,inpatient,,,,,,15136.8,100,MS-DRG,12109.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13781.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23428.4,170,MS-DRG,18742.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24117.47,175,MS-DRG,19293.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19293.97,140,MS-DRG,15435.18,other,140% of Medicare CMS MS-DRG,17226.76,125,MS-DRG,13781.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,13781.41,100,MS-DRG,11025.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13781.41,24117.47,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,inpatient,,,,,,8435,100,MS-DRG,6748,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7648.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13002.59,170,MS-DRG,10402.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13385.02,175,MS-DRG,10708.016,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10708.01,140,MS-DRG,8566.41,other,140% of Medicare CMS MS-DRG,9560.73,125,MS-DRG,7648.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,7648.58,100,MS-DRG,6118.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7648.58,13385.02,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,inpatient,,,,,,30284.8,100,MS-DRG,24227.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27795.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47252.49,170,MS-DRG,37801.992,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48642.27,175,MS-DRG,38913.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38913.81,140,MS-DRG,31131.05,other,140% of Medicare CMS MS-DRG,34744.48,125,MS-DRG,27795.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,27795.58,100,MS-DRG,22236.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27795.58,48642.27,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,inpatient,,,,,,16032.1,100,MS-DRG,12825.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13786.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23436.8,170,MS-DRG,18749.44,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24126.11,175,MS-DRG,19300.888,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19300.89,140,MS-DRG,15440.71,other,140% of Medicare CMS MS-DRG,17232.94,125,MS-DRG,13786.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,13786.35,100,MS-DRG,11029.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13786.35,24126.11,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,inpatient,,,,,,9216.2,100,MS-DRG,7372.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7973.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13554.7,170,MS-DRG,10843.76,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13953.36,175,MS-DRG,11162.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11162.69,140,MS-DRG,8930.15,other,140% of Medicare CMS MS-DRG,9966.69,125,MS-DRG,7973.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,7973.35,100,MS-DRG,6378.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7973.35,13953.36,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,inpatient,,,,,,35993.3,100,MS-DRG,28794.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,28572.29,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,48572.89,170,MS-DRG,38858.312,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50001.51,175,MS-DRG,40001.208,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,40001.21,140,MS-DRG,32000.97,other,140% of Medicare CMS MS-DRG,35715.36,125,MS-DRG,28572.29,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,28572.29,100,MS-DRG,22857.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28572.29,50001.51,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,inpatient,,,,,,17042.9,100,MS-DRG,13634.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,14306.83,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24321.61,170,MS-DRG,19457.288,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25036.95,175,MS-DRG,20029.56,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20029.56,140,MS-DRG,16023.65,other,140% of Medicare CMS MS-DRG,17883.54,125,MS-DRG,14306.83,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,14306.83,100,MS-DRG,11445.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14306.83,25036.95,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,inpatient,,,,,,12173.7,100,MS-DRG,9738.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10128.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17217.84,170,MS-DRG,13774.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17724.25,175,MS-DRG,14179.4,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14179.4,140,MS-DRG,11343.52,other,140% of Medicare CMS MS-DRG,12660.18,125,MS-DRG,10128.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,10128.14,100,MS-DRG,8102.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10128.14,17724.25,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,inpatient,,,,,,22152.9,100,MS-DRG,17722.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19472.16,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33102.67,170,MS-DRG,26482.136,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34076.28,175,MS-DRG,27261.024,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27261.02,140,MS-DRG,21808.82,other,140% of Medicare CMS MS-DRG,24340.2,125,MS-DRG,19472.16,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,19472.16,100,MS-DRG,15577.73,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19472.16,34076.28,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,inpatient,,,,,,10293.5,100,MS-DRG,8234.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9762.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16596.45,170,MS-DRG,13277.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17084.59,175,MS-DRG,13667.672,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13667.67,140,MS-DRG,10934.14,other,140% of Medicare CMS MS-DRG,12203.28,125,MS-DRG,9762.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,9762.62,100,MS-DRG,7810.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9762.62,17084.59,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,inpatient,,,,,,8363.6,100,MS-DRG,6690.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6639.11,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11286.49,170,MS-DRG,9029.192,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11618.44,175,MS-DRG,9294.752,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9294.75,140,MS-DRG,7435.8,other,140% of Medicare CMS MS-DRG,8298.89,125,MS-DRG,6639.11,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,6639.11,100,MS-DRG,5311.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6639.11,11618.44,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,inpatient,,,,,,4903.5,100,MS-DRG,3922.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4554.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7742.97,170,MS-DRG,6194.376,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7970.71,175,MS-DRG,6376.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6376.57,140,MS-DRG,5101.26,other,140% of Medicare CMS MS-DRG,5693.36,125,MS-DRG,4554.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,4554.69,100,MS-DRG,3643.75,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4554.69,7970.71,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,inpatient,,,,,,3528,100,MS-DRG,2822.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3159.95,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5371.92,170,MS-DRG,4297.536,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5529.91,175,MS-DRG,4423.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4423.93,140,MS-DRG,3539.14,other,140% of Medicare CMS MS-DRG,3949.94,125,MS-DRG,3159.95,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,3159.95,100,MS-DRG,2527.96,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3159.95,5529.91,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,inpatient,,,,,,38710,100,MS-DRG,30968,other,Custom DRG with base of 7000. See MS-DRG rows for rates,34569.28,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,58767.78,170,MS-DRG,47014.224,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,60496.24,175,MS-DRG,48396.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,48396.99,140,MS-DRG,38717.59,other,140% of Medicare CMS MS-DRG,43211.6,125,MS-DRG,34569.28,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,34569.28,100,MS-DRG,27655.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34569.28,60496.24,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,inpatient,,,,,,14679.7,100,MS-DRG,11743.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13802.4,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23464.08,170,MS-DRG,18771.264,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24154.2,175,MS-DRG,19323.36,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19323.36,140,MS-DRG,15458.69,other,140% of Medicare CMS MS-DRG,17253,125,MS-DRG,13802.4,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,13802.4,100,MS-DRG,11041.92,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13802.4,24154.2,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,inpatient,,,,,,10981.6,100,MS-DRG,8785.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8717.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14819.46,170,MS-DRG,11855.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15255.33,175,MS-DRG,12204.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12204.26,140,MS-DRG,9763.41,other,140% of Medicare CMS MS-DRG,10896.66,125,MS-DRG,8717.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,8717.33,100,MS-DRG,6973.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8717.33,15255.33,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,inpatient,,,,,,37675.4,100,MS-DRG,30140.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29907.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,50843.21,170,MS-DRG,40674.568,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52338.6,175,MS-DRG,41870.88,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,41870.88,140,MS-DRG,33496.7,other,140% of Medicare CMS MS-DRG,37384.71,125,MS-DRG,29907.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,29907.77,100,MS-DRG,23926.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29907.77,52338.6,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,inpatient,,,,,,15568.7,100,MS-DRG,12454.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12358.87,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21010.08,170,MS-DRG,16808.064,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21628.02,175,MS-DRG,17302.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17302.42,140,MS-DRG,13841.94,other,140% of Medicare CMS MS-DRG,15448.59,125,MS-DRG,12358.87,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,12358.87,100,MS-DRG,9887.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12358.87,21628.02,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,inpatient,,,,,,9622.9,100,MS-DRG,7698.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8045.59,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13677.5,170,MS-DRG,10942,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14079.78,175,MS-DRG,11263.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11263.83,140,MS-DRG,9011.06,other,140% of Medicare CMS MS-DRG,10056.99,125,MS-DRG,8045.59,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,8045.59,100,MS-DRG,6436.47,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8045.59,14079.78,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,inpatient,,,,,,21749,100,MS-DRG,17399.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19295.57,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32802.47,170,MS-DRG,26241.976,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33767.25,175,MS-DRG,27013.8,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27013.8,140,MS-DRG,21611.04,other,140% of Medicare CMS MS-DRG,24119.46,125,MS-DRG,19295.57,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,19295.57,100,MS-DRG,15436.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19295.57,33767.25,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,inpatient,,,,,,11163.6,100,MS-DRG,8930.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9715.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16515.65,170,MS-DRG,13212.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17001.41,175,MS-DRG,13601.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13601.13,140,MS-DRG,10880.9,other,140% of Medicare CMS MS-DRG,12143.86,125,MS-DRG,9715.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,9715.09,100,MS-DRG,7772.07,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9715.09,17001.41,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,inpatient,,,,,,7725.9,100,MS-DRG,6180.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6584.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11193.06,170,MS-DRG,8954.448,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11522.26,175,MS-DRG,9217.808,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9217.81,140,MS-DRG,7374.25,other,140% of Medicare CMS MS-DRG,8230.19,125,MS-DRG,6584.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,6584.15,100,MS-DRG,5267.32,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6584.15,11522.26,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,inpatient,,,,,,13561.8,100,MS-DRG,10849.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11487.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19529.07,170,MS-DRG,15623.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20103.46,175,MS-DRG,16082.768,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16082.77,140,MS-DRG,12866.22,other,140% of Medicare CMS MS-DRG,14359.61,125,MS-DRG,11487.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,11487.69,100,MS-DRG,9190.15,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11487.69,20103.46,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,inpatient,,,,,,7984.2,100,MS-DRG,6387.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7144.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12146.13,170,MS-DRG,9716.904,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12503.37,175,MS-DRG,10002.696,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10002.69,140,MS-DRG,8002.15,other,140% of Medicare CMS MS-DRG,8930.98,125,MS-DRG,7144.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,7144.78,100,MS-DRG,5715.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7144.78,12503.37,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,inpatient,,,,,,5918.5,100,MS-DRG,4734.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5340.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9078.09,170,MS-DRG,7262.472,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9345.09,175,MS-DRG,7476.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7476.07,140,MS-DRG,5980.86,other,140% of Medicare CMS MS-DRG,6675.06,125,MS-DRG,5340.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,5340.05,100,MS-DRG,4272.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5340.05,9345.09,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,inpatient,,,,,,16863,100,MS-DRG,13490.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15089.72,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,25652.52,170,MS-DRG,20522.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26407.01,175,MS-DRG,21125.608,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21125.61,140,MS-DRG,16900.49,other,140% of Medicare CMS MS-DRG,18862.15,125,MS-DRG,15089.72,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,15089.72,100,MS-DRG,12071.78,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15089.72,26407.01,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,inpatient,,,,,,8526.7,100,MS-DRG,6821.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7486.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12727.59,170,MS-DRG,10182.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13101.94,175,MS-DRG,10481.552,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10481.55,140,MS-DRG,8385.24,other,140% of Medicare CMS MS-DRG,9358.53,125,MS-DRG,7486.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,7486.82,100,MS-DRG,5989.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7486.82,13101.94,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,inpatient,,,,,,6503.7,100,MS-DRG,5202.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5162.86,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8776.86,170,MS-DRG,7021.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9035.01,175,MS-DRG,7228.008,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7228,140,MS-DRG,5782.4,other,140% of Medicare CMS MS-DRG,6453.58,125,MS-DRG,5162.86,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,5162.86,100,MS-DRG,4130.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5162.86,9035.01,
RADIOTHERAPY,849,MS-DRG,,,,,inpatient,,,,,,16372.3,100,MS-DRG,13097.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16617.21,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28249.26,170,MS-DRG,22599.408,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29080.12,175,MS-DRG,23264.096,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23264.09,140,MS-DRG,18611.27,other,140% of Medicare CMS MS-DRG,20771.51,125,MS-DRG,16617.21,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,16617.21,100,MS-DRG,13293.77,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16372.3,29080.12,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,inpatient,,,,,,34307,100,MS-DRG,27445.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,30866.62,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,52473.25,170,MS-DRG,41978.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,54016.59,175,MS-DRG,43213.272,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43213.27,140,MS-DRG,34570.62,other,140% of Medicare CMS MS-DRG,38583.28,125,MS-DRG,30866.62,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,30866.62,100,MS-DRG,24693.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30866.62,54016.59,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,inpatient,,,,,,14389.2,100,MS-DRG,11511.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12584.23,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21393.19,170,MS-DRG,17114.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22022.4,175,MS-DRG,17617.92,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17617.92,140,MS-DRG,14094.34,other,140% of Medicare CMS MS-DRG,15730.29,125,MS-DRG,12584.23,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,12584.23,100,MS-DRG,10067.38,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12584.23,22022.4,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,inpatient,,,,,,10693.9,100,MS-DRG,8555.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10507.24,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17862.31,170,MS-DRG,14289.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18387.67,175,MS-DRG,14710.136,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14710.14,140,MS-DRG,11768.11,other,140% of Medicare CMS MS-DRG,13134.05,125,MS-DRG,10507.24,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,10507.24,100,MS-DRG,8405.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10507.24,18387.67,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,inpatient,,,,,,30888.9,100,MS-DRG,24711.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,27341.77,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46481.01,170,MS-DRG,37184.808,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,47848.1,175,MS-DRG,38278.48,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,38278.48,140,MS-DRG,30622.78,other,140% of Medicare CMS MS-DRG,34177.21,125,MS-DRG,27341.77,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,27341.77,100,MS-DRG,21873.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27341.77,47848.1,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,inpatient,,,,,,14763,100,MS-DRG,11810.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13186.22,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22416.57,170,MS-DRG,17933.256,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23075.89,175,MS-DRG,18460.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18460.71,140,MS-DRG,14768.57,other,140% of Medicare CMS MS-DRG,16482.78,125,MS-DRG,13186.22,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,13186.22,100,MS-DRG,10548.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13186.22,23075.89,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,inpatient,,,,,,9902.2,100,MS-DRG,7921.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7923.96,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13470.73,170,MS-DRG,10776.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13866.93,175,MS-DRG,11093.544,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11093.54,140,MS-DRG,8874.83,other,140% of Medicare CMS MS-DRG,9904.95,125,MS-DRG,7923.96,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,7923.96,100,MS-DRG,6339.17,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7923.96,13866.93,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,inpatient,,,,,,12803.7,100,MS-DRG,10242.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11372.85,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19333.85,170,MS-DRG,15467.08,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19902.49,175,MS-DRG,15921.992,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15921.99,140,MS-DRG,12737.59,other,140% of Medicare CMS MS-DRG,14216.06,125,MS-DRG,11372.85,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,11372.85,100,MS-DRG,9098.28,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11372.85,19902.49,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,inpatient,,,,,,7041.3,100,MS-DRG,5633.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6208.15,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10553.86,170,MS-DRG,8443.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10864.26,175,MS-DRG,8691.408,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8691.41,140,MS-DRG,6953.13,other,140% of Medicare CMS MS-DRG,7760.19,125,MS-DRG,6208.15,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,6208.15,100,MS-DRG,4966.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6208.15,10864.26,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,inpatient,,,,,,5937.4,100,MS-DRG,4749.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5450.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9265.99,170,MS-DRG,7412.792,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9538.52,175,MS-DRG,7630.816,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7630.81,140,MS-DRG,6104.65,other,140% of Medicare CMS MS-DRG,6813.23,125,MS-DRG,5450.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,5450.58,100,MS-DRG,4360.46,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5450.58,9538.52,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,inpatient,,,,,,11709.6,100,MS-DRG,9367.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10125.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17212.59,170,MS-DRG,13770.072,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17718.84,175,MS-DRG,14175.072,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14175.07,140,MS-DRG,11340.06,other,140% of Medicare CMS MS-DRG,12656.31,125,MS-DRG,10125.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,10125.05,100,MS-DRG,8100.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10125.05,17718.84,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,inpatient,,,,,,6297.9,100,MS-DRG,5038.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5666.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9632.3,170,MS-DRG,7705.84,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9915.61,175,MS-DRG,7932.488,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7932.48,140,MS-DRG,6345.98,other,140% of Medicare CMS MS-DRG,7082.58,125,MS-DRG,5666.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,5666.06,100,MS-DRG,4532.85,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5666.06,9915.61,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,inpatient,,,,,,14793.8,100,MS-DRG,11835.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12918.26,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21961.04,170,MS-DRG,17568.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22606.96,175,MS-DRG,18085.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18085.56,140,MS-DRG,14468.45,other,140% of Medicare CMS MS-DRG,16147.83,125,MS-DRG,12918.26,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,12918.26,100,MS-DRG,10334.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12918.26,22606.96,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,inpatient,,,,,,7389.9,100,MS-DRG,5911.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6702.08,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11393.54,170,MS-DRG,9114.832,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11728.64,175,MS-DRG,9382.912,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9382.91,140,MS-DRG,7506.33,other,140% of Medicare CMS MS-DRG,8377.6,125,MS-DRG,6702.08,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,6702.08,100,MS-DRG,5361.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6702.08,11728.64,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,inpatient,,,,,,5185.6,100,MS-DRG,4148.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4264.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7249.67,170,MS-DRG,5799.736,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7462.89,175,MS-DRG,5970.312,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5970.31,140,MS-DRG,4776.25,other,140% of Medicare CMS MS-DRG,5330.64,125,MS-DRG,4264.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,4264.51,100,MS-DRG,3411.61,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4264.51,7462.89,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,inpatient,,,,,,47536.3,100,MS-DRG,38029.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,43002.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,73104.44,170,MS-DRG,58483.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75254.57,175,MS-DRG,60203.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,60203.65,140,MS-DRG,48162.92,other,140% of Medicare CMS MS-DRG,53753.26,125,MS-DRG,43002.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,43002.61,100,MS-DRG,34402.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43002.61,75254.57,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,inpatient,,,,,,85451.1,100,MS-DRG,68360.88,other,Custom DRG with base of 7000. See MS-DRG rows for rates,75735.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,128749.6,170,MS-DRG,102999.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,132536.36,175,MS-DRG,106029.088,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,106029.08,140,MS-DRG,84823.26,other,140% of Medicare CMS MS-DRG,94668.83,125,MS-DRG,75735.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,75735.06,100,MS-DRG,60588.05,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75735.06,132536.36,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,inpatient,,,,,,7196,100,MS-DRG,5756.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6358.79,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10809.94,170,MS-DRG,8647.952,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11127.88,175,MS-DRG,8902.304,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8902.31,140,MS-DRG,7121.85,other,140% of Medicare CMS MS-DRG,7948.49,125,MS-DRG,6358.79,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,6358.79,100,MS-DRG,5087.03,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6358.79,11127.88,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,inpatient,,,,,,22374.1,100,MS-DRG,17899.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23038.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39166.27,170,MS-DRG,31333.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40318.22,175,MS-DRG,32254.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32254.57,140,MS-DRG,25803.66,other,140% of Medicare CMS MS-DRG,28798.73,125,MS-DRG,23038.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,23038.98,100,MS-DRG,18431.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22374.1,40318.22,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,inpatient,,,,,,6343.4,100,MS-DRG,5074.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5893.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10019.6,170,MS-DRG,8015.68,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10314.29,175,MS-DRG,8251.432,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8251.43,140,MS-DRG,6601.14,other,140% of Medicare CMS MS-DRG,7367.35,125,MS-DRG,5893.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,5893.88,100,MS-DRG,4715.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5893.88,10314.29,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,inpatient,,,,,,5988.5,100,MS-DRG,4790.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5596.91,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9514.75,170,MS-DRG,7611.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9794.59,175,MS-DRG,7835.672,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7835.67,140,MS-DRG,6268.54,other,140% of Medicare CMS MS-DRG,6996.14,125,MS-DRG,5596.91,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,5596.91,100,MS-DRG,4477.53,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5596.91,9794.59,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,inpatient,,,,,,6114.5,100,MS-DRG,4891.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5799.42,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9859.01,170,MS-DRG,7887.208,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10148.99,175,MS-DRG,8119.192,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8119.19,140,MS-DRG,6495.35,other,140% of Medicare CMS MS-DRG,7249.28,125,MS-DRG,5799.42,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,5799.42,100,MS-DRG,4639.54,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5799.42,10148.99,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,inpatient,,,,,,11301.5,100,MS-DRG,9041.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11579.08,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19684.44,170,MS-DRG,15747.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20263.39,175,MS-DRG,16210.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16210.71,140,MS-DRG,12968.57,other,140% of Medicare CMS MS-DRG,14473.85,125,MS-DRG,11579.08,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,11579.08,100,MS-DRG,9263.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11301.5,20263.39,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,inpatient,,,,,,10990,100,MS-DRG,8792,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10847.44,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18440.65,170,MS-DRG,14752.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18983.02,175,MS-DRG,15186.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15186.42,140,MS-DRG,12149.14,other,140% of Medicare CMS MS-DRG,13559.3,125,MS-DRG,10847.44,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,10847.44,100,MS-DRG,8677.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10847.44,18983.02,
PSYCHOSES,885,MS-DRG,,,,,inpatient,,,,,,9068.5,100,MS-DRG,7254.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8436.41,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14341.9,170,MS-DRG,11473.52,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14763.72,175,MS-DRG,11810.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11810.97,140,MS-DRG,9448.78,other,140% of Medicare CMS MS-DRG,10545.51,125,MS-DRG,8436.41,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,8436.41,100,MS-DRG,6749.13,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8436.41,14763.72,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,inpatient,,,,,,9555,100,MS-DRG,7644,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10383.13,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17651.32,170,MS-DRG,14121.056,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18170.48,175,MS-DRG,14536.384,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14536.38,140,MS-DRG,11629.1,other,140% of Medicare CMS MS-DRG,12978.91,125,MS-DRG,10383.13,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,10383.13,100,MS-DRG,8306.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9555,18170.48,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,inpatient,,,,,,9075.5,100,MS-DRG,7260.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7999.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13598.76,170,MS-DRG,10879.008,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13998.72,175,MS-DRG,11198.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11198.98,140,MS-DRG,8959.18,other,140% of Medicare CMS MS-DRG,9999.09,125,MS-DRG,7999.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,7999.27,100,MS-DRG,6399.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7999.27,13998.72,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,inpatient,,,,,,4002.6,100,MS-DRG,3202.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3547.07,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6030.02,170,MS-DRG,4824.016,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6207.37,175,MS-DRG,4965.896,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4965.9,140,MS-DRG,3972.72,other,140% of Medicare CMS MS-DRG,4433.84,125,MS-DRG,3547.07,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,3547.07,100,MS-DRG,2837.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3547.07,6207.37,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,inpatient,,,,,,10910.9,100,MS-DRG,8728.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9933.03,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16886.15,170,MS-DRG,13508.92,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17382.8,175,MS-DRG,13906.24,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13906.24,140,MS-DRG,11124.99,other,140% of Medicare CMS MS-DRG,12416.29,125,MS-DRG,9933.03,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,9933.03,100,MS-DRG,7946.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9933.03,17382.8,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,inpatient,,,,,,12289.2,100,MS-DRG,9831.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10978.32,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18663.14,170,MS-DRG,14930.512,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19212.06,175,MS-DRG,15369.648,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15369.65,140,MS-DRG,12295.72,other,140% of Medicare CMS MS-DRG,13722.9,125,MS-DRG,10978.32,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,10978.32,100,MS-DRG,8782.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10978.32,19212.06,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,inpatient,,,,,,5959.1,100,MS-DRG,4767.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5282.63,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8980.47,170,MS-DRG,7184.376,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9244.6,175,MS-DRG,7395.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7395.68,140,MS-DRG,5916.54,other,140% of Medicare CMS MS-DRG,6603.29,125,MS-DRG,5282.63,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,5282.63,100,MS-DRG,4226.1,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5282.63,9244.6,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,inpatient,,,,,,30790.2,100,MS-DRG,24632.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,26720.65,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,45425.11,170,MS-DRG,36340.088,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,46761.14,175,MS-DRG,37408.912,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37408.91,140,MS-DRG,29927.13,other,140% of Medicare CMS MS-DRG,33400.81,125,MS-DRG,26720.65,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,26720.65,100,MS-DRG,21376.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26720.65,46761.14,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,inpatient,,,,,,13872.6,100,MS-DRG,11098.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11636.5,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19782.05,170,MS-DRG,15825.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20363.88,175,MS-DRG,16291.104,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16291.1,140,MS-DRG,13032.88,other,140% of Medicare CMS MS-DRG,14545.63,125,MS-DRG,11636.5,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,11636.5,100,MS-DRG,9309.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11636.5,20363.88,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,inpatient,,,,,,8509.2,100,MS-DRG,6807.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7665.25,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13030.93,170,MS-DRG,10424.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13414.19,175,MS-DRG,10731.352,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10731.35,140,MS-DRG,8585.08,other,140% of Medicare CMS MS-DRG,9581.56,125,MS-DRG,7665.25,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,7665.25,100,MS-DRG,6132.2,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7665.25,13414.19,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,inpatient,,,,,,24863.3,100,MS-DRG,19890.64,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20104.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34177.46,170,MS-DRG,27341.968,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35182.68,175,MS-DRG,28146.144,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,28146.15,140,MS-DRG,22516.92,other,140% of Medicare CMS MS-DRG,25130.49,125,MS-DRG,20104.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,20104.39,100,MS-DRG,16083.51,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20104.39,35182.68,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,inpatient,,,,,,10919.3,100,MS-DRG,8735.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9778.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16622.7,170,MS-DRG,13298.16,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17111.61,175,MS-DRG,13689.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13689.28,140,MS-DRG,10951.42,other,140% of Medicare CMS MS-DRG,12222.58,125,MS-DRG,9778.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,9778.06,100,MS-DRG,7822.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9778.06,17111.61,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,inpatient,,,,,,12514.6,100,MS-DRG,10011.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11617.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19749.5,170,MS-DRG,15799.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20330.36,175,MS-DRG,16264.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16264.29,140,MS-DRG,13011.43,other,140% of Medicare CMS MS-DRG,14521.69,125,MS-DRG,11617.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,11617.35,100,MS-DRG,9293.88,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11617.35,20330.36,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,inpatient,,,,,,27059.9,100,MS-DRG,21647.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,22964.89,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,39040.31,170,MS-DRG,31232.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40188.56,175,MS-DRG,32150.848,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,32150.85,140,MS-DRG,25720.68,other,140% of Medicare CMS MS-DRG,28706.11,125,MS-DRG,22964.89,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,22964.89,100,MS-DRG,18371.91,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22964.89,40188.56,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,inpatient,,,,,,14395.5,100,MS-DRG,11516.4,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12373.69,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21035.27,170,MS-DRG,16828.216,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21653.96,175,MS-DRG,17323.168,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17323.17,140,MS-DRG,13858.54,other,140% of Medicare CMS MS-DRG,15467.11,125,MS-DRG,12373.69,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,12373.69,100,MS-DRG,9898.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12373.69,21653.96,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,inpatient,,,,,,9552.9,100,MS-DRG,7642.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8374.06,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14235.9,170,MS-DRG,11388.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14654.61,175,MS-DRG,11723.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11723.68,140,MS-DRG,9378.94,other,140% of Medicare CMS MS-DRG,10467.58,125,MS-DRG,8374.06,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,8374.06,100,MS-DRG,6699.25,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8374.06,14654.61,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,inpatient,,,,,,10598.7,100,MS-DRG,8478.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9227.33,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15686.46,170,MS-DRG,12549.168,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16147.83,175,MS-DRG,12918.264,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12918.26,140,MS-DRG,10334.61,other,140% of Medicare CMS MS-DRG,11534.16,125,MS-DRG,9227.33,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,9227.33,100,MS-DRG,7381.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9227.33,16147.83,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,inpatient,,,,,,6223.7,100,MS-DRG,4978.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5604.31,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9527.33,170,MS-DRG,7621.864,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9807.54,175,MS-DRG,7846.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7846.03,140,MS-DRG,6276.82,other,140% of Medicare CMS MS-DRG,7005.39,125,MS-DRG,5604.31,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,5604.31,100,MS-DRG,4483.45,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5604.31,9807.54,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,inpatient,,,,,,12740.7,100,MS-DRG,10192.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10953.01,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18620.12,170,MS-DRG,14896.096,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19167.77,175,MS-DRG,15334.216,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15334.21,140,MS-DRG,12267.37,other,140% of Medicare CMS MS-DRG,13691.26,125,MS-DRG,10953.01,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,10953.01,100,MS-DRG,8762.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10953.01,19167.77,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,inpatient,,,,,,4649.4,100,MS-DRG,3719.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4067.55,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6914.84,170,MS-DRG,5531.872,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7118.21,175,MS-DRG,5694.568,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5694.57,140,MS-DRG,4555.66,other,140% of Medicare CMS MS-DRG,5084.44,125,MS-DRG,4067.55,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,4067.55,100,MS-DRG,3254.04,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4067.55,7118.21,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,inpatient,,,,,,10657.5,100,MS-DRG,8526,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9853.39,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16750.76,170,MS-DRG,13400.608,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17243.43,175,MS-DRG,13794.744,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13794.75,140,MS-DRG,11035.8,other,140% of Medicare CMS MS-DRG,12316.74,125,MS-DRG,9853.39,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,9853.39,100,MS-DRG,7882.71,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9853.39,17243.43,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,inpatient,,,,,,5723.9,100,MS-DRG,4579.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5315.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9036.11,170,MS-DRG,7228.888,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9301.88,175,MS-DRG,7441.504,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7441.5,140,MS-DRG,5953.2,other,140% of Medicare CMS MS-DRG,6644.2,125,MS-DRG,5315.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,5315.36,100,MS-DRG,4252.29,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5315.36,9301.88,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,inpatient,,,,,,12555.2,100,MS-DRG,10044.16,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11266.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19152.27,170,MS-DRG,15321.816,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19715.57,175,MS-DRG,15772.456,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15772.46,140,MS-DRG,12617.97,other,140% of Medicare CMS MS-DRG,14082.55,125,MS-DRG,11266.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,11266.04,100,MS-DRG,9012.83,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11266.04,19715.57,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,inpatient,,,,,,7152.6,100,MS-DRG,5722.08,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6382.88,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10850.9,170,MS-DRG,8680.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11170.04,175,MS-DRG,8936.032,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8936.03,140,MS-DRG,7148.82,other,140% of Medicare CMS MS-DRG,7978.6,125,MS-DRG,6382.88,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,6382.88,100,MS-DRG,5106.3,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6382.88,11170.04,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,inpatient,,,,,,5095.3,100,MS-DRG,4076.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4308.35,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7324.2,170,MS-DRG,5859.36,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7539.61,175,MS-DRG,6031.688,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6031.69,140,MS-DRG,4825.35,other,140% of Medicare CMS MS-DRG,5385.44,125,MS-DRG,4308.35,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,4308.35,100,MS-DRG,3446.68,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4308.35,7539.61,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,inpatient,,,,,,10890.6,100,MS-DRG,8712.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10773.34,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18314.68,170,MS-DRG,14651.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18853.35,175,MS-DRG,15082.68,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15082.68,140,MS-DRG,12066.14,other,140% of Medicare CMS MS-DRG,13466.68,125,MS-DRG,10773.34,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,10773.34,100,MS-DRG,8618.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10773.34,18853.35,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,inpatient,,,,,,6602.4,100,MS-DRG,5281.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6244.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10615.79,170,MS-DRG,8492.632,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10928.02,175,MS-DRG,8742.416,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8742.41,140,MS-DRG,6993.93,other,140% of Medicare CMS MS-DRG,7805.73,125,MS-DRG,6244.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,6244.58,100,MS-DRG,4995.66,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6244.58,10928.02,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,inpatient,,,,,,132875.4,100,MS-DRG,106300.32,other,Custom DRG with base of 7000. See MS-DRG rows for rates,162743.58,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,276664.09,170,MS-DRG,221331.272,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,284801.27,175,MS-DRG,227841.016,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,227841.01,140,MS-DRG,182272.81,other,140% of Medicare CMS MS-DRG,203429.48,125,MS-DRG,162743.58,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,162743.58,100,MS-DRG,130194.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,132875.4,284801.27,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,inpatient,,,,,,43339.1,100,MS-DRG,34671.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,42723.53,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,72630,170,MS-DRG,58104,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,74766.18,175,MS-DRG,59812.944,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,59812.94,140,MS-DRG,47850.35,other,140% of Medicare CMS MS-DRG,53404.41,125,MS-DRG,42723.53,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,42723.53,100,MS-DRG,34178.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42723.53,74766.18,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,inpatient,,,,,,20571.6,100,MS-DRG,16457.28,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19853.1,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33750.27,170,MS-DRG,27000.216,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34742.93,175,MS-DRG,27794.344,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27794.34,140,MS-DRG,22235.47,other,140% of Medicare CMS MS-DRG,24816.38,125,MS-DRG,19853.1,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,19853.1,100,MS-DRG,15882.48,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19853.1,34742.93,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,inpatient,,,,,,21231,100,MS-DRG,16984.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18720.14,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31824.24,170,MS-DRG,25459.392,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,32760.25,175,MS-DRG,26208.2,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,26208.2,140,MS-DRG,20966.56,other,140% of Medicare CMS MS-DRG,23400.18,125,MS-DRG,18720.14,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,18720.14,100,MS-DRG,14976.11,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18720.14,32760.25,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,inpatient,,,,,,13132,100,MS-DRG,10505.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12919.49,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21963.13,170,MS-DRG,17570.504,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22609.11,175,MS-DRG,18087.288,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18087.29,140,MS-DRG,14469.83,other,140% of Medicare CMS MS-DRG,16149.36,125,MS-DRG,12919.49,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,12919.49,100,MS-DRG,10335.59,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12919.49,22609.11,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,inpatient,,,,,,14168.7,100,MS-DRG,11334.96,other,Custom DRG with base of 7000. See MS-DRG rows for rates,12602.13,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,21423.62,170,MS-DRG,17138.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22053.73,175,MS-DRG,17642.984,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17642.98,140,MS-DRG,14114.38,other,140% of Medicare CMS MS-DRG,15752.66,125,MS-DRG,12602.13,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,12602.13,100,MS-DRG,10081.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,12602.13,22053.73,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,inpatient,,,,,,21679.7,100,MS-DRG,17343.76,other,Custom DRG with base of 7000. See MS-DRG rows for rates,19851.87,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,33748.18,170,MS-DRG,26998.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,34740.77,175,MS-DRG,27792.616,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,27792.62,140,MS-DRG,22234.1,other,140% of Medicare CMS MS-DRG,24814.84,125,MS-DRG,19851.87,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,19851.87,100,MS-DRG,15881.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19851.87,34740.77,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,inpatient,,,,,,15423.1,100,MS-DRG,12338.48,other,Custom DRG with base of 7000. See MS-DRG rows for rates,13377,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,22740.9,170,MS-DRG,18192.72,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23409.75,175,MS-DRG,18727.8,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18727.8,140,MS-DRG,14982.24,other,140% of Medicare CMS MS-DRG,16721.25,125,MS-DRG,13377,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,13377,100,MS-DRG,10701.6,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13377,23409.75,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,inpatient,,,,,,13211.8,100,MS-DRG,10569.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,11459.3,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,19480.81,170,MS-DRG,15584.648,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20053.78,175,MS-DRG,16043.024,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16043.02,140,MS-DRG,12834.42,other,140% of Medicare CMS MS-DRG,14324.13,125,MS-DRG,11459.3,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,11459.3,100,MS-DRG,9167.44,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11459.3,20053.78,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,inpatient,,,,,,10536.4,100,MS-DRG,8429.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9319.94,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15843.9,170,MS-DRG,12675.12,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16309.9,175,MS-DRG,13047.92,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,13047.92,140,MS-DRG,10438.34,other,140% of Medicare CMS MS-DRG,11649.93,125,MS-DRG,9319.94,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,9319.94,100,MS-DRG,7455.95,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9319.94,16309.9,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,inpatient,,,,,,7858.2,100,MS-DRG,6286.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6252.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10629.42,170,MS-DRG,8503.536,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10942.05,175,MS-DRG,8753.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8753.64,140,MS-DRG,7002.91,other,140% of Medicare CMS MS-DRG,7815.75,125,MS-DRG,6252.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,6252.6,100,MS-DRG,5002.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6252.6,10942.05,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,inpatient,,,,,,8509.2,100,MS-DRG,6807.36,other,Custom DRG with base of 7000. See MS-DRG rows for rates,7727.61,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13136.94,170,MS-DRG,10509.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,13523.32,175,MS-DRG,10818.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10818.65,140,MS-DRG,8654.92,other,140% of Medicare CMS MS-DRG,9659.51,125,MS-DRG,7727.61,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,7727.61,100,MS-DRG,6182.09,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,7727.61,13523.32,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,inpatient,,,,,,5443.2,100,MS-DRG,4354.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,4945.52,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8407.38,170,MS-DRG,6725.904,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8654.66,175,MS-DRG,6923.728,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6923.73,140,MS-DRG,5538.98,other,140% of Medicare CMS MS-DRG,6181.9,125,MS-DRG,4945.52,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,4945.52,100,MS-DRG,3956.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,4945.52,8654.66,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,inpatient,,,,,,8344,100,MS-DRG,6675.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6623.66,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11260.22,170,MS-DRG,9008.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11591.41,175,MS-DRG,9273.128,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9273.12,140,MS-DRG,7418.5,other,140% of Medicare CMS MS-DRG,8279.58,125,MS-DRG,6623.66,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,6623.66,100,MS-DRG,5298.93,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6623.66,11591.41,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,inpatient,,,,,,4966.5,100,MS-DRG,3973.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3942.83,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6702.81,170,MS-DRG,5362.248,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6899.95,175,MS-DRG,5519.96,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5519.96,140,MS-DRG,4415.97,other,140% of Medicare CMS MS-DRG,4928.54,125,MS-DRG,3942.83,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,3942.83,100,MS-DRG,3154.26,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3942.83,6899.95,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,inpatient,,,,,,3984.4,100,MS-DRG,3187.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,3642.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6192.73,170,MS-DRG,4954.184,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6374.87,175,MS-DRG,5099.896,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5099.89,140,MS-DRG,4079.91,other,140% of Medicare CMS MS-DRG,4553.48,125,MS-DRG,3642.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,3642.78,100,MS-DRG,2914.22,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,3642.78,6374.87,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,inpatient,,,,,,47152,100,MS-DRG,37721.6,other,Custom DRG with base of 7000. See MS-DRG rows for rates,37602.05,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,63923.49,170,MS-DRG,51138.792,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,65803.59,175,MS-DRG,52642.872,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,52642.87,140,MS-DRG,42114.3,other,140% of Medicare CMS MS-DRG,47002.56,125,MS-DRG,37602.05,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,37602.05,100,MS-DRG,30081.64,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,37602.05,65803.59,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,inpatient,,,,,,26629.4,100,MS-DRG,21303.52,other,Custom DRG with base of 7000. See MS-DRG rows for rates,23944.74,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,40706.06,170,MS-DRG,32564.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,41903.3,175,MS-DRG,33522.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,33522.64,140,MS-DRG,26818.11,other,140% of Medicare CMS MS-DRG,29930.93,125,MS-DRG,23944.74,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,23944.74,100,MS-DRG,19155.79,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,23944.74,41903.3,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,inpatient,,,,,,51873.5,100,MS-DRG,41498.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,44654.82,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,75913.19,170,MS-DRG,60730.552,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,78145.94,175,MS-DRG,62516.752,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,62516.75,140,MS-DRG,50013.4,other,140% of Medicare CMS MS-DRG,55818.53,125,MS-DRG,44654.82,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,44654.82,100,MS-DRG,35723.86,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,44654.82,78145.94,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,inpatient,,,,,,29193.5,100,MS-DRG,23354.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,24973.36,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42454.71,170,MS-DRG,33963.768,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,43703.38,175,MS-DRG,34962.704,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,34962.7,140,MS-DRG,27970.16,other,140% of Medicare CMS MS-DRG,31216.7,125,MS-DRG,24973.36,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,24973.36,100,MS-DRG,19978.69,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,24973.36,43703.38,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,inpatient,,,,,,17980.9,100,MS-DRG,14384.72,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15635.51,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26580.37,170,MS-DRG,21264.296,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,27362.14,175,MS-DRG,21889.712,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21889.71,140,MS-DRG,17511.77,other,140% of Medicare CMS MS-DRG,19544.39,125,MS-DRG,15635.51,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,15635.51,100,MS-DRG,12508.41,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15635.51,27362.14,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,inpatient,,,,,,19412.4,100,MS-DRG,15529.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,16882.09,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,28699.55,170,MS-DRG,22959.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29543.66,175,MS-DRG,23634.928,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,23634.93,140,MS-DRG,18907.94,other,140% of Medicare CMS MS-DRG,21102.61,125,MS-DRG,16882.09,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,16882.09,100,MS-DRG,13505.67,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16882.09,29543.66,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,inpatient,,,,,,10251.5,100,MS-DRG,8201.2,other,Custom DRG with base of 7000. See MS-DRG rows for rates,9267.46,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15754.68,170,MS-DRG,12603.744,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,16218.06,175,MS-DRG,12974.448,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12974.44,140,MS-DRG,10379.55,other,140% of Medicare CMS MS-DRG,11584.33,125,MS-DRG,9267.46,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,9267.46,100,MS-DRG,7413.97,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9267.46,16218.06,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,inpatient,,,,,,6369.3,100,MS-DRG,5095.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5901.9,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10033.23,170,MS-DRG,8026.584,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10328.33,175,MS-DRG,8262.664,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8262.66,140,MS-DRG,6610.13,other,140% of Medicare CMS MS-DRG,7377.38,125,MS-DRG,5901.9,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,5901.9,100,MS-DRG,4721.52,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5901.9,10328.33,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,inpatient,,,,,,50733.2,100,MS-DRG,40586.56,other,Custom DRG with base of 7000. See MS-DRG rows for rates,42432.73,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,72135.64,170,MS-DRG,57708.512,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,74257.28,175,MS-DRG,59405.824,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,59405.82,140,MS-DRG,47524.66,other,140% of Medicare CMS MS-DRG,53040.91,125,MS-DRG,42432.73,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,42432.73,100,MS-DRG,33946.18,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,42432.73,74257.28,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,inpatient,,,,,,21618.8,100,MS-DRG,17295.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,17161.78,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29175.03,170,MS-DRG,23340.024,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30033.12,175,MS-DRG,24026.496,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,24026.49,140,MS-DRG,19221.19,other,140% of Medicare CMS MS-DRG,21452.23,125,MS-DRG,17161.78,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,17161.78,100,MS-DRG,13729.42,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17161.78,30033.12,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,inpatient,,,,,,20111,100,MS-DRG,16088.8,other,Custom DRG with base of 7000. See MS-DRG rows for rates,18007.02,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,30611.93,170,MS-DRG,24489.544,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,31512.29,175,MS-DRG,25209.832,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,25209.83,140,MS-DRG,20167.86,other,140% of Medicare CMS MS-DRG,22508.78,125,MS-DRG,18007.02,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,18007.02,100,MS-DRG,14405.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18007.02,31512.29,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,inpatient,,,,,,9629.9,100,MS-DRG,7703.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8417.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14309.36,170,MS-DRG,11447.488,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14730.22,175,MS-DRG,11784.176,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,11784.18,140,MS-DRG,9427.34,other,140% of Medicare CMS MS-DRG,10521.59,125,MS-DRG,8417.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,8417.27,100,MS-DRG,6733.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8417.27,14730.22,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,inpatient,,,,,,6459.6,100,MS-DRG,5167.68,other,Custom DRG with base of 7000. See MS-DRG rows for rates,5219.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8872.37,170,MS-DRG,7097.896,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,9133.32,175,MS-DRG,7306.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,7306.66,140,MS-DRG,5845.33,other,140% of Medicare CMS MS-DRG,6523.8,125,MS-DRG,5219.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,5219.04,100,MS-DRG,4175.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,5219.04,9133.32,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,inpatient,,,,,,9099.3,100,MS-DRG,7279.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,8743.27,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,14863.56,170,MS-DRG,11890.848,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15300.72,175,MS-DRG,12240.576,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,12240.58,140,MS-DRG,9792.46,other,140% of Medicare CMS MS-DRG,10929.09,125,MS-DRG,8743.27,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,8743.27,100,MS-DRG,6994.62,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,8743.27,15300.72,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,inpatient,,,,,,32062.8,100,MS-DRG,25650.24,other,Custom DRG with base of 7000. See MS-DRG rows for rates,29268.12,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,49755.8,170,MS-DRG,39804.64,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,51219.21,175,MS-DRG,40975.368,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,40975.37,140,MS-DRG,32780.3,other,140% of Medicare CMS MS-DRG,36585.15,125,MS-DRG,29268.12,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,29268.12,100,MS-DRG,23414.5,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,29268.12,51219.21,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,inpatient,,,,,,17557.4,100,MS-DRG,14045.92,other,Custom DRG with base of 7000. See MS-DRG rows for rates,15349.04,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26093.37,170,MS-DRG,20874.696,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,26860.82,175,MS-DRG,21488.656,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,21488.66,140,MS-DRG,17190.93,other,140% of Medicare CMS MS-DRG,19186.3,125,MS-DRG,15349.04,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,15349.04,100,MS-DRG,12279.23,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,15349.04,26860.82,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,inpatient,,,,,,11691.4,100,MS-DRG,9353.12,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10096.03,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17163.25,170,MS-DRG,13730.6,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17668.05,175,MS-DRG,14134.44,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14134.44,140,MS-DRG,11307.55,other,140% of Medicare CMS MS-DRG,12620.04,125,MS-DRG,10096.03,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,10096.03,100,MS-DRG,8076.82,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10096.03,17668.05,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,inpatient,,,,,,23228.8,100,MS-DRG,18583.04,other,Custom DRG with base of 7000. See MS-DRG rows for rates,20848.38,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,35442.25,170,MS-DRG,28353.8,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,36484.67,175,MS-DRG,29187.736,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,29187.73,140,MS-DRG,23350.18,other,140% of Medicare CMS MS-DRG,26060.48,125,MS-DRG,20848.38,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,20848.38,100,MS-DRG,16678.7,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,20848.38,36484.67,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,inpatient,,,,,,11874.8,100,MS-DRG,9499.84,other,Custom DRG with base of 7000. See MS-DRG rows for rates,10477.6,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,17811.92,170,MS-DRG,14249.536,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,18335.8,175,MS-DRG,14668.64,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,14668.64,140,MS-DRG,11734.91,other,140% of Medicare CMS MS-DRG,13097,125,MS-DRG,10477.6,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,10477.6,100,MS-DRG,8382.08,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,10477.6,18335.8,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,inpatient,,,,,,7716.8,100,MS-DRG,6173.44,other,Custom DRG with base of 7000. See MS-DRG rows for rates,6669.98,100,MS-DRG,,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,,,,,,,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11338.97,170,MS-DRG,9071.176,other,170% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,11672.47,175,MS-DRG,9337.976,other,175% of Medicare CMS MS-DRG. See MS-DRG rows for rates,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,9337.97,140,MS-DRG,7470.38,other,140% of Medicare CMS MS-DRG,8337.48,125,MS-DRG,6669.98,other,125% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,6669.98,100,MS-DRG,5335.98,other,100% of Medicare CMS MS-DRG,,,,,other,Not separately reimbursable per contract terms,,,,,other,Not separately reimbursable per contract terms,6669.98,11672.47,